Factors Affecting Exclusive Breastfeeding

INTRODUCTION

Kitano et al (2016) defines exclusive breast-feeding as a process where the infant receives only breast milk; in such cases, no other solids or liquids are given with the exception of medicines, minerals, vitamin syrups and rehydration solutions. Breast milk, in exclusive breast feeding, can be obtained either expressly or from a wet nurse. In situations where the infant no longer meets the nutritional requirements by breast feeding alone, other foods and liquids may be needed; this is referred to as complementary feeding (Asare et al, 2018). The average global levels of exclusive breastfeeding remain relatively low compared to the targets set by the World Health Organization (Rollins et al., 2016). The factors leading to these dismal levels are diverse and enormous. These factors are mostly capable of being eliminated. This study reveals some of these factors that relate to the socio-economic and cultural practices of the modern society. Moreover, there are physiological factors that can be modified to ensure maximum benefit to the infant and the mother. In this regard, this study explores these modifiable factors and concludes on the most effective intervention initiatives such as health education for mothers, which increase the chances of breastfeeding especially during the first six months postpartum.

Background of the study

Most mothers do not follow the practice of breastfeeding despite the numerous health benefits it provides to both mother and child (Rollins et al., 2016). According to Motee and Jeewan (2004), breastfeeding should be introduced to the infant within an hour of childbirth. As such, breastfeeding could save more than 800,000 children under the age of five years from mortality and more than 300 billion US dollars (World Health Organization, 2016). Between 2007 and 2014, 36% of infants worldwide were exclusively breastfed. The World Health Organization (WHO) (2010) suggests exclusive breastfeeding for the first 6 months of life, and a subsequent introduction of solid foods at 6 months with continued breastfeeding up to two years and beyond. Cai, Wardlaw and Brown (2012), studied trends in exclusive breastfeeding among infants younger than 6 month in 66 countries. Less than 40% of infants were estimated to be exclusively breastfed as of 2010, which is still below the universal target of 90%. The key phrases used in this analysis include: breastfeeding, exclusive breastfeeding, supplementary and complementary breastfeeding. They have been summarized in table 1.

Importance of breastfeeding

Breast milk is the ideal nutrition recommended for new born babies as it contains the right amounts of nutrients necessary for the baby’s growth and development (Alimoradi et al., 2014). The nutritional value of breastfeeding enhances the immune system of a child hence acting as a major enabler for the infant’s body to fight off germs and disease-causing microorganisms (Victora et al., 2016). The maternal antibodies found in human breast milk protect the baby against gastrointestinal illness and provide some protection against respiratory infections (Lamberti et al., 2011). Breast milk substitutes lack the capacity to provide immunological protection and even pose the risk of infection to infants if contaminated with pathogens and/or chemicals, or incorrectly formulated (Gribble and Hausman, 2012). Oddy, Whitehouse, Zubrick and Malacova (2011) recommend early introduction of newborns to breastfeeding, within an hour of childbirth, to protect the infant from risk of infections such as diarrhea and pneumonia which are the two major causes of infant mortality. Numerous studies show that breastfeeding reduces the risk of respiratory diseases such as asthma, as well as allergies (Gribble and Hausman, 2012). Indeed studies show, including those conducted on British women, that breastfeeding is closely associated with reduced depression (Victora et al., 2016). Emotional satisfaction, as well as reduced Body Mass Index (BMI) can also be associated with breastfeeding. This, therefore, reduces the risk of obesity among women (Victora et al., 2016).Whereas postpartum bleeding is expected to recur after birth, it has also been shown that breastfeeding significantly reduces the chances of menses recurring at least in the first 8 weeks after birth (Visness, Kennedy and Ramos, 1997). Noel-Weiss (2006) outlines the importance of breastfeeding in the reduction of risk of mothers developing breast and ovarian cancer and in some cases, osteoporosis. Breastfeeding has also been shown to help increase birth spacing (the period of time between one pregnancy and another) especially in low income countries (Victora et al., 2016). Exclusive breastfeeding (EBF) is particularly important as it acts as a natural birth control method referred to as the Lactation Amenorrhea Method, which is accredited by the World Health Organization as an effective and natural family planning method (Tiwari, Khanam and Savarna, 2018). Birth spacing allows the recuperation of the mother before she is able to conceive again (Victora et al., 2016).

Factors affecting breastfeeding

There are several factors affecting the rate of EBF. One of them is the lack of knowledge by healthcare providers such as assumptions made that complementary feeding is more beneficial to the baby than EBF (Bai, Wu and Tarrant, 2013). Breastfeeding self-efficacy is defined as a mother’s confidence to breastfeed her own infant (Otsuka et al., 2014). Lack of enough support in a hospital setting, through separation of the mother and child during the hospital stay, restricted breastfeeding and supplementing breast milk with baby formula are also factors that contribute to less breastfeeding time (Neil-Weiss et al., 2006). Lack of support from the mother’s family, partner and peers, frequent advertisements of baby formula as an alternative, and lack of information on the importance of EBF to the mother, her partner as well as policy makers and healthcare providers were also found by Lamberti et al (2011) to be some of the factors affecting breastfeeding. Persad and Mensinger (2008) states that women experience support when they receive help, encouragement, advice and understanding from their professional colleagues, family and close friends. When breastfeeding mothers receive support from the people around them, they are positively influenced (Borra, Locovou and Sevilla, 2005).

Practices that improve breastfeeding

Exclusive breastfeeding can be improved by providing skilled counselling in health facilities, as part of the policies and programmes (McFadden et al., 2019). Strengthening the link between communities and health facilities to encourage and promote community support for breastfeeding mothers is also another way in which breastfeeding can be improved (Brown, 2014). Anderson et al., (2015) also suggested initiation of paid maternal leaves to encourage women to take time off work to focus on exclusive breastfeeding which will not only meant to improve bonding of mother and child, but also ensure that women are secure at their workplaces without worry of losing their jobs. Breastfeeding can also be strengthened by monitoring systems that track the progress of policies, programs and funding towards achieving both national and global breastfeeding targets. This can be done by monitoring data from select groups of mothers exposed to these programs exclusively. Policies and programs that do not work should be scraped and replaced with better alternatives (Oddy, Whitehouse, Zubrick and Malcova, 2011). However, these practices may not be enough to alter the general social culture which undermines breastfeeding. This is because there are many other factors which affect the failure of mothers to breastfeed.

Aims and Objectives

The aim of this study is to find out the factors that improve the ability of breastfeeding mothers to breastfeed exclusively for the recommended 6 months as recommended by WHO. In so doing, this study enriches the discussion of improving breastfeeding levels among mothers, thus motivating more women to find solutions to their breastfeeding barriers. The study also helps health care providers to identify gaps in their policy initiatives thus enabling them provide expansive and convincing breastfeeding education to mothers.

The specific objectives were:

To identify the factors that limit exclusive breastfeeding

To assess methods of interceding aimed at improving the duration of exclusive breastfeeding.

2.0 METHODOLOGY

2.1 Search Strategy

In this study, keywords were generated. According to Aromataris and Ritano (2014), the use of Boolean Operator: AND/OR, reduces the database search to only include relevant titles. The search yielded almost 6000 pertinent results but they were narrowed down using the inclusion and exclusion criteria. This was necessary so as to achieve only articles that answered the question. The key words generated have been summarized below, table 2. Based on the relevance to the research focus, the researcher decided on the relevant results. Relevant results were also decided based on duplicity of articles as some of the articles appeared more than once.

2.2 Literature Search

Databases such as Cochrane library, Google scholar, PubMed and Semantic scholar were used to search for relevant articles. The searches were made using the inclusion and exclusion criteria formulated by the researcher, the next section details these criteria. A literature search from the four databases used ensured that no paper relevant to the study was omitted (Timmnis and McCabe 2005).

2.3 Inclusion and Exclusion Criteria

Collection of data was focused on publications done in the English language, and those published between the years of 2010 and 2020. Articles published on or after 2010 were selectable because recently published provide the most reliable current information on a particular topic of interest. Only literature published in the English language were included because the researcher is most familiar with the English language. Additionally, it is easier to understand the English language as it is the official language in the researcher’s setting. Endnote X7 was used to remove duplicate articles and manual identification of titles was done. Titles that did not contain the key term searched were excluded, as well as non-peer reviewed articles. Specific focus was given to peer-reviewed journals and articles because these have undergone public criticism and professional scrutiny; thereby increasing the validity of the researches. Duplicated data and publications that failed to meet the aims and objectives being researched were not included. Publications that relied on secondary data were also excluded to ensure accuracy in the data collected. In this context, Ware (2008) supports that the exclusion of pseudoscientific journals is necessary as such evidence may not be reliable. Articles that had no definite conclusion or incorrect conclusions were also excluded from the data collection process. Papers with incorrect methods and population used were also excluded. The inclusion criterion also involves articles with information pertaining to single birth mothers; because the concept of ‘exclusive’ feeding is best explored in instances where the mother only has a single birth.

2.4 Critical Appraisal of Studies Quality

The critical appraisal tool used in this study was the Critical Appraisal Skills Programme (CASP (CASP, 2003). The tool was adopted to measure the validity, reliability and credibility of the articles used in the study. CASP ensures that the question of study was addressed, the methodological designs were valid and that the results from the study were applicable to a particular population. The research papers used in the study were found to meet the required standards of quality and the findings approved.

2.5 Ethical consideration

The researchers consulted with the ethical board on the study areas prior to beginning the research. All papers chosen for review contained written and signed consent from the participants who were first educated on the importance of the study, and their rights as respondents. The respondents were also made aware of their right to drop off from the research at any point as the studies continued.

2.6 Search Results

Literature search was conducted across the databases mentioned in the methodology section: Pubmed, Cochrane library, Semantic scholar and Google scholar. The PRISMA diagram in Appendix 1 depicts the results of the literature search

2.7 Research results

Table 4 shows a tabulated representation of the research papers selected for the quantitative studies. Young et al (2019) conducted a study with an aim of understanding the multiple influences on breastfeeding practices and to set out potential programs that would improve breastfeeding. The researchers conducted a cross-sectional survey among 1838 new mothers, 1194 husbands and 1343 mothers/mothers-in-law. Data collected was examined using the bivariate ad multivariable logistic regression models. The focus on the multilevel determinants such as maternal health service, community and family level factors associated with breastfeeding practices gives the study a legitimate standing in this research. The study’s detailed methodological design also creates a strong foundation of its results. The large population sample used by Young et al (2019) also infers that the findings can be generalizable. Findings of the study show that 39% of the women received counseling during pregnancy and 21% after delivery. Mothers who received prenatal counseling were 1.4 times more likely to begin breastfeeding within an hour of delivery. Maternal knowledge of EBF practices reduced complementary feeding by 56%, while maternal self-efficacy reduced it by 55%. The baby’s father and MMIL knowledge of EBF are also shown to have an impact in reducing prelacteal feeding. Only 36% of the mothers with college and university education in Canada did not initiate breastfeeding while just about 8% of mothers with high school education did. High stress levels also reduced the likelihood of breastfeeding by 38% (CI; 0.62). Women who are victims of domestic violence (37%) also had a 25%-38% less likelihood of initiating EBF. Brown et al (2013) conducted a population-based longitudinal cohort study to identify predictors of early cessation of exclusive breastfeeding. The researchers in the study linked data from a public health database for infants born between 2006 and 2009 in 2 regions, and a perinatal database. The study measured hazard ratios for the early cessation of exclusive breastfeeding through Cox proportional hazards regression modelling. The population-based longitudinal cohort study was conducted in adherence with ethical considerations, thereby enhancing the credibility and validity of the findings. Data on Nova Scotia showed that only half of the women initiated breastfeeding in the first hour after delivery (Brown et al, 2013). The study conducted showed how location of residence affect breastfeeding duration. Women who lived in Western Canada had higher rates of prolonged breastfeeding compared to those residing in Atlantic Provinces. 70.6% of older women (30+ years) initiated exclusive breastfeeding compared to 61% of mothers between 20 and 29 years. Of the 1332 married women surveyed in Canada, 70.8% of them initiated breastfeeding while only 29% of single women (n=1328) did. Only 30% of mother in the Nova Scotia study indicated intention to not breastfeed (Brown et al, 2013). Low confidence levels (HR=3.90) in the ability to breastfeed was the major factor that led to discontinuation of EBF before the 6 months in Kinshasa (Babakazo et al 2015). Breastfeeding problems experienced in the first week (HR=1.54) and low levels of knowledge on the importance of EBF (HR=1.52) also led to decreased breastfeeding duration in the DRC. Mothers who smoked during their pregnancy had higher rates (HR 1.39) of abandoning breastfeeding during the first 6 weeks postpartum, compared to non-smokers and mothers who had quit smoking during the pregnancy (HR 1.09). Multiparous mothers with a hazard ratio of 0.76 were unlikely to discontinue breastfeeding earlier than prim parous women. Women who underwent caesarian delivery were 40% less likely to practice EBF (CI; 0.61), while women of higher socio-economic status showed a 50% likelihood of complementary feeding. Health facility deliveries had 1.7 more likelihood of infants being breastfed and the mothers had a 69% reduction rate to introduce supplementary foods noted in both studies done in Kinshasa and Uttar Pradesh (Babakazo et al 2015; Young et al 2019).

3.0 DISCUSSION

According to the results obtained, various factors were found to have an impact on the breastfeeding duration (Babakazo et al., 2015; Brown et al., 2013). From a thematic analysis of the findings, a number of issues were found. These were age, income level, marital status, social support, self-efficacy, and mother’s intention, level of employment, breastfeeding problems, insufficient milk and health problems. These factors can be grouped into either socio-economic, biophysical and socio-demographic or psychosocial factors.

3.1 Socio-demographic factors

These are factors that relate to a combination of both social and demographic factors. They include age, language, ethnicity and race. Kitano et al (2016) foundationally acknowledges that younger women, less educated women, single, jobless and women with insufficient information on exclusive breastfeeding practices tend to exclusively breastfeed less. Young women (20-24 years) are more unlikely to breastfeed or practice EBF to six months compared to older women (30+years) (Brown et al., 2013). Brown et al. (2013) showed that 61% of young mothers initiated breastfeeding early on after birth. However, Chaves et al (2019) had contradicting results that showed age did not influence a mother’s self- efficacy in breastfeeding. Mothers who have previous children (multiparous) were noted to have higher intentions to exclusively breastfeed compared to first time parents (prim parous). These first time parents need more support and guidance on the best breastfeeding practices (Kitano et al., 2016). Certain factors compromise the initiation of breastfeeding by young mothers. These factors include lack of confidence to seek help on issues arising from breastfeeding, interruption of skin to skin bonding after birth by health workers, and anxiety on breastfeeding (bosnjack 2010). Fear of being judged by older more experienced mothers is also a factor noted to cause cessation of breastfeeding by young mothers. Another factor that decreases the duration of breastfeeding is employment and education interference (Lumbiganon et al., 2016). Older women have a better chance of exclusively breastfeeding because they are more likely to have the resources to enable them take time off work and focus on exclusive breastfeeding. This is difficult in the case of young women, who are just starting off in life and lack the comfort to take 6 months off work or school to focus on exclusive breast feeding (Tan, 2011). Breast aesthetics is also more likely to affect younger women compared to older women (Rinker, Veneracion and Walsh, 2008). Fear of sagging breasts resulting from breastfeeding highly reduces the duration of breastfeeding in younger mothers, despite studies by Onah et al (2014) showing no correlation between sagging of breasts and breastfeeding. In the Dominican Republic, studies showed that breast aesthetics ranked second as one of the major reasons why women did not initiate breastfeeding and ceased EBF (Rinker, Veneracion and Walsh, 2008). A study conducted by Lambert (2011) established that 36% of babies born to married mothers were exclusively breastfed, compared to 19% and 9% born to cohabiting and single women respectively. Brown et al’s (2013) study showed only 29.8% of single women having the intention to breastfeed compared to 70.8% of women with spouses. Specifically looking at married women, their study was supported by Chaves et al (2019), who showed that the marital status influenced the decision to exclusively breastfeed by 86.4%. They stated that the main reason for prolonged breastfeeding in women with partners is influenced by the partner. Male figures in Iran and Malaysia were shown to be the important decision makers in influencing a woman’s decision to breastfeed (Noughabi et al., 2014). Generally, informal sources of support, such as the partners of the mother, have more influence on the breastfeeding practices of the mother, compared to the formal healthcare providers. 37% of women who were victims of domestic violence had a reduced likelihood of initiating breastfeeding and prolonging the duration they breastfed (Young et al., 2019). Mothers who receive verbal and generally active support from their partners are more likely to breastfeed longer (Mannion et al., 2013). However, the study by Mannion et al (2013) showed no big difference between mothers with supportive partners and those without, although they recommended clinics to engage more with partners so as to achieve prolonged breastfeeding. As such, single women are less likely to breastfeed or prolong breastfeeding because they lack the support system to keep them going or to get them started (Brand, Kothari and Stark, 2011). In cases where they lack family support, single women become solely responsible for their provisions (Entwistle, Kendall and Mead, 2010). In such cases, they have to resume work to fend for themselves, which makes it more difficult for them to exclusively breastfeed their babies. This may even lead them into introducing infant formula or complementary feeding so that they may wholly satisfy the needs of the baby. The inadequate time they get to exclusively breastfeed the child forces them into making these decisions (Bai, Wu and Tarrant, 2013). Low income countries report higher levels of EBF because mothers have limited access to complementary foods such as baby formula, leaving them with the only option of breastfeeding their babies (Babakazo et al., 2015). In some of these countries, culturally breast feeding the baby is a norm adopted by the local communities to ensure that the baby receives all it needs. Mothers who are full time employees breastfeed for much shorter periods so that they can get back to work, compared to unemployed or self-employed mothers employed women. According to Entwistle, Kendall and Mead (2010), they have a 9% rate of breastfeeding at 6 months. Further research on American mothers indicate that where women are given paid maternity leave, their likelihood of breastfeeding beyond 3 months is higher (Ogbuanu et al., 2011). Fewer leave days provided to mothers is a factor that greatly reduces the breastfeeding duration. Women in lower occupations and less flexible schedules are also less likely to breastfeed due to work policies that might not be as supportive as those of their counterparts in higher income jobs, which are more flexible (Bosnjack et al., 2010). This difference in incomes decreases their ability to exclusively breastfeed to the required 6 months forcing them to introduce infant formula or supplement breast milk with other animal milk options, or to introduce solid foods. Employers are often reluctant to allow children in the workplace, therefore, this forces most women to provide complementary foods to their babies when they have to go to work (Tan, 2011). Additionally, a study conducted in Iran by Noughabi et al (2014) showed that unemployed housewives stopped breastfeeding much earlier than employed women. Their conclusion in this contradicting result was that the availability of better work policies encouraged more employed women to breastfeed. However, the truth of this analysis is put to question by several others, more recently, studies done in the United States show that women with low income are more likely to pump milk than expressly feed from the breast; this is still exclusive breast feeding (Keim et al., 2017).

Rollins et al., (2016) attribute longer breastfeeding duration to the level of education of the breastfeeding mothers. Highly educated mothers have been shown to breastfeed longer than less educated mothers. For instance, women with college education had a 67% likelihood of initiating breastfeeding compared to those with secondary school or no formal education (Noughabi et al., 2014; Onah et al., 2014). Knowledge on the importance of exclusive breastfeeding to both the mother and child improves the duration and the mothers’ intention to breastfeed. Less educated women who believed in outdated cultural practices and beliefs such as colostrum being “bad” for the newborn are more inclined to introduce complementary feeding within the first few days of child birth, as an alternative to providing colostrum (Young et al., 2019). Having an educated partner in a household also positively influences the duration of a woman to breastfeed (Wanjohi et al., 2016). Educated fathers who possess the knowledge on the importance of breastfeeding pass it on to their partners and children, compared to less/non-educated fathers (Bich, Long and Hoa, 2019). Educated fathers are more likely to provide support to their partners after birth, therefore improving the mother’s intention to continue breastfeeding. In the study conducted in Uttar Pradesh, knowledge of the importance of breastfeeding by the father substantially improved the breastfeeding duration and initiation by mothers (Young et al., 2019). The findings of this study were supported by that of McFadden et al (2017) who found that community education on the benefits of EBF led to increased support in improving the breastfeeding duration. Health care workers who were better educated on the benefits of exclusive breastfeeding were found to play a significant role in improving the rates of breastfeeding mothers post discharge. Research done by Lamberti et al (2011) showed that mothers were introduced to supplementary feeding in the hospital setting post-delivery. Health care personnel who were unaware of the importance of EBF within the first 6 months reported having introduced supplementary foods to the mothers under their care, as they made an assumption that breast milk on its own was not sufficient enough for the baby (Noughabi et al., 2014). This obviously reduced the rates of breastfeeding. Various studies reviewed have shown that socio-demographic factors have an impact on exclusive breastfeeding by the mother. Different studies have portrayed differences in age; where older women are considered to be in a better position of exclusively breastfeeding the baby compared to younger women; marital status; in which the informal support by partners, spouses or companions, have been found to greatly influence the rates of exclusive breast feeding; income; and education.

3.2 Physiological factors

Physiological factors refer to factors related to the physical body of a person that affect a certain assertion. Physiological factors that were found to have an effect on exclusive breastfeeding were breast feeding problems, perceived insufficient milk and the mode of delivery. 63% of the mothers in research conducted by Galipeau et al., (2018) believed that they had inadequate milk to feed their babies and were more inclined to supplement their breast milk within the first week postpartum. Perceived insufficient milk influences the mothers’ confidence and self-efficacy, leading to the fear of not providing sufficient nutrition via breast milk, hence encouraging the use of animal milk, infant formula and solid/semi-solid foods (Gatti, 2008). The perception of insufficient milk is experienced when the mother doubts her ability to produce milk or the quantity of milk she drops. Bosnjack et al (2010) found that primiparous women are more likely to doubt their milk quality and quantity compared to multiparous women. However, the research conducted by Oddy et al (2011) found no significant connection between parity and perceived insufficient milk. Worrying about the rate of baby growth is also a factor noted by Galipeau et al (2018) that led to the introduction of complementary feeding, and cessation of exclusive breastfeeding. Slow growth rate of the baby was found to make mothers doubt their milk quality. This makes the mothers conclude that the baby is not satisfied (Galipeau et al., 2018). Breast feeding problems experienced by women such as nipple pain, mother’s health status, postpartum depression and smoking are also linked to reduced breastfeeding durations (DiFranza, Aligne and Weitzman, 2004). Breast tenderness is normal when a mother begins breastfeeding and often disappears with continued nursing. Poor latching by the baby, and infections sometimes brings about pain in the nipples (Galipeau et al., 2018). Women are aware of the different methods they can use to help reduce the likelihood of these issues from occurring (McFadden et al., 2018). When these factors occur within the first week of childbirth, the mother’s intention to breastfeed might change. This makes her obliged to introduce the infant to complementary feeding, rather than exclusively breastfeeding the child (Lumbiganon et al., 2016). Knowledge on ways in which breast and nipple discomfort can be reduced should be made accessible to the mother during prenatal visits and postpartum. Support groups and peer counseling play a huge role in knowledge dissemination of management of breastfeeding problems (Osman, Zein and Wick, 2009). Bora, Lacovou and Sevilla (2015) noted that maternal depression, prenatal or postpartum, also has an impact of the exclusivity and intention to breastfeed. Prenatal depression influences a mother’s intention to breastfeed. However, according to Insaf et al (2011), this can be changed through proper education and support by nurses and family members. Women who fail to initiate breastfeeding are more likely to have developed postpartum depression compared to those who do. The nature and precision of the relationship between the two is, however, unclear (Pope and Mazmanian, 2016).

A mothers’ health status plays a major role in her practicing exclusive breastfeeding. Mothers infected with HIV are less likely to initiate breastfeeding, especially where they received no or less information about ways in which they could breastfeed without risk of mother-child transmission (WHO/UNICEF, 2016). Women with undetectable viral load have a reduced risk of spreading the virus to their babies and can therefore breastfeed (Moore, 2013). They, however, have to take drugs during breastfeeding so that they can provide the necessary nutrition to the baby, without actually infecting them. Lack of finances to purchase infant formula, as well as inaccessibility of clean water and refrigeration to preserve the formula, all encourage breastfeeding by HIV infected mothers (WHO/UNICEF, 2016). Women who smoke not only cease breastfeeding earlier, but are also more likely to have lower milk supply compared to non-smokers. It has been studied by DiFranza, Aligne and Weitzman (2004) that smoking alters the composition of milk and decreases the production. The benefits of breast milk to infants of smoking women, however, outweigh the effects of nicotine subjection. Smoking mothers are less motivated to breastfeed because of their low milk production (Brown et al., 2013). Breast milk offers protection against respiratory complications. Research carried out by Brown et al (2013) showed that babies breast fed by smoking women had lower risks of respiratory diseases compared to those who were fed on infant formula. According to Regan, Thomson and DeFranco (2013), mothers who have a normal delivery are 67% more likely to breastfeed than those who had to undergo repeated caesarean. Caesarean delivery has been shown to affect the duration of breastfeeding either due to pain, discomfort from the surgery and limited skin to skin contact between mother and child after birth (Bich, Long and Hoa, 2019). Women who underwent caesarean delivery and had skin to skin connection with the baby immediately were reported to have successfully breastfed one to four months postpartum (Moore, 2013). Moore’s study showed that 50% of women in her study across 21 countries exclusively breastfed due to initiation of skin-to-skin contact, despite undergoing caesarian delivery. Studies by Onah et al., (2014) showed that mode of delivery was an important factor affecting exclusive breastfeeding in Nigeria. Their research showed that mothers who had normal deliveries were 2.6 times more probable to practice EBF than women who underwent caesarian delivery. Studies by Prior et al., (2012) however showed no relation between the duration of breastfeeding and the type of delivery a mother underwent. They attributed this to other underlying factors such as knowledge, support and level of education, which play a major role in determining a mother’s intention to breastfeed and her duration of breastfeeding. Ahluwalia et al., (2012) found that women, who induced vaginal deliveries similar to emergency caesarean mothers, had lower rates of inducing breastfeeding. From their study women with induced vaginal delivery breastfed for about 25 weeks, while those who had spontaneous vaginal delivery breastfed for 14 weeks longer. Evidently, physiological factors influence exclusive breastfeeding. The results show that physical problems arising from breastfeeding matters to do with perceived insufficient breast milk production, pain and health statuses greatly influence exclusive breastfeeding by the mother.

3.3 Socio-cultural factors

There are larger scales factors or issues within societies and cultures that affect the behaviours, feelings or thought. A mother's intention to breastfeed, according to Bosnjack et al. (2010) is a prediction of her initiation and duration of breastfeeding. However, breastfeeding intention and initiation were initially high postpartum (90%) but dropped by 70% within the first week, as studied by Brown (2014). Women who had initially intended to breastfeed were 26.6 times inclined to practice EBF compared to those who were unsure or had no intention. Intention to breastfeed can be affected not only by a mother's attitude but also her social circle, i.e. husband, family and co-workers (Lumbiganon et al., 2016). Single women lack the support and opinion of a partner that has been shown to increase breastfeeding duration, as father's opinion are often considered by the mother when breastfeeding (Borra, Lacovou and Sevilla, 2015). The cultural practices also hinder a mother's intention to breastfeed that the particular area of study might conform to. Cultural practices that deem the feeding of the baby after birth as taboo have been shown to alter a mother's intention (Liu et al., 2013). In the study by Osman, Zein and Wick (2009), Lebanese women had the perception of "an evil eye" on breastfeeding mothers, which prevents mothers from initiating and exclusively breastfeeding. In rural China, girls are breastfed for short periods to preserve the mother's fertility to enable her to bear male children who are more cherished (Liu et al., 2013). The study, however, had contrary results in other areas sampled as boys were fed on infant formula, which is considered more prestigious than breast milk, therefore leading girls to experience EBF. Though colostrum is nutrient-packed and full of antibodies, many cultures consider it "dirty" and often discard it immediately after childbirth. Complimentary food is, therefore, usually introduced by many mothers until all the colostrum is expressed out (Onah et al., 2014). Confidence levels on the ability to breastfeed drop depending on how soon a mother ceases breastfeeding. The longer a mother was found to breastfeed, the higher her confidence level was thus increasing the duration in which she ultimately breastfeeds (Brown, 2014). Hesitation by the mothers in their capacity to breastfeed was a main factor in both Kinshasa and Nova Scotia as well the mother lack of knowledge on the length of time they would exclusively breastfeed (Young et al., 2019; Brown et al., 2013). Mothers who reported breastfeeding problems during the first week were more likely to cease breastfeeding before the recommended six months (Prior et al., 2012). However, mothers with strong mental capacity are able to overcome the barriers previously faced and improve their self-efficacy when it comes to breastfeeding as researched by Victora et al., (2016). They concluded that breastfeeding education equips mothers with solutions to problems they might experience during breastfeeding and might be an essential factor in improving a mother's confidence. Breastfeeding satisfaction is brought about by the successful cooperation of mother and child when breastfeeding is initiated. This satisfaction can encourage mothers to extend their breastfeeding for up to 24 months (Bich, Long and Hoa, 2019). In the case of Uttar Pradesh, counselling before and after delivery, as well as support by health care providers post-delivery, contributed to longer breastfeeding duration. Young mothers who had prim parous were less confident in breastfeeding due to lack of experience. Lack of support led to them abandoning breastfeeding and instead introducing infant formula as an alternative (Bai, Wu and Tarrant, 2013). Health care providers with insufficient skills are less likely to provide the proper support to mothers to ensure breastfeeding exclusivity. Professional support is recommended during postpartum and prenatal visits to ensure successful initiation of breastfeeding during the first critical weeks. This support can be provided through phone hotlines and live online chats (Chaves et al., 2019). Prenatal support provided through information dissemination is important when preparing pregnant women to practice EBF. Preparing the new mothers on the possible issues they might encounter during breastfeeding and the solutions to lessen the effects ensure the mothers embrace initiation of breastfeeding (Kitano et al., 2016). Peer counsellors help women to overcome the problems experienced during breastfeeding and prepare the mothers for the potential barriers they might face and provide management solutions. Support groups are often tailored to cater to different demographics, thus encouraging women to seek the help they need without fear of standing out (Brown et al., 2013). Women who visited peer counselling groups and clinics were shown by Bosnjack et al. (2014) to have higher rates of breastfeeding than those who did not. Fathers and maternal influences are also vital as a woman's' support system. Maternal influences (mothers, grandmothers and mothers-in-law) played a great role in a mothers' intention to breastfeed. Grandmothers and MMIL with breastfeeding experience shared their knowledge and offered solution and support when the mother experienced problems after delivery (Liu et al., 2013). MMIL who did not breastfeed may discourage a mother to breastfeed and even offer infant formula and complementary food as solutions to breastfeeding barriers (Osman, Zein and Wick, 2009). Studies by Chaves et al., (2019) and McFadden et al., (2007) showed a strong correlation between support and breastfeeding duration and initiation.

SUMMARY

These results contribute to a clear understanding of how certain factors influence the duration that mothers breastfeed. The studies carried out showed suppressed breastfeeding in low-income countries as compared to high-income countries. Mothers exposed to high income were more prone to breastfeeding as compared to those with less income. High income allowed the mothers the comfort of taking more extended time off work. High levels of education meant mothers were more educated on the benefits of exclusive breastfeeding and had better workplace policies that allowed for child care. Lack of information given to the mothers during prenatal visits played a massive role in the cessation of breastfeeding by mothers postpartum. Mothers who had accessed information from health care workers about exclusive breastfeeding and its benefits breastfed much longer than mothers who had no access to this information. There was a significant drop in mothers who had the intention to breastfeed after childbirth. There are not enough studies that show reasons for a change in the mother's intention. Most of the literature reviewed majorly focused on the socioeconomic and demographic factors that led to a decline in exclusive breastfeeding among the mothers. Mothers who reported receiving support from health care providers and the community were shown to have breastfed longer than those who received little to no support. Health problems such as HIV, smoking and use of medication made mothers more reluctant to initiate breastfeeding as well as cease earlier than healthy mother with no smoking past and medication use. Breastfeeding problems such as fussy infants, inverted nipple, poor breast latch and insufficient milk were the main reasons that led mothers to cease breastfeeding within the first month of childbirth. Younger mothers were noted to be less inclined to breastfeed compared to older, more mature women. Multiparous women were more likely to breastfeed in contrast to prim parous mothers. The method of delivery also affected the initiation and duration of EBF. Caesarian births reported lower levels of breastfeeding initiation as compared to normal vaginal delivery. Mothers who had undergone caesarian delivery experienced no skin to skin contact, pain after surgery and a slower rate of milk expression. Location of delivery also influenced a mothers' decision to breastfeed longer. Babies delivered in health facilities were more likely to be exclusively breastfed as compared to those delivered at home. Hospital deliveries ensured the mothers' access to information and support from health care providers while home deliveries exposed the mothers to cultural beliefs that might hinder breastfeeding. Single women and those living without their partners had low rates of practising EBF in contrast to married women or women living with their partners. Lack of a partner indicated a lack of support to the breastfeeding mother causing her to initiate complementary feeding after birth. Strategies found to initiate breastfeeding and prolong its exclusivity were education and support. Proper education given to all parties involved, including mothers, community and health care providers was shown to impact the duration and exclusivity of breastfeeding. Most studies showed a strong correlation between breastfeeding education and the intention and duration of breastfeeding. Support from health care providers family and peers also improved maternal breastfeeding duration and exclusivity.

3.4 Strengths and Limitations of the study

The method selected for this study was a systematic literature review on the modifiable factors that positively influence breastfeeding duration at six months. The core principles of a systematic review include transparency, replicability and rigour. By adhering to these core principles, this study has improved strength and quality. The selected method enabled a more comfortable and more efficient method of study that was convenient and time-effective. On the same note, conducting a systematic review helps reduce researcher bias. The adoption of a search strategy, predefined search strings and a workable inclusion and exclusion criteria forced the researcher into searching for studies beyond their networks and subject areas. In that regard, the likelihood of generating and achieving a more precise and more objective answer to the research question is improved. The quality of a systematic review is improved through greater objectivity, reduction of research bias, greater breadth of the studies included and transparency. However, this method may result in research that is difficult to apply in practice; or entail a variety of challenges in practice.

CONCLUSION

The rates of exclusive breastfeeding in the studies carried out in Uttar Pradesh, Nova Scotia and Kinshasa were lower than the recommended by the World Health Organization. Non-exclusive breastfeed is shown to contribute to about 800,000 cases of child mortality worldwide for children under the age of five (WHO/UNICEF, 2016). Modifiable factors that were found to positively increase breastfeeding duration according to the WHO (2016) recommended guidelines were; mothers objective to breastfeed, mother’s confidence and support system of the mother. Most mothers had high intentions to breastfeed but only managed to continue to the first month. By the fifth month, only a number of women were exclusively breastfeeding with most already practising complementary feeding. The average duration for EFB was three months, regardless of all the factors that influenced the breastfeeding duration. The significant factors that affected breastfeeding in the three papers reviewed were: maternal age, level of education, maternal knowledge and income level, social support from family and cultural practices. Maternal knowledge on the significance of exclusive breastfeeding was a factor in the number of participants who breastfed until the recommended six months. Support from family, peers and health care providers to mothers prenatal and postpartum played a massive role in enabling extended duration of exclusive breastfeeding. Mothers who exclusively breastfed to 6 months reported having support from those around them as well as receiving physical support and information from skilled health workers. The importance of breastfeeding was also highlighted on the mother, baby and society (Noel-Weiss, 2016). The benefits included a low risk of maternal cancer cases, osteoporosis and postpartum bleeding. Babies that were exclusively breastfed were less prone to respiratory complications, obesity and diarrhea. Research conducted by Victora et al., (2016) showed that longer breastfeeding duration positively impacted the physical and mental health of both the mother and child.

Implications for policy

Policymakers are advised to include breastfeeding and breast milk importance in the calculation of a country's GDP (WHO/UNICEF, 2016). Factoring in breastfeeding in the GDP calculation puts the emphasis required on the importance of breast milk to a country's economy. Smith and Folbre (2020) described the failure to account for breast milk in the GDP as having an impact on policies, which reduces the priorities set aside for programs that support breastfeeding. Monitoring and enforcing laws that relate to the International Code of Marketing Breast-milk substitutes which are health strategies that put restrictions on breast milk substitute marketing (Unicef UK Baby Friendly Initiative, 2019). This code is put in place to ensure that mothers are not dissuaded from breastfeeding, and those infant formulas are only introduced when necessary and not as a replacement to breastfeeding. Health facilities should emphasize to mothers and pregnant women on the benefits of exclusive breastfeeding to not only them but the babies. Advice on supplementary feeding should also be encouraged particularly to women unable to breastfeed either due to illnesses to avoid misinformation from non-medical sources. Creating awareness in workplaces and especially to employers on the importance of exclusive breastfeeding in the work environment by encouraging their employees to use their leave days on exclusively breastfeeding encourages women to embrace EBF. Creating child-friendly workplaces such as availability of on-site child care programs, breastfeeding breaks, and safe spaces for women to express milk or breastfeed comfortably will make women more comfortable in exclusive breastfeeding practices. These safe spaces could be an extra room or a rarely used room in the organization set up for breastfeeding mothers to cut on organizational costs.

Implications for practice

The ten steps to successful breastfeeding of the Baby-Friendly Hospital Initiative should be focused on by health systems (Babakazo et al., 2015). Health care systems should ensure that their employees understand the benefit of mother and child staying together 24 hours to improve bonding and breastfeeding initiation. As a health visitor, I am passionate about encouraging practices that promote exclusive breastfeeding practices. Encouraging the mothers to breastfeed on baby's demand, non-provision of complementary feeding and initiating breastfeeding within 30 minutes of child delivery is part of the BFHI that were shown to increase breastfeeding in the research study. Health care systems should also invest in exclusive breastfeeding training and counselling expectant women on the importance of breastfeeding exclusively as well as how service providers might help in the management of problems encountered during breastfeeding such as insufficient milk let down. Healthcare professions should include breastfeeding management in their education systems and provide opportunities for health care providers to improve on their previous skills and information. They should be able to provide a solution to breastfeeding problems experienced by mothers such as painful nipples. Health care providers should be advised on the importance of EBF to both the mother and child and be encouraged to pass on this information to the mother during prenatal visits as well as during follow up visits. Community-based interventions such as mother to mother support as recommended by Lumbiganon et al., (2016) are aimed at targeting a mother's family and close social circle. From their study, data showed that a mothers' social circle had significant influence in her decision to breastfeed. Mothers, mothers in law, fathers and grandmothers should be targeted in community-based education to get their views regarding breastfeeding and advised on the importance of exclusive breastfeeding practices. Community health nurses should also be trained to improve their outreach to the community on breastfeeding practices by Introducing community-based support groups for mothers and pregnant women with trained peer counsellors to lead these support groups.

Implications for research

Further research is required in identifying factors that might change a mother's intention of breastfeeding. Most of the literature reviewed lacked clear reasons as to why a mother changes her intention upon maternity discharge. This research will be necessary for creating intervention measures during prenatal visits and immediately after birth. More studies should be done to find out if breastfeeding interventions taken postpartum will have a significant impact on the mothers’ exclusive breastfeeding duration. A comparison should be made between mothers who receive interventional support after birth and those who do not to be able to understand the effect of information and support on breastfeeding mothers. There is lack of sufficient data to support the economic impact of breastfeeding, therefore putting severe barriers to key policy formulations and implementations. Research should be done to find the cost of health care burden brought about by lack of breastfeeding. The health implications should include both those experienced by the mother and the child.

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