Prevalence of Exclusive Breastfeeding Practice in Ethiopia and Its Association with Maternal Employment: A Systematic Review and Meta-analysis, 2019

Background: Exclusive breastfeeding dened as the practice of providing only breast-milk for an infant for the rst 6 months of life without the addition of any other food or water, which recommends initiation of breastfeeding within one hour of life and continued breastfeeding for up to 2 years of age or more. Maternal employment is the most important factor contributing to the low practice of exclusive breastfeeding. However; the effect of maternal employment on exclusive breastfeeding is not investigated in Ethiopia. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was used in this systematic review and meta-analysis. The databases used were; PubMed, Google Scholar, Science Direct, and Cochrane library were systematically searched. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal of studies. Results: 36 studies were included in the nal analysis after reviewing 541 studies in this meta-analysis yielding the pooled prevalence of EBF 59.79% (95% [CI] 54.58, 65.00) in Ethiopia. Those employed mothers were 57% less likely to practice exclusive breastfeeding in comparison to unemployed mothers in Ethiopia [OR] 0.43; 95% CI (0.3, 0.62). Conclusions: The overall prevalence of exclusive breastfeeding in this meta-analysis is low in comparison to the global recommendation of the practice of exclusive breastfeeding. Maternal employment was signicantly associated with the practice of exclusive breastfeeding in comparison to their counterparts. Based On our review ndings, we recommended that the Ethiopian government should increase legislated paid maternity leave after delivery beyond current paid maternity leave and implement policies that empower women and create a conducive environment for mothers to practice exclusive breastfeeding at workplace.

to the global recommendation of the practice of exclusive breastfeeding. Maternal employment was signi cantly associated with the practice of exclusive breastfeeding in comparison to their counterparts. Based On our review ndings, we recommended that the Ethiopian government should increase legislated paid maternity leave after delivery beyond current paid maternity leave and implement policies that empower women and create a conducive environment for mothers to practice exclusive breastfeeding at workplace.

Background
Breast milk is the natural food for newborns and reduces infant mortality and morbidity. Breast milk also helps the newborn to attain normal growth and development. Not only for neonatal health but also breastfeeding has health bene ts for mothers and it plays a great role in improving public health [1][2][3].
To help newborn get appropriate growth and development, in 2001(WHO) set up the recommendation that declares that mothers from both low income and high-income countries should exclusively breastfeed their infants for the rst 6 months of life, and then make sure that the infants receive adequate and nutritious semi-solid foods in addition to breastfeeding until the infant reaches 2 years of age or more [4,5].
Exclusive breastfeeding (EBF) de ned as the practice of providing only breast-milk for an infant for the rst 6 months of life without the addition of any other food or water, which recommends initiation of breastfeeding within one hour of life and continued breastfeeding for up to 2 years of age or more accordingly. Exclusive breastfeeding (EBF) is the foundation of child survival and child health.it helps as a child's rst immunization which used for protection from respiratory infections, diarrheal disease, and other potentially life-endangering problems. Besides these Exclusive breastfeeding protects maternal obesity and certain non-communicable diseases later in her life [6,7].
One of the targets of sustainable development goal (SDG) that was set in 2015 was to reduce the global maternal mortality ratio to less than 70 per 100,000 live births and to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under 5 mortality to at least as low as 25 per 1,000 live births by 2030 [8].
But still, we are far behind to make exclusive breastfeeding during the rst 6 months of life the norm for infant feeding. Currently, the worldwide prevalence of EBF for infants aged 0-6 months is only 38%.
Different researchers indicate that 11.6% of mortality in children under 5 years of age was contributed by non-exclusive breastfeeding which was equivalent to about 804 000 child deaths in 2011 [9,10].
In 2012, the World Health Assembly endorsed a Comprehensive implementation plan on the maternal, infant, and young child nutrition with speci ed six global nutrition targets for 2025 and from this, the fth target states that, to increase the rate of exclusive breastfeeding in the rst 6 months up to 50%. In 2018, only 31 of 194 countries were on the line to meet the global target of exclusive breastfeeding, which aims to increase the prevalence of exclusive breastfeeding to 50% for the infants under 6 months by 2025 [11,12].
According to 2015 UNICEF, Breastfeeding Advocacy Initiative For the best start in life report, the rate of EBF is low with the aimed goal of 2015.accordingly the rate of EBF is (25,30,47,32,51,46,38)% in western and central Africa, East Asia and Paci c, South Asia, Central America and the Caribbean, eastern and southern Asia, least developed countries and worldwide respectively [13].
During the years between 1985 and 1995, global rates of exclusive breastfeeding raised by 2.4%. Twentyve countries raised their rates of exclusive breastfeeding by 20% or more after 1995 [14,15].
In addition to the above Cambodia and Malawi showed an increment of exclusive breastfeeding (EBF) from (11 to 74) % and (3 to 71) % respectively for infants less than 6months between (1992-2010) [16].
Another study conducted in 13 western African countries and sub-Saharan countries showed the prevalence of exclusive breastfeeding for infants under 6 months of age ranges from 13.0% in Côte d'Ivoire to 58.0% in Togo and 45.2% in sub-Saharan countries respectively [17,18].
According to the result of the 2016 Ethiopian demographic health survey (EDHS), the prevalence of exclusive breastfeeding for infants under 6 months was 58% [19].
Worldwide around 600,000 children and 100,000 women die each year because of complications that could easily be prevented with breastfeeding. Besides this Millions of dollars have been lost to treat children with different health problems such as diarrhea and pneumonia that can easily be prevented with only exclusive breastfeeding [20].
Globally 595 379 childhood deaths among (6 to 59) months of age from diarrhea and pneumonia each year were associated with the problem of not breastfeeding according to global recommendations of WHO and UNICEF for breastfeeding [21].
According to a study conducted In Latin America and the Caribbean countries, exclusive breastfeeding for the rst 3 months of life can prevent 55% of infant deaths related to diarrheal disease and acute respiratory infection [22].
A study conducted in Bangladesh showed that Infants who were partially breastfed or not breastfed had a risk of diarrheal death 3.94 times greater than those exclusively breastfed infants [23]. Globally, more than 1.45 million lives were lost due to suboptimal breastfeeding in developing countries [24].
A study conducted in Ghana showed that the risk of neonatal death was fourfold higher in children given milk-based uids or solids in addition to breast milk in comparison to those fed breast milk exclusively according to WHO recommendation [25].
According to the Federal Democratic Republic of Ethiopia, the Ministry of Health report, In Ethiopia up to 70,000 infant deaths were associated with problems of nonexclusive breastfeeding [26].
Inadequate rates of exclusive breastfeeding result from different factors. These factors include Inadequate maternity and paternity leave legislation that enforces the mothers returning early to work and other workplace policies that don't support a woman's ability to breastfeed when she returns to work plays a great role.
In addition to the above factors, caregiver and societal belief which favor nonexclusive breastfeeding before 6 months of age also affect adequacy and quality of exclusive breastfeeding.
To attain progress on the global exclusive breastfeeding target by 2025 women should be empowered to practice exclusively breastfeed, by providing 6 months of mandatory paid maternity leave [27].
Breastfeeding and work shouldn't be a dilemma for employed women. They should not have to decide between breastfeeding and working. The International Labour Organization states that countries should enact legislation giving women the right to 18 weeks of paid maternity leave and make sure that women have time and adequate space for continuing breastfeeding when they return to work [28].
Countries are expected to make policies that create a conducive environment for breastfeeding in the workplace and help women to breastfeed their children exclusively for the rst6 months and thereafter. Some Evidence shows that longer maternity leave helps the mothers to practice exclusive breastfeeding more as per WHO recommendations [29].
The governments of India and Viet Nam have been successfully protecting exclusive breastfeeding by the implementation of supportive policies that guarantee mothers to get six months' paid maternity leave.in addition to the above, both countries place strong legislation that prohibits the use of marketing breast milk substitutes, bottles, and teats before 6 months of infants age [30,31].
But, contrary to WHO recommendation, the Constitution of Ethiopia and Labour Proclamation, recommends employed mothers to get fully paid maternity leave of 120 working days only (30 days antenatal and 90 days postnatal) on the recommendation of the medical doctor and the proclamation doesn't support women to breastfeed in the workplace and the public area after they return to work which has its effect on good practice of exclusive breastfeeding [32].
In Ethiopia, many studies have been conducted to determine the prevalence of exclusive breastfeeding (EBF) and its associated factors between January 1/2015 to October 30/2019. But the ndings of these different studies documented that there was great variability in the prevalence of EBF across the regions of the country during the mentioned year in the above.
From the above factors, we selected one factor (maternal employment) to investigate its effect on the practice of exclusive breastfeeding (EBF). We selected this factor because of the following reasons: The rst reason is that maternal employment was the most important factor, which ultimately in uencing EBF, especially in our country where the legislation of civil Service give only 4 months of paid maternity leave and enforce mother to return quickly to their job before 6months after delivery. The second reason is that the primary studies conducted previously showed that controversial ndings regarding the effect of maternal employment on EBF. among those primary studies some of them showed negative association of maternal employment with exclusive breastfeeding with the presence of grate variation among them [33][34][35][36][37][38][41][42][43][44][45][46][47][48][49][50]and the rest studies showed a positive association of maternal employment with EBF [39,40]. Because of the above-mentioned factors, we intended to undertake this meta-analysis. As far as our knowledge is concerned, Even if there were small and fragmented studies, there is no published systematic review and meta-analysis which investigated the pooled prevalence of exclusive breastfeeding and its association with maternal employment between January 1/2015 to October 30/2019 which is in line with 3rd target of sustainable development goal by 2030 in Ethiopia. So, the purpose of this systematic review and meta-analysis was to estimate the pooled prevalence of EBF and its association with maternal employment in the context of Ethiopia.
This Systematic review will generate concrete evidence that helps policymakers and program planners to make an appropriate intervention and remold some policies concerning maternal employment and practice of exclusive breastfeeding for the best bene ts of mothers and infants in Ethiopia.

Searching strategies
The current systematic review and meta-analysis was reported by using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [69]. Guideline to determine the pooled prevalence of exclusive breastfeeding practice and its association with maternal employment in the context of Ethiopia. Publication condition: Articles published in peer-reviewed journals.
Study design: All observational study designs (Cross-sectional, case-control, and cohort) reporting the prevalence of EBF or associations between maternal employments with EBF were considered.
The outcome of interests: Studies reported data on the prevalence of EBF or the association between EBF and maternal employment were considered.
Language: Articles reported in the English language were considered.
Publication year: only studies published from January 1/2015 to October 30/2019 were considered.
Exclusion criteria study Conducted in women with HIV/AIDS, preterm newborn and newborn in an intensive care unit Study with abstracts without full text and Qualitative studies, symposium/conference, case reports.
Articles, which were not fully accessed, after at least two Email contact of the primary author was excluded.

Outcome measurement
This systematic review has two main outcomes. The rst one is the Prevalence of Exclusive Breastfeeding practice, which is de ned as the practice of providing only breast-milk for an infant for the rst 6 months of life without the addition of any other food or water, except for vitamins, mineral supplements or medicines [6]. The prevalence was calculated from each primary study by dividing the number of women breastfeeding exclusively to the total number of women who had ever breastfed multiplied by 100. The second outcome was to investigate the association between maternal employment and exclusive breastfeeding. For this second outcome, we calculated the log odds ratio based on the primary studies that examined the relationship between maternal employment and exclusive breastfeeding.
Data extraction: Data was extracted using a standardized data extraction format, which was adopted from the JBI data extraction format. Two authors (GE and YM) independently extracted all necessary data using the format. Any disagreements at the time of data abstraction were resolved through discussion and consensus. The data extraction format included primary author, publication year, and study Area, study design, sample size, the prevalence of exclusive breastfeeding, and the quality score of each study.
Quality assessment: The Joanna Briggs Institute Critical Appraisal tools for use in JBI Systematic Reviews (JBI-MAStARI) was used for critical appraisal of studies [70].The tool has 8 major criteria for critical appraisal of each primary study. Accordingly primary studies with a score of 50% and above included in the Meta-analysis research.
Statistical analysis and methods: Data were extracted in Microsoft Excel format, then analysis was done using STATA version 11software. Heterogeneity regarding reported prevalence was assessed by computing p-values for Cochrane Q-statistics and I2 tests. I2 test statistics of 25%, 50%, and 75% were declared as low, moderate, and high heterogeneity respectively [71].
Forest plot was used to present the combined prevalence of exclusive breastfeeding with a 95% con dence interval (CI) in this meta-analysis. Accordingly, the size of each box corresponds to the weight of the study, the crossed line refers to a 95% con dence interval of the study.
Besides, to minimize the Random variations between primary study subgroup analysis was done by region in Ethiopia and publication year of primary studies.
We checked Publication bias by funnel plot and Egger's and Begg's tests subjectively and objectively respectively and a p-value less than 0.05 was used to declare the statistical signi cance of publication bias [72]. Ln odds ratio was applied to examine the association between maternal employment and EBF in Ethiopia For the 2 nd outcome.

Results
As described in Fig.1, 541 studies were identi ed regarding EBF in Ethiopia through PubMed, Google Scholar, Science Direct, and others in the rst step. Then 90 studies were excluded because of duplication. From the remaining 451 studies, 200 articles were excluded after reviewing their titles based on assessment since they were not relevant to this review. The remaining 251 studies were screened by abstracts yielding an additional 198 studies to be excluded. Moreover, 53 full-text articles were assessed for eligibility based on the preset inclusion criteria. From these 17 articles were excluded due to the inclusion criteria. Among excluded studies, three of the studies were excluded because they didn't report our outcome of interests [73,74,75]. Two studies conducted among HIV infected mothers [76,77]. The rest 12 articles were excluded because of publication year; one Study published in 2009 [78], two studies were published in 2012 [79,80],three of the studies were published in 2013 [81,82,83],six studies were published in 2014 [84,85,86,87,88,89].Finally,36 studies ful lled the inclusion criteria and included in the systematic review and meta-analysis.
As shown in Additional le1: table S1, all of these 36 studies were published between January 1/2015 to October 30/2019. A total of 27907 breastfeeding women were included to estimate the pooled prevalence of exclusive breastfeeding in the current Meta-analysis. Regarding study design, most 33 of the studies are cross-sectional study design. The sample size of the studies ranges from 226 -5,227.The lowest prevalence (29.29%) of EBF was observed in a study conducted in Addis Ababa, Ethiopia [54] whereas the highest prevalence (86.44%) was observed in a study conducted in Bahir dar, Ethiopia [35]. from nine regions of Ethiopia, seven regions and one council city were represented in this meta-analysis.

Meta-analysis
High heterogeneity (I2 = 85.8% and p-value < 0.000) was observed across the included studies and a random effect meta-analysis model was applied to examine the association between maternal employment and EBF in Ethiopia ( g.3).
We also assessed publication bias subjectively using the funnel plot and objectively using Begg's and Egger's tests. Even if the funnel plot showed the presence of publication bias, Begg's and Egger's tests showed the absence of signi cant publication bias (p-value>0.544 and p=0.190) respectively ( g.4).

Discussion
To our knowledge, this is the rst systematic review and meta-analysis research examining the impact of maternal employment on exclusive breastfeeding in Ethiopian using a study published between 2015 -2019. The main aim of this systematic review and meta-analysis research was to estimate the pooled prevalence of exclusive breastfeeding and its association with maternal employment in Ethiopia among study conducted between January 1/2015 and October 30/2019.
Breastfeeding is core is part of the 2030 Agenda for Sustainable Development goal which is linked with many targets of Sustainable Development Goals (SDGs) especially with 3rd target which deals with ending preventable maternal and neonatal death [8]. This type of meta-analysis plays a great role for program planners and policymakers to make all mothers practice optimum breastfeeding practice in Ethiopia according to WHO recommendation and helps to end preventable maternal and neonatal death.
According to the results of 36 studies included in this meta-analysis the pooled prevalence of exclusive breastfeeding in Ethiopia is 59.79 %( 95% CI=54.58-65.00).
The overall prevalence of exclusive breastfeeding in this study is almost similar with the result of the 2016 Ethiopian demographic and health survey (EDHS) result (58%) [19] And the result of a metaanalysis conducted in Ethiopia (59.3%) [90].This similarities could be attributed to similarities in sociodemographic, methodological, and the characters of individual studies included in both review and EDHS reports. The overall reported prevalence of EBF in this review is higher than the result of meta-analysis result conducted in Iran(49.1%) [91] and 29 sub-Saharan African countries, which showed the prevalence of EBF (23.70% in Central Africa) and (56.57% in Southern Africa) [92]. The pooled prevalence in this review is also higher than the results of the study conducted in 27 sub-Saharan African countries (SSA) (36%) [93], Demographic and health survey of Tanzania (22.9%) [94], demographic and health survey of Madagascar (48.8% [95] and study conducted in developing countries (39%) [96].
This variation might be because of methodological differences, differences in infants and maternal socio-demographic characteristics, economical, health service utilization, the gap of the year at which the study was conducted, and the number of studies included in the review.
Again the overall prevalence of exclusive breastfeeding in this research is much higher than the results of primary study conducted in Bangladesh(5%) [97], Southern Brazil (43.7%) [98], Lebanon (27.4%) [99], Al Hassa, Saudi Arabia (12.2%) [100], Tamil Nadu India (34%) [101], Canada (15.3%) [102],Tabuk Saudi Arabia (31.4%) [103]. This difference might be because of methodological differences and differences in health service utilization and health service coverage. But the overall prevalence exclusive breastfeeding in our review is lower than the result of the primary study conducted in Indian regains, which indicated the prevalence of exclusive breastfeeding was (79.2% in southern India and 68.0% in northeastern India )respectively (104), Nepal demographic and health survey result (66.3%) [105], and the result of the study conducted in Ghana (64%) [106].
Besides, we performed sub-group analysis based on the study areas or Regions in Ethiopia where the studies were conducted and year of publication of the primary studies. Accordingly, the highest (71.15%) and lowest (36.71%) prevalence of exclusive breastfeeding was reported in a study conducted in Somalia and Addis Ababa City respectively. This regional difference of prevalence of exclusive breastfeeding might be because of differences in socio-demographic, the difference in numbers of the study included the two regions during analysis. In addition to the above, in the study conducted in the Somalia region, a large number of study participants were unemployed mothers and according to different literature, unemployment is associated with a high prevalence of exclusive breastfeeding practice [41,84].
We also performed a subgroup analysis using a year of study publication. Accordingly, the highest (64.65%) and lowest (57.04%) prevalence of exclusive breastfeeding were reported in the study published during 2015-2016 and 2017-2019 respectively. This difference could be attributed to the difference in coverage of health information regarding exclusive breastfeeding and effective utilization of health extension workers, adherence to the national and international policy by health institutions [107]. Also, this difference might be attributed to the number of studies included in each category during analysis.
Maternal employment was signi cantly associated with exclusive breastfeeding in this systematic review and meta-analysis research. Accordingly, Employed mothers were 57% less likely to practice exclusive breastfeeding as compared to unemployed mothers. This result is in line with the results of the primary study conducted in Lebanon [99], a study conducted in Iran [108], a study conducted in Malaysia [109], a study conducted in Saudi Arabia [103] and the study conducted in Somalia [110].
This similarity could be attributed to Mothers who returned to work at an earlier time before 6 months have less frequency of contact with their baby and employed mothers begin liquid and solid based supplementation of food before the expected age of starting weaning food which will end up with the decreased practice of exclusive breastfeeding [111].
Some evidence showed that employed mothers face unique barriers to practice exclusive breastfeeding and returning to work too early after the birth has been shown to harm the practice of exclusive breastfeeding.one study showed that the more we increase the legislated duration of paid maternity leave, the more the mothers practice exclusive breastfeeding and this will result in higher prevalence of exclusive breastfeeding [112,113,114].
Limitations of the study like other studies, our systematic review and meta-analysis research has some limitation. Among these; majorities of the primary study included in the review were cross-sectional study which might affect the outcome variable because of other confounding factors, studies published in a language other than English were not included in the review, the review addressed only one associated factor (maternal employment) on exclusive breastfeeding and the last limitation is that the review included some studies with small sample size which might affect the pooled report of exclusive breastfeeding.

Conclusions
The overall prevalence of exclusive breastfeeding in this meta-analysis is low in comparison to the global recommendation of practice of exclusive breastfeeding.
Maternal employment was signi cantly associated with the practice of exclusive breastfeeding in comparison to their counterparts. Based On our review ndings, we recommended that the Ethiopian government should increase legislated paid maternity leave after delivery beyond current paid maternity leave and implement policies that empower women and create a conducive environment for employed mothers to practice exclusive breastfeeding at the workplace.    The pooled odds ratio of the association between maternal employment and exclusive breastfeeding in Ethiopia in 2019.