In humanitarian emergencies, either caused by conflict or natural disasters, breastfeeding becomes even more important for infants’ survival (1, 2). As refugees, mothers and children are hosted in overcrowded and poorly equipped living conditions, unsafe water supply, poor sanitation, reduced immunization rates, and overburdened healthcare systems (1, 3). In such conditions, the infant’s health is jeopardized because of the increased risk of diarrheal diseases, pneumonia, food insecurity and malnutrition, and communicable diseases. In instances like these, breastfeeding is documented as having a central role in protecting infants from such complications. The crucial role of breastfeeding in maintaining children’s health in crises is often disregarded, worsened, and challenged by the uncontrolled distribution of breast-milk substitutes, and shortages of healthcare services (1).
Breastfeeding is key in reducing maternal, neonatal, infant, and childhood mortality and morbidity rates (4). Early initiation of breastfeeding, within the first hour after birth, and exclusive breastfeeding (EBF) until an infant is six months old have enormous health benefits for infants, mothers, and their families (5). Exclusive breastfeeding is the practice whereby an infant only receives breast milk without any additional food or drink, not even water. Mothers should breastfeed their child exclusively for the first 6 months and continue breastfeeding up to 2 years (1, 6).
Several studies have shown that breastfed infants are protected against infections, have a lower incidence of childhood and adulthood obesity and an enhanced cognitive and psycho-social development (7). Exclusive breastfeeding promotes all aspects of infants’ mental, physical, social, psychological, and spiritual growth and development (5, 8).
Breastfeeding also includes benefits to breastfeeding mothers. For instance, breastfeeding enhances infant–mother bonding and attachment and decreases postpartum hemorrhage – a primary cause of maternal morbidity and mortality. Additionally, EBF suppresses fertility in amenorrheic women by providing more than 98% protection against pregnancy in the first six months after birth. On the long term, breastfeeding decreases the incidence of breast and ovarian cancers and reduces the effort and cost of the healthcare delivery system (5).
Breastfeeding literature reveals several facilitators and barriers to EBF. Among the facilitating factors are singleton pregnancy, delivery site (giving birth in a maternity hospital), normal delivery, infant’s appropriate weight gain during EBF, female gender, infants’ tranquility(9), initiation of breastfeeding within the first hour of birth, being a housewife, and receiving pre- and post-natal breastfeeding counselling (10, 11). Moreover, low-income mothers, husbands’ and parents’ support (12, 13), and previous successful breastfeeding experiences were also associated with increased duration of EBF (14).
The literature about EBF have also revealed several factors which negatively affect the duration of EBF constituting barriers to EBF. These include post-partum infection and depression in mothers, employment, shorter duration of maternity leave, perceived breastmilk insufficiency, positive history of smoking during pregnancy, medications usage, and higher maternal age (15, 16). Other factors include the use of a pacifier, giving water and or multi-vitamins during the first six months of the infant’s life (9, 17), mother’s lack of knowledge, lactation problems, lack of family and social support, social norms, and public breastfeeding embarrassment (17, 18). Further, it was found that caesarean births and low-birthweight infants (small for gestational age) had a lower EBF (19). Moreover, maternal age < 20 years, no plan to exclusively breastfeed, no decision to breastfeed before pregnancy, and no EBF during the first week post-partum were also found as barriers EBF (20). Displacement and being in a female-headed household were also barriers to EBF among refugee mothers (21).
A consequence of displacement is the loss of the required counseling for breastfeeding mothers. Accordingly, breastfeeding mothers face difficulties on their own, leading to lower rates of initiation and continuation of breastfeeding. A previous study showed that about 90% of Syrian infants under 12 months old residing in Jordan were never breastfed, and certain breastfeeding practices were lower than optimal (22). For instance, appropriate early initiation of breastfeeding (within one hour of birth) was limited to 35%, and only 19% of infants under six months were exclusively breastfed. The study added that 57% of the infants received liquids other than breastmilk in the first three days of life, and 35% of the mothers received the formula from hospitals. In addition, approximately 64% of Syrian mothers were counseled on breastfeeding, and only 57% of the newborns were breastfed (23).
Forced migration of Syrians to Jordan began as the war broke out in Syria in 2011(24). The numbers of refugees have escalated over the last six years, constituting a challenge for the Jordanian government in all aspects of services, namely economic, environmental, educational, social, and healthcare (25). Refugees are concentrated in the north of Jordan, mostly residing in urban areas (83%), while the rest of them (17%) live in three refugee camps: Zaatari, Azraq, and Emirati Jordanian Camp. Approximately 48% of the refugees are children (26), and women of reproductive age constitute 75% of all Syrian refugees (27).
Having introduced the benefits of EBF, facilitators and barriers in normal day to day circumstances and in crises situations, and the background of the Syrian refugees migrating to Jordan, it becomes eminent to assess rates of EBF and identify the facilitators and barriers to EBF among Syrian refugee mothers residing in the host communities in Jordan. There is a gap of knowledge in how refugees outside the camps manage to continue their breastfeeding practices using the new community healthcare services. The results of this study will help nurses and midwives working with refugees to develop health strategies for promoting positive breastfeeding practices and health outcomes for refugee mothers and their children.