A Comprehensive Literature Review

Author:

Nathalie Likhite

Dedenyo Adossi

Lesley Oot

Publication Date

Affiliation:

Alive & Thrive (Likhite, Oot); former consultant, UNICEF (Likhite); consultant, Alive & Thrive (Adossi)

"To improve exclusive breastfeeding rates, a deeper understanding of why competing feeding behaviours are occurring and who is influencing them is necessary."

In most parts of West and Central Africa, breastfeeding is the norm. However, exclusive breastfeeding (EBF) is far less prevalent, with only 31% of infants in the region exclusively breastfed in 2019. Improving breastfeeding practices requires social and behavioural changes at multiple levels, as nutrition behaviours are complex. This literature review shares research findings on the social and behavioural determinants of infant feeding practices in West and Central Africa. Produced under the leadership of the United Nations Children's Fund (UNICEF) West and Central Africa Regional Office and Alive & Thrive, the review's findings will guide the development of social and behavioural change activities, messaging, and other tools supporting Alive & Thrive's existing Stronger with Breastmilk Only regional initiative (see Related Summaries, below).

The literature review included quantitative, qualitative, and mixed-method studies on feeding practices of infants in West and Central Africa published from 1988 to August 2018 that focus on the social and behavioural determinants of: (i) EBF of infants aged zero to six months; and/or (ii) the provision of water and other liquids or foods to infants in the same age group. The literature search resulted in 225 research references, representing 19 of the 24 countries supported by the UNICEF West and Central Africa regional office. The majority of studies were from Nigeria (n=108) and Ghana (n=45).

The conceptual model used in the review focuses on three levels of determinants: structural, settings, and individual.

At the structural level, which includes factors like the media, national policies, and social trends that help shape the enabling environment for breastfeeding, two key factors emerged:

  • Work: Maternal work, both informal and formal, was a key obstacle to EBF. Women need help with duties within the home to find the time and space to breastfeed. Mothers also need supportive policies such as paid parental leave and lactation support within workplaces (including clean and private places to express and store breastmilk). These benefits help mothers maintain a connection with their infants and maintain EBF when they return to work.
  • "Water is life": Beliefs and norms driven by the hot and dry climate of West and Central Africa are the main drivers of the ubiquitous practice of giving water to infants (to quench their thirst). The social expectations related to this practice and fears of life-threatening repercussions should water not be given suggests that this is a social norm in numerous West and Central African communities, particularly in countries in or bordering the Sahel.

At the setting level, which includes key influentials such as the health system, family and community members, and the mother's workplace and/or employment, key findings include:

  • Social norms surrounding breastfeeding: The gap between high levels of awareness of EBF recommendations and low levels of adoption and maintenance of the recommended behaviour can be explained by parents' and family members' perceived benefits of giving water and the strong social norms around giving water due, for example, to the belief that providing herbal remedies and other concoctions welcomes the infant and protects the infant's health and wellbeing. Results from this review indicate that the practice of giving water was supported by traditional justifications and social expectations expressed by respected elders and many adults in the family and communities.
  • Women's limited autonomy: Many women live in family systems in which they have limited autonomy regarding infant feeding and care. Younger and first-time mothers were particularly vulnerable to family and other influences.
  • The role of grandmothers: These elders are the closest and most influential people regarding infant care and feeding, including breastfeeding, in most families. Whether in favour or not of EBF, grandmothers' decisions and recommendations are rooted in their beliefs and experiences and motivated by the desire to maximise infant survival, health, and development, and to minimise risks.
  • Gender-related dynamics: Many women feel they have limited say over some decisions related to or influencing infant feeding and care, since the ultimate decision authority lies with their husbands.
  • Healthcare facilities and workers: Health workers are well respected by mothers and strong influencers of infant feeding, but contradictory social norms and belief systems challenged their role in helping mothers to breastfeed as recommended. Access to maternal health care, exposure to breastfeeding counselling, and early initiation of breastfeeding positively influence EBF. At the same time, there are gaps in knowledge, skills, and practices among healthcare workers that affect breastfeeding counselling and support. Some health workers face deep-rooted traditional beliefs and social norms that counter EBF recommendations.

Key determinants at the individual level, including maternal socio-economic attributes, perceptions, beliefs, and mother-infant interactions, include:

  • Sociodemographic attributes: Higher levels of maternal and paternal education, maternal literacy, and being married are statistically associated with improved EBF practices.
  • Maternal knowledge and perceived benefits about breastfeeding: Mothers' perceived benefits of breastfeeding were positively associated with EBF. However, in some countries, women who think they are exclusively breastfeeding were not actually doing so due to a low maternal understanding of what "exclusive" breastfeeding means and its duration.
  • Maternal intention to breastfeed: A woman's intent to breastfeed is generally associated with EBF.
  • Individual and social expectations: In general, there are personal and social expectations to breastfeed; families and communities often shape feeding choices, as explained above.
  • Misconceptions around the quality and quantity of breastmilk: These misconceptions include beliefs around colostrum and spoiled breastmilk and doubts that mothers have the sufficient quantity and/or quality of breastmilk to satisfy the needs of their infants, motivating them to give water or other liquids/foods.
  • Maternal- and caregiver-infant interactions: Mothers and family members take cues from infants to provide water or other liquids/foods, such as the infant crying after being breastfed, the infant wanting to suckle frequently, and/or the infant suffering from colic.
  • Costs of EBF: Many women find breastfeeding inconvenient, stressful, and time-consuming; some mothers reported being afraid that breastfeeding would negatively impact their bodies and body image.

The review underlines the importance of identifying and understanding the motivations of the people who influence infant feeding and care practices and the factors that both facilitate and prevent EBF when designing interventions. "Implementation of social and behavioural change interventions grounded in this understanding are needed to tailor responses that are respectful, genuine, and acceptable to the families and communities for whom they are designed." Recommendations include:

  • Counsel and support mothers while involving grandmothers, fathers, and other family members in interpersonal communication to strengthen understanding of and support for EBF within family systems.
  • Help family members find and implement solutions to overcome emotional and practical barriers to EBF.
  • Work with traditional healers, traditional birth attendants, and religious leaders to adapt existing practices and recommendations that impede early initiation and maintenance of EBF; they can model positive practices while acknowledging longstanding traditions and deep-rooted cultural beliefs and values in their communities.
  • Consult and involve communities in devising effective ways to raise awareness and build commitment to EBF - e.g., by showcasing the experiences of mothers and families who have adopted this change, fostering community dialogue around positive practices for early childhood feeding, and advocating for improvements in communication with healthcare workers.
  • Strengthen health workers' knowledge, skills, and motivation to counsel and support initiation and maintenance of EBF - acknowledging the challenges they face and engaging them in identifying ways to overcome them.
  • Design evidence-informed communication campaigns that resonate with and inspire families and implement them through multiple channels to shift social norms and promote family practices in favour of EBF - e.g., through mass media and mobilisation of journalists; engagement of champions, role models, and other credible spokespeople (formal and informal) to share positive experiences and outcomes of EBF and to address misconceptions; and use of social media to influence social perceptions and expectations, particularly among young people and young families with infants.
  • Invest in pro-breastfeeding programmes and policies to provide appropriate and long-lasting structure for the protection, promotion, and support for EBF.

Source:

The MIYCN Update from Alive & Thrive, February 21 2022. Image credit: ©UNICEF/UN0161673/KEÏTA