Rates, Facilitators, and Barriers to Exclusive Breastfeeding among Syrian Refugee Mothers: A Cross-sectional Survey

doi:10.21203/rs.3.rs-1670497/v1

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Rates, Facilitators, and Barriers to Exclusive Breastfeeding among Syrian Refugee Mothers: A Cross-sectional Survey

https://doi.org/10.21203/rs.3.rs-1670497/v1

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Background: Exclusive breastfeeding becomes more crucial for infants’ survival during humanitarian crises. The purpose of this study was to assess breastfeeding rates and identify the facilitators of and barriers to exclusive breastfeeding (EBF) among Syrian refugee mothers residing in host communities in Jordan.

Methods: A descriptive cross-sectional survey using a proportional quota sampling technique was employed. The sample consisted of 523 Syrian refugee mothers with an infant less than or equal to six months old. A developed questionnaire was used to collect door-to-door data over a period of six months. Descriptive and inferential statistics were used.

Results: This study demonstrated low rates of (EBF) (35.8 %), low early initiation rate (37%), and high pre-lacteal feeding rate (64.3%) among Syrian refugee mothers. The facilitators of adherence to (EBF) included mothers’ satisfaction with breastfeeding, past breastfeeding experience, and giving birth to a female infant. The main barriers to breastfeeding included perceptions of insufficient milk supply, perceptions of the infant staying hungry after breastfeeding, and mothers’ and infants’ health problems.

Conclusions: The findings revealed factors that are modifiable with appropriate counseling efforts. Considering the facilitators and barriers of EBF, nurses and midwives must encourage refugee mothers to initiate and continue EBF to promote both mothers’ and infants’ well-being.

Barriers to breastfeeding

Exclusive breastfeeding

Infants

Initiation of breastfeeding

Jordan

Pre-lacteal feed

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.

Aim

The aim of this study was to assess breastfeeding rates and identify the facilitators of and barriers to exclusive breastfeeding among Syrian refugee mothers residing in host communities in Jordan.

Design

Descriptive cross-sectional survey

Sample and Sampling

Syrian refugee mothers meeting the following inclusion criteria and living in host communities in Jordan were selected: (1) aged 16–49 years with an infant less than or equal to six months old; (2) beneficiaries of reproductive services in the community; and (3) a minimum of six months of residence in Jordan. A proportional quota sampling technique was used based on the density of Syrian refugee mothers in North and Central Jordan. According to the Cohen power primer (1992), the required sample size had to be at least 393 mothers based on a 0.05 two-tailed level of significance, an effect size = 0.20 (small), and a power = 0.80 using mean difference t-test (28). In this study, 523 participants were selected to represent Syrian refugee mothers living in Jordanian host communities. Approximately 65% (n = 340) of them were living in Jordanian urban areas.

Mothers were recruited from four major cities with the largest proportion of Syrian refugees in the country. These included Amman, (center, 34.42%), Irbid (north, 27.14%), Mafrak (north, 16.43%), and Zarka, (center, 13.85%). Southern Jordan was excluded as there is a small proportion of refugees there (2.79%) (25).

Data collection: Instruments and procedures

A door-to-door survey using a face-to-face structured interview was conducted by 27 trained research assistants to collect the data. Eligible mothers (523) were approached by the research assistants to complete the questionnaires. After obtaining the mother’s consent for participation in the study, an interview was conducted at her home. Illiterate mothers were assisted by research assistants who read each question out loud and completed the form with the answers given.

The questionnaire was developed by the researchers based on breastfeeding literature that examined factors affecting EBF within six months of birth (9, 17). The state of mothers’ exclusive breastfeeding was determined initially and based on a direct question about whether her baby is receiving breast milk without mixing it with water, other liquids, tea, herbal preparations or food within the first six months of life, with the exception of vitamins, mineral supplements or medicines (29). The study tool comprised two parts. The first part included questions related to maternal age, parity, and education; family monthly income and employment status; infant’s birthweight and gender; gestational age at birth, and infant’s health status, history of breastfeeding of the previous child, and mode of birth (normal versus caesarean birth). The second part consisted 14 statements that summed up the reported barriers of EBF in previous studies. This section also included questions regarding the source of information about breastfeeding and mothers’ level of satisfaction with breastfeeding in consideration of their refugee status and living in a host community.

Two clinicians with wide expertise in breastfeeding practices confirmed the suitability and clarity of the questions. The experts’ suggestions of adding more barriers that are commonly observed in their practice were considered. Moreover, few adjustments in wording were made to simplify the language and ensure that it is understood by participants of all educational levels. The questionnaire was written in English and then translated into Arabic to be used in data collection. Next, it was translated back into English by a bilingual translator to determine that the meaning was preserved.

Analysis methods

Descriptive and inferential statistics of correlation and differences were used. Appropriate statistical tests were used based on the level of measurement of the variables and sample size in the groups (t-test, Mann–Whitney, and Chi-Square) to compare between mothers who exclusively breastfed their infant with those who did not breastfeed their infants (Table 4). Statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 23.0 for Windows (SPSS Inc. Chicago, IL, USA). Statistical significance was set at p < 0.05.

Characteristics of Syrian refugee mothers

The study was based on a sample of 523 refugee mothers. Their age ranged between 16 and 44 years (M ± SD = 26.11 ± 6.11). The characteristics of the Syrian refugee mothers and their infants are presented in Table 1. The majority of the mothers’ education level was (lower than high school (83.0%), and they were unemployed (97.5%). More than two-thirds of them had given birth normally (68.7%) to a term infant (37–42 weeks) (67%). The majority of the infants had normal birth weight (80.9%), and all of them had been born in hospitals. Most mothers were multiparas (79.3%), with the number of children in their family ranging between 1 and 11 (M ± SD = 3.21 ± 1.84). The majority of multiparous mothers had breastfed their previous children (87.1%) from 1 to 36 months (M ± SD = 12.1 ± 7.4). About 18.7% of the infants had been born with a health problem. The family monthly income in Jordanian dinar (JOD) ranged from 30 to 940 JOD (M ± SD = 223.44 ± 105.45) (1 JOD = 1.41 U.S. dollars). Based on the Department of Statistics Household Expenditure and Income Survey (2010), the current absolute poverty line in Jordan at the household level is 4,395.6 JOD (USD 6,189) per household per year (or JOD 366.3 (USD 516) per household per month) (30).

Table 1

Characteristics of the mothers and their infants (*N = 523*)
Characteristics	N (%)
Mother Age < 18 18–35 > 35	27 (5.2) 459 (87.8) 37 (7.0)
Mothers’ Education Less than high school High school College/diploma Bachelor’s degree	434 (83.0) 63 (12.0) 10 (1.9) 16 (3.1)
Spouse Nationality Syrian Jordanian	513 (98.1) 10 (1.9)
Spouse Work Yes No	461 (88.1) 62 (11.9)
Medical Insurance Yes No	165 (31.5) 358 (68.5)
Current Infant’s Weight at Birth Less than 2500 grams 500–4000 grams More than 4000grams	87 (16.6) 423 (80.9) 13 (2.5)
Infant’s Gender Male Female	255 (48.8) 268 (51.2)

Breastfeeding rates, barriers, and facilitators

Infants’ age at the time of the interviews ranged from less than one month to six months (M ± SD = 3.28 ± 1.789). Although most mothers (82.6%) at the time of the interview breastfed their infants, only 35.8% of them were breastfeeding their infants exclusively. While the proportion of mothers who exclusively breastfed their infants from birth to three months was 20.3%, this number dropped to 15.5% among mothers of infants between four to six months of age. About 37% of the mothers-initiated breastfeeding immediately after birth (in less than 1 hour). The mothers who breastfed their infants intended to continue breastfeeding until the infant’s mean age was 16.8 ± 7.0 months.

Ninety-one (17.4%) mothers discontinued breastfeeding when their infants were at a mean age of 1.58 ± 1.01 months. Nearly two-thirds of the mothers (64.3%) gave pre-lacteal feeds (PLFs) to their infants besides breastfeeding within the first three days after birth. The most frequent fluids given besides breastfeeding were water (99.7%), glucose water (64.5%), milk formula (52.7%), and herbal tea (29.3%). The majority of the mothers (74.6%) did not receive free milk formula.

The most commonly reported barriers to breastfeeding were, ‘do not have enough breast milk’ (n = 55, 60.4%), ‘my infant stays hungry after breastfeeding’ (n = 17, 18.7%), and ‘I have health problems that prevent me from breastfeeding’ (n = 11, 12.1%). Barriers are ranked in descending order of their importance in Table 2. Other factors, as reported in Table 2, had little or no effect on breastfeeding.

Table 2

Barriers to breastfeeding (*n = 91*)
Rank	Barriers	N	Percentage*
1.	I don’t have enough breast milk	55	60.4
2.	My infant stays hungry after breastfeeding	17	18.7
3.	I have health problems that prevent me from breastfeeding	11	12.1
4.	My infant has health problems that prevent him/her from breastfeeding	9	9.9
5.	Problems related to breastfeeding e.g., inverted nipple, nipple sore	5	5.5
6.	My infant is always in a bad mood and cries all the time	5	5.5
7.	I am currently pregnant or planning a new pregnancy	5	5.5
8.	Self-weaning (infant stops breastfeeding on his or her own)	5	5.5
9.	Prematurity and neonatal intensive care unit admission	2	2.2
10.	I felt that my infant was ready to stop breastfeeding	1	1.1
11.	I got free formula	0	0
12.	I feel more comfortable while breastfeeding my infant formula	0	0
13.	I don’t have enough time to breastfeed	0	0
14.	I have to go back to work/studies	0	0
*Note: 91 mothers gave 115 barriers (some mothers reported more than one answer)

Less than half of the Syrian refugee mothers (45.8%) had received counseling about breastfeeding from a health care provider. Table 3 shows the sources of information for these mothers on the importance of breastfeeding and its benefits, ranked in descending order. Mothers reported nurses/midwives (n = 89, 37.1%) as the most frequent source of information followed by physicians (n = 83, 34.6%). Private non-governmental foundations (Nour Al-Hussein) and international organization workers have a moderate contribution in providing information to mothers on breastfeeding. Social workers, health students, and friends had minimal contributions.

Table 3

Source of information regarding breastfeeding (*n = 240*)
Source of information	N	Percentage (%)*
Nurses/Midwives	89	37.1
Physicians	83	34.6
Nour Al-Hussein Foundation	46	19.2
International organization workers	40	16.7
Social service workers	8	3.3
Health science students	6	2.5
Family and friends	6	2.5
*Note: mothers could report more than one source

Most importantly, we found that mothers who exclusively breastfed their infants were highly satisfied with the method of feeding (Mann–Whitney = 22577.0, p < .001). We also found that mothers had more exclusively breastfed their female rather than male infants (Chi-Square = 4.94, p = .03). Further, the results showed that mothers who did not exclusively breastfeed their current infants also did not do so with their previous ones (Chi-Square = 16.77, p < .001). The variables (mothers’ age, level of education, and infants’ health problems) did not show significant differences between mothers who exclusively breastfed their infants versus those who did not. Table 4

Table 4

Comparisons on breast-feeding method and mothers’ and infants’ factors (*N = 523*)
Variables	Breastfeeding		Statistics test	P value
Variables	Non-exclusive (n = 336)	Exclusive (n = 187)	Statistics test	P value
Maternal age	M = 26.15 SD = 6.32	M = 26.04 SD = 5.72	t=.-.20	.85
Mother education	Mean rank = 257.34	Mean rank = 270.37	Mann-Whitney = 29850.500	.24
Satisfaction with breastfeeding	Mean rank = 235.69	Mean rank = 309.27	Mann-Whitney 22577.0	< .001
Not satisfied at all	37 (11.0%)	4 (2.1%)
Not satisfied (somewhat)	40 (11.9%)	11 (5.9%)
Neither nor	14 (4.2%)	3 (1.6%)
Somewhat satisfied	99 (29.5%)	42 (22.5%)
Highly satisfied	146 (43.5%)	127 (67.9%)
Baby gender Male Female	176 (52.4%) 160 (47.6%)	79 (42.2%) 108 (57.8%)	Chi-Square = 4.94	.03
Health problems with the infant Yes No	67 (19.9%) 269 (80.1%)	27 (14.4%) 160 (85.6%)	Chi-Square = 2.467	.12
Breastfeeding previous child (n = 416) † Yes No	210 (81.7%) 47 (18.3%)	152 (95.6%) 7 (4.4%)	Chi-Square = 16.77	< .001
Breastfeeding counseling Yes No	160(47.6) 176(52.4)	79 (42.2) 108 (57.8)	Chi-Square = 1.398	0.24
† The number (416) is for mothers with a previous child. This was the first baby for the rest of the participants.

This study aimed at assessing the rates of initiation and exclusive breastfeeding and identifying facilitators and barriers to EBF among Syrian refugee mothers living in host communities in Jordan. Although most infants in this study had been breastfed, the overall breastfeeding rates remained suboptimal. We found that over one-third of the infants were exclusively breastfeeding at the time of the interview and slightly more than one-third of the mothers had initiated breastfeeding within the first hour of birth. Nearly two-thirds of the infants received PLF in the first three days of life. These findings are consistent with a previous study conducted by the United Nations Children’s Fund (UNICEF) in 2016 in Jordan, which found that, although a large proportion of under 12-month-old infants living in host communities were breastfed, certain breastfeeding practices remained inadequate (31). The current study showed similar rates of EBF (15.5% versus 19% in the UNICEF study); the rates were 37% in our study versus 35% in the UNICEF study for mothers initiating breastfeeding in the first hour, and 64.3% of infants in our study versus 59.9% in the UNICEF study received PLF within the first three days of birth. While our study showed a slightly higher percentage of EBF and early initiation of breastfeeding as well as a slightly higher percentage of PLF than the UNICEF study, this result is not considered significant.

In this study, the percentages of EBF and early initiation of breastfeeding among Syrian refugee mothers were lower than the percentages reported by the Syrian Family Health Survey (SFHS) (2009), a survey conducted in Syria before the crisis. According to SFHS (2009), the percentage of EBF was 42.6%, whereas the percentage of newborns introduced to breastfeeding within the first hour of life was 42.2% (32, 33). Further, another study supports our findings, wherein the researcher compares the breastfeeding behavior of Syrian refugee mothers with that of Turkish mothers. The result showed that 61.4% of Syrian refugee mothers initiated breastfeeding within one hour after birth, compared to 71.1% of Turkish mothers, whereas the rate of EBF was 28.1% for Syrian refugee mothers and 34.1% for Turkish mothers (34). On the other hand, a study aimed at identifying breastfeeding characteristics of Syrian refugees in Turkey showed a higher percentage than our study, in which 73% of Syrian infants were breastfed within one hour after birth and only half of them (51.6%) aged 5 months and less were exclusively breastfed (35). This apparent variation of breastfeeding duration as related to before and after migration proportions, and variation of breastfeeding duration as related to the countries where they migrated to, and healthcare services provided, is worth understanding further. By investigating these variations, we may develop an insight into the most influential factors – whether they are inherent demographic, cultural, or environmental –in changing or maintaining the patterns of breastfeeding. This understanding may assist nurses and midwives to develop effective interventions that address the issues of concern for the promotion of exclusive breastfeeding among refugee populations.

Regarding breastfeeding practices and related factors for the surveyed mothers, we found a significant relationship between EBF and the infant’s gender, mother’s previous experience of breastfeeding, and satisfaction with breastfeeding. Our result is in congruence with the findings from another study which showed that mothers have exclusively breastfed their female infants more than male ones (9). This result is perplexing, and an explanation is warranted within the cultural context of this finding. One potential explanation may be situated within the gendered meaning of giving preference to the male child. In this context, mothers are exposed to social and family pressure to give additional care to their male child, and this includes formula feeding for rapid weight gain. The misconception that gaining weight or obesity is a sign of ‘being healthy’ compels mothers to feed formula to their infants as soon as they face breastfeeding challenges; thus, for the infant to ‘look healthy or fat’ becomes a priority.

Further, this study showed that the mothers who did not exclusively breastfeed their current infant also did not breastfeed their previous children. This result is consistent with other studies (9, 14) that found that previous breastfeeding experience is the dominant factor in EBF. Additionally, Syrian refugee mothers who exclusively breastfed their infants were highly satisfied with the method of feeding, and this is supported by the previous literature (36). Maternal satisfaction with breastfeeding increases their confidence and has a direct effect on breastfeeding duration (37).

In examining mothers’ perception of barriers to breastfeeding, the findings of this study revealed that mothers’ perception of insufficient breast milk was the most common barrier to breastfeeding. This was followed by mothers’ perception that their infant stayed hungry after breastfeeding along with maternal and infant health problems. Mothers’ perception that they did not produce enough breast milk, and hence their infants stayed hungry, was also reported by Jordanian mothers (38, 39) and by mothers in the Arab (2, 19, 40) and Western countries (41). This perception appears to be the primary concern for mothers, leading to the discontinuation of EBF.

Mothers’ perception of insufficient breastmilk production may play a role in starting PLF. Feeds such as plain water, glucose water, formula, and herbal tea within the first three days after birth were, perhaps, the mothers’ alternatives to satisfy their infants’ hunger, calm them, and stop their crying. This practice is contradictory to the American Academy of Pediatrics (AAP) and the WHO recommendations of introducing nutritional supplements only at the second half of infancy for promoting infants’ health and wellbeing (5). Introducing PLF, a common practice in many cultures including the Arab region, may be related to many causes, including, but not limited to, a lack of or delay in milk secretion, living with extended family (42–44), breastfeeding difficulties (engorgement, flat nipple, soreness, and inflammation) (45, 46), lack of breastfeeding counseling (42), as a relief to the infant’s abdominal pain and “colic(44) and to prevent dehydration, hypoglycemia, and neonatal jaundice (47).

The above results concerning misconceptions and barriers to breastfeeding highlight the importance of breastfeeding counseling. The results of this study show that less than half of the Syrian refugee mothers received counseling about breastfeeding. Nurses and midwives were the major sources of breastfeeding counseling, followed by physicians. This result should be considered seriously because, in times of crisis, refugees lose their social support and their familiar health care system, and, hence, nurses, midwives, and physicians remain the only source of information for the mothers. Pre-natal and post-natal breastfeeding counseling benefits are well supported in the previous literature for improving mothers’ breastfeeding initiation and continuation practices (10, 11).

A survey, self-report design has its weaknesses concerning validity and accuracy of respondents reports. We believe this could be more threatening in case of vulnerable people like refugees. Further, non-random sampling limits causal inferences and generalizability of the findings of this study.

This study revealed that Syrian mothers’ breastfeeding rates were lower than those recommended by the World Health Organization and UNICEF standards. It also showed that Syrian mothers held some commonly prevalent misconceptions that enhanced EBF cessation. Importantly, results showed that Syrian refugee mothers received less than optimum counseling from health care professionals to support them in host communities. There is an increased obligation on nurses and midwives working with refugees to consider the critical situation of refugees, understand their cultural background when assessing needs, and structure and implement programs that address these needs.

Strategic planning by the host country’s policymakers and the healthcare system (physicians, nurses, and midwives) is crucial in encouraging prenatal and postnatal educational programs that emphasize the importance of breastfeeding among mothers, especially in times of crises. Future research, both quantitative and qualitative, is recommended to explore breastfeeding barriers and facilitators among refugees to increase our understanding of the relationship between displacement and breastfeeding. This would thus promote mothers’ and infants’ health while still valuing the traditional breastfeeding and post-partum practices.

EBF: Exclusive breastfeeding; DOS: Department of Statistics; PLF: Pre-lacteal feed; UNICEF: United Nations Children’s Fund; WHO: World Health Organization.

Authors’ contributions

RS, DA and SH: coordinated data collection; MA, DA and MS: data management and analysis; RS & DA and SH: Wrote the first draft (the background, results, methods and discussion sections). RS: Corresponding author. All authors read and approved the final manuscript.

Funding

This Study was funded by Columbia University, School of Nursing

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for conducting this study was obtained from the Research Ethics Committee at the School of Nursing The University of Jordan (PF 17.2), and the Department of Statistics (DOS), which is responsible for national surveys in Jordan, for approved recruiting mothers from host communities. Assent was obtained from mothers below the age of 18 besides obtaining a guardian’s consent for inclusion in the study. Each participant was informed that she had the right to participate, decline, or withdraw from the study at any time without reprimand. Participants were informed that they will not be compensated for their participation, however, their input may assist in promoting health services for breastfeeding refugee mothers. They were reassured that the gathered information will be confidential and no one other than the researchers will have access to this data. Further, the research assistants explained the purpose and procedures of the study and informed the participants they will have access to the study results when completed. Each participant signed a consent form, (or gave a verbal consent for illiterate mothers), and a copy of this form, including the research team’s contact number, was provided to them for future reference.

Competing interests

The authors declare that they have no competing interests

Acknowledgements

The authors would like to thank all the mothers who participated in this study and acknowledge the contribution of Columbia University for funding this research study and The University of Jordan for supporting and facilitating this research study.

Consent for publication

Not applicable

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No competing interests reported.

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Rates, Facilitators, and Barriers to Exclusive Breastfeeding among Syrian Refugee Mothers: A Cross-sectional Survey

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Abstract

Background

Methods

Aim

Design

Sample and Sampling

Data collection: Instruments and procedures

Analysis methods

Results

Characteristics of Syrian refugee mothers

Breastfeeding rates, barriers, and facilitators

Discussion

Limitations

Conclusions

Abbreviations

Declarations

References

Competing Interests

Status:

Version 1