Breastfeeding experience, barriers, and facilitators among mothers of vulnerable low birth weight infants in Amhara Region, Ethiopia: a qualitative exploratory study

doi:10.21203/rs.3.rs-3337973/v1

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Research Article

Breastfeeding experience, barriers, and facilitators among mothers of vulnerable low birth weight infants in Amhara Region, Ethiopia: a qualitative exploratory study

https://doi.org/10.21203/rs.3.rs-3337973/v1

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Introduction: Globally, 15% - 20% of all live births are low birthweight (LBW) newborns, and many mothers with LBW newborns experience feeding difficulties. Concrete efforts to understand and mitigate the barriers to breastfeeding among this vulnerable group are urgently needed.

Methods:Mother-newborn pairs were recruited from 8 facilities from the government’s Saving Little Lives initiative in Amhara Region, Ethiopia. We conducted a qualitative study using in-depth interviews among 30 mothers of LBW newborns (10 with very low birthweight [VLBW, <1500 gm]; 8 with LBW [<2000 gm] who experience breastfeeding difficulties, and 12 without difficulties). The interviews were analyzed using thematic analysis to describe the breastfeeding barriers and facilitators for mothers with and without feeding difficulties.

Results: Despite strong intentions to exclusively breastfeed during pregnancy and knowledge of breastfeeding benefits, many mothers of LBW newborns had difficulties initiating and continuing breastfeeding while in-patient. Self-reported insufficient milk (SRIM), suboptimal breastfeeding support in hospitals, prolonged mother-newborn separation in Neonatal Intensive Care Units (NICUs), and limited knowledge of effective feeding techniques (limited antenatal and postnatal care education) were the most common barriers. Further, mothers with multiple births reported greater feeding difficulties; they were more likely to adopt formula feeding compared to those with single births. The primary facilitators of LBW breastfeeding were the synergy between health workers (mainly women health workers) and mothers, mothers’ peer counseling, and family support. However, health worker support varied widely across facilities.

Conclusion:The findings from this study provide contextual insights into maternal LBW breastfeeding barriers and facilitators of successful and sustained breastfeeding. For example, creating NICU expectations to minimize maternal-newborn separation, targeting neonates’ feeding support for mothers with VLBW newborns and/or multiple births, and designing a standardized protocol for LBW nutritional support to guide health worker support are critically needed.

low birthweight (LBW)

breastfeeding

qualitative research

infant formula

vulnerable newborns

antenatal care (ANC)

postnatal care (PNC)

neonatal intensive care unit (NICU)

Low birth weight (LBW), defined by the World Health Organization (WHO) as birth weight below 2500 grams regardless of gestational age¹, remains a major public health problem (emerging research has defined LBW as less than 2000 g)^2–4. Globally, 15% − 20% of all live births are LBW infants, and this high burden is unequally distributed across varied geographical regions. Low- and middle-income countries (LMICs) account for 95% of reported cases^1,5. Infants with LBW are more susceptible to neonatal mortality, severe respiratory distress, feeding problem, cognitive impairment, and higher risks of non-communicable diseases in adult life compared to normal-weight infants^6–9.

In Ethiopia, the national pooled prevalence of LBW is 18%¹⁰ and an estimated 5% of the total under-five deaths in the country are attributable to LBW¹¹. Despite the numerous government programs designed to improve infant and young child feeding (IYCF) practices, particularly for vulnerable infants, the proportion of newborns who are breastfed has not increased substantively in the past two decades; only 47% of infants are exclusively breastfed, which is substantively lower than the WHO’s coverage target of 70% by 2030^12,13. Although there are no nationally representative data on breastfeeding for LBW infants in Ethiopia, a recent study using data from Ethiopia’s Demographic and Health Survey showed that LBW is strongly associated with late initiation of breastfeeding¹⁴, a practice that can drive newborn mortality^15,16. Furthermore, there is no standardized breastfeeding care or education protocol for mothers with LBW infants nor is there adequate, locally-specific evidence to support interventions that can be targeted at mothers or health facilities to improve the quality of feeding support given to mothers, particularly those with breastfeeding difficulties in Ethiopia or the Amhara Region.

Although the efficacy of breastfeeding in the neonatal period has been well established^13,17, there is still a critical knowledge gap on optimal feeding strategies for small and vulnerable newborns, particularly LBW infants who experience breastfeeding difficulties. There is convincing evidence that the uptake and duration of breastfeeding among LBW infants are decreased compared to normal-weight infants.^18–20 This suggests newborns with the most nutritional needs are most likely to be deprived of breastfeeding and its benefits. Furthermore, several studies on the feeding experiences of mothers with LBW infants in sub-Saharan Africa show that lack of breastfeeding support from healthcare workers^21,22, the high burden of care due to lack of resources essential for the management of LBW infants^23,24, and prolonged mother-infant separation during hospitalization²⁵ are the key factors that negatively influence breastfeeding experience. However, these studies primarily focused on the drivers of breastfeeding from one perspective, drawing from the experiences of mothers often selected from one hospital, with no systematic attempt to recruit mothers with varying degrees of breastfeeding difficulty (BFD). Hence, to design more effective interventions that can be rooted in social and health policies and backed by the government’s political will and financial support, robust evidence is needed to better describe the determinants of breastfeeding success among LBW newborns¹³.

To improve survival for vulnerable LBW infants, the Federal Government of Ethiopia in collaboration with GFF, WHO, UNICEF, and a consortium of universities rolled out the “Saving Little Lives (SLL)” initiative in 2021. This 3-year program, currently being implemented in Ethiopia’s 4 largest regions that account for three-quarters of the total births per year, targets key drivers of mortality among preterm and LBW neonates. To optimize routine clinical care of LBW neonates, the consortium is implementing the SLL Minimum Care Package that constitutes care packages at birth, at Labor and Delivery Units, Neonatal Intensive Care Units (NICU), Kangaroo Mother Care (KMC) units, and Quality Improvement interventions in SLL-supported hospitals²⁶.

This study will describe the breastfeeding experience of mothers with vulnerable LBW newborns by assessing existing practices, strategies, and support for early feeding in government SLL health facilities in Amhara region. To achieve this, we collected data using qualitative methods from two groups of mothers with a range of experiences. We sampled mothers who are successfully breastfeeding or providing expressed breast milk and those who are having difficulty providing breast milk to their newborns. Data from this study will be valuable in informing the design and implementation of targeted interventions aimed at improving the quality of feeding support for vulnerable newborns.

Study Design, Setting, and Participants

This is a descriptive qualitative study designed to describe the breastfeeding challenges experienced by mothers of LBW newborns with varying degrees of feeding difficulty. This work is designed to generate evidence on successes and barriers to LBW breastfeeding as the first step in developing potential intervention strategies to improve LBW neonates’ exclusive breastfeeding (EBF). Participants were selected from facilities currently implementing the SLL project in Amhara, Ethiopia. The SLL interventions are being implemented in 12 zones and three town administrations of the Amhara region. The Amhara region is home to more than 21.8% of the country’s population, and based on the Ministry of Health’s ‘Health and Health –related Indicators annual report 2021/2022’, the total population of Amhara region is 22,877,366 with estimated 770,967 annual births—23,129 of which are LBW²⁷. To reflect the clinical care diversity at government hospitals, we recruited mothers from a range of facilities—including primary, general, and referral hospitals.

Health services in Ethiopia are provided by a “network of health facilities arranged in a three-tier health care delivery model”—primary, secondary, and tertiary services²⁸. The primary level services are provided by health posts (HP), health centers (HC), and primary hospitals (PH), collectively called a “primary health care unit,” PHCU); the secondary level services are provided by general hospitals; and tertiary services are provided by specialized hospitals. A health post (HP) is the lowest-level health facility at the community/kebele level, and a health center (HC) is a referral site for about five catchment HPs and is designed to serve a population of 15,000–25,000 people. Primary Hospitals serving a population of 60,000–100,000 are referral centers for health centers²⁸. Similarly, general hospitals serve 1–1.5 million people and are referral centers for PHs. Finally, specialized hospitals serve 3.5–5 million people and are the highest level of hospital care in Ethiopia. For this study, we collected data from 8 of the twenty facilities currently implementing the SLL package of newborn survival services in the Amhara Region. Health facilities were purposefully selected to represent three levels of hospital care in Ethiopia based on geographical location and availability of NICU services.

After securing ethical clearance and a support letter from Amhara Public Health Institute to conduct this study, the process of recruiting mothers for the qualitative part of the study started with the research coordinator informing the medical director of each facility of the objectives of the research and securing permission to recruit mothers who met the inclusion criteria: has a LBW delivery, able to communicate in Amharic or English, and willing to provide verbal and written consent to participate in the study. The research team approached mothers who expressed their willingness to participate in the study and selected a convenience sample (n = 30). We collected in-depth interviews on breastfeeding intentions, practices, and experiences of mothers in three categories: 10 mothers with VLBW infants—with a few multiple births; 8 mothers with LBW infants who experience breastfeeding difficulties; and 12 mothers with LBW infants without breastfeeding difficulties. According to operational definitions of neonates’ birth weight specific to this study, LBW neonates were < 2000 g at birth and VLBW neonates were < 1500 g at birth^3,29.

Data collection

Data were collected from June to July 2022. The questionnaire included open-ended questions that focused on capturing data related to prenatal feeding intentions, breastfeeding practices, barriers and facilitators of EBF, and breastfeeding support. We also collected data on maternal age, education level, and occupation. This questionnaire was developed by the research team, pre-tested on a sample of mothers at a hospital in Bahir Dar City which was not part of the main study, and modified accordingly with inputs from Emory-Ethiopia teams based in Amhara and Atlanta. The questionnaires were administered at the health facilities by 2 social science experts, who were trained by a senior researcher from Bahir Dar University using a semi-structured interview guide that included all the questions and tips for probing mothers. This was to ensure reflexivity and reduce the potential for bias in the data collection process. All interviews lasted for about 35–60 minutes and were conducted in person at the hospital—with only the mother, sometimes the newborn, and interviewer in the room—using the local language, Amharic.

Data analysis

The audio-recorded interviews and field notes were transcribed/translated verbatim into English by the two research assistants. The translated versions were de-identified and entered into MAXQDA 2022 Software, version 22.3.0, (VERBI Software, Berlin, Germany). Thematic analysis was used for the analysis based on predetermined research themes derived from the interview guide and inductive themes that surfaced from the interview data. Two members of the team (MCE and YAT) developed the codebook by utilizing the study questionnaire and identifying segments of the data that were relevant to our research question, and several iterations were made after consultations with the larger research team. The first line of coding was conducted by YAT, and MCE double-coded 20% of the interviews to compute inter-coder agreement. The patterns and relationships between the codes were explored further to develop broader themes, which were reviewed by the team to ensure it accurately reflects the data as a whole.

We report mothers’ breastfeeding perspectives and experiences before delivery and after delivery and used the key findings from themes and sub-themes to present a summary of the key barriers and facilitators of breastfeeding among mothers with LBW infants. Breastfeeding experience before delivery resulted in 3 main themes (1) mothers’ feeding plan before delivery; (2) Breastfeeding counseling at prenatal visits; and (3) Mother’s knowledge of different neonate feeding options and practices. Breastfeeding experience after delivery had 3 main themes (1) First day feeding practices; (2) Challenges when initiating and continuing feeding; (3) and Feeding support (at facilities) after delivery.

Before delivery

Mothers’ feeding plans before delivery

All mothers who participated in the study—regardless of their newborn’s birth weight or severity of breastfeeding difficulties—asserted that their feeding plan before delivery was to exclusively breastfeed for the first six months of life. Although a few mothers highlighted that health workers also played a crucial role in influencing their feeding decisions before delivery, they asserted that they did not get any specific information about effective strategies for providing breast milk to newborns, particularly those with LBW. The decision to exclusively breastfeed is determined primarily by mothers based on their past experiences or from observing their friends and family members (primarily mothers or mothers-in-law). When discussing her feeding plan before delivery, a young mother of a LBW newborn stated:

“When I was pregnant, I was thinking that I would breastfeed my child for the first six months of her life. I will then add supplementary foods such as cow's milk and other fruits after that. During my pregnancy, my friends told me that breastfeeding was extremely important, so I planned accordingly based on what they had told me.” (Participant 21, LBW without BFD)

We observed that a few of the participants got their knowledge of the benefits of breastfeeding from online sources. “I am influenced by social media, readings, and health professional education from the media. Health professionals suggested that breast milk is very important for the growth of the baby in a healthy way. I know that if the baby gets the mother's breast milk the baby would be healthy and not susceptible to disease” (Participant 17, LBW with BFD).

Breastfeeding counseling at prenatal visits

The content of the prenatal counseling sessions mothers had received during pregnancy differed between participants—regardless of birth weight or the severity of feeding difficulties experienced. Only seven of thirty mothers received breastfeeding-specific counseling from health workers during their prenatal visits; this advice focused on the need for exclusive breastfeeding, the benefits of providing human breast milk (versus other feeding options), feeding duration, latching techniques, frequency of feeding, and the avoidance of household foods for the first 6 months. One notable example came from a 32 years old high school-educated mother who had a LBW baby without breastfeeding difficulty. She reported:

“They [the health workers] advised me on how to breastfeed my baby using the proper protocol including how I should attach my baby to my nipple area, proper baby positioning, and proper handling of my baby during breastfeeding…. and they also advised me that newborn babies should not be fed with any additional food except breast milk until they are six months old. I also got advised that breast milk volume would be increasing when the baby fed the breast continuously and frequently.” (Participant 26, LBW without BFD)

The mothers who were not specifically counseled on breastfeeding still received some form of counseling during their prenatal visits to the health facilities. The counseling these mothers received was primarily centered around consuming a “balanced diet” during pregnancy for optimal weight gain and development of the embryo, avoidance of physically-tasking work, and taking supplements. The experience of the twenty-three mothers who did not receive breastfeeding-specific counseling was perfectly summed up by a 25-year woman who stated:

“The nurses in the hospital where I went for ANC service did not inform me of anything concerning the feeding of the newborn child. However, they told me that you have to eat a balanced diet of fruit and liquid foods. Similarly, the nurses also told me that I do not have to do any heavy work and I have to take iron medicine.” (Participant 21, LBW without BFD)

Mother’s knowledge of different neonate feeding options and practices

Although most mothers were not counseled on the substantial advantages of human breastmilk feeding over other prevalent feeding options, all mothers in this study demonstrated a fair understanding of the advantages and disadvantages of several feeding options. Mothers were very clear about the benefits of exclusive breastfeeding for neonates’ physical growth and development, cognitive development, prevention of common illnesses, and the ‘mental satisfaction’ for mothers as a result of having a healthy baby. This knowledge was largely due to prior breastfeeding experience, advices from health workers and education by peers. A 30-year-old mother with breastfeeding difficulty states the benefits of breastfeeding:

“In addition to providing minerals necessary for their development, breastfeeding is of the utmost importance for babies up to six months old. Once they reach the age of six months, babies should begin drinking cow's milk regularly. Breastmilk is incredibly vital for the strength of the child's body.” (Participant 1, LBW with BFD)

The most common alternatives to human breastmilk reported among mothers was cow’s milk or infant formula. When asked about the risks associated with different feeding practices of newborns, most mothers stressed the absence of any risk with breastfeeding as it is the ‘most natural’ feeding method. Notwithstanding, study participants repeatedly cited “heaviness”—referring to the inability of neonates’ less-developed digestive tract to digest certain foods—as a reason for not providing cow’s milk until after 6 months. Some mothers who had experimented with providing cow’s milk in the past highlighted that it caused ‘gastrointestinal disturbance’ for the infant which could result in other dangerous health outcomes. One mother, a 25-year-old collage diploma holder, highlighted the detriments of providing cow’s milk from her prior experience with her older child:

“However, I have prior experience from having my first child. I was giving him cow's milk. He was frequently ill as a result of a high intake of animal milk.”(Participant 19, LBW without BFD)

Infant formula was perceived to be less dangerous by mothers and was seen as an alternative to human breastmilk in situations where mothers may be unable to breastfeed effectively, especially when they have multiple births. However, most mothers were not as knowledgeable about the potential risks associated with providing infant formula. Overall, informants tend to limit their responses to “I don’t know” when asked about the risks or potential downsides of other newborn feeding practices. This was effectively summarized by a 30-year-old mother who had a VLBW delivery and had not completed primary school:

“Regarding formula milk; I don’t know more about it. If breast milk is not productive, we may not have any other options except using formula milk so we should use it when the breast milk is not productive. In the previous time (i.e., the experience of our mothers and grandmothers) animal milk including butter was good and considered very important to give to the newborn. But, nowadays the health care professional was informing and teaching not to give it up to six months to the baby.” (Participant 4, VLBW with BFD)

After delivery

First-day feeding practices

After delivery, the feeding practices of mothers in this study differed substantially since we recruited those with LBW and VLBW newborns, with and without feeding difficulties (FD). Although breastfeeding intentions before delivery were followed by most mothers despite breastfeeding difficulties, others reported they had no option but to introduce formula after delivery. While these mothers still expressed strong sentiments on the value of breastfeeding, several barriers made it difficult to initiate and continue breastfeeding, particularly among mothers with multiple births.

At the time of the interview, all VLBW neonates were admitted to the Neonate Intensive Care Unit (NICU), separated from their mothers, and taken care of by neonate nurses. All VLBW newborns in this study were also born preterm. Most of the mothers of these neonates gave birth at other facilities (mostly health centers) and were referred to SLL hospitals to access the NICU services. The feeding experience of mothers with VLBW newborns was consistent for most participants. The VLBW newborns were not breastfed during their first few days of life. However, some received medicines or supplements from neonate nurses through a nasogastric (NG) tube. While separated from their newborns in the NICU, very few mothers were supported to immediately express breastmilk for future feedings once their newborn became stable. This support was very inconsistent across facilities; some mothers reported only being asked to express breastmilk 3 days after delivery. One reported,

“The baby didn’t feed on my breastmilk on the first day of birth because he was born prematurely. They took him to the NICU and after 3 days, we were told to bring breastmilk through hand expression but that was unsuccessful. When it was problematic to get breast milk, we gave formula/milk powder.” (Participant 11, VLBW with BFD)

Furthermore, some of the VLBW neonates were multiples and required a substantial amount of time in the NICU for stabilization before breastfeeding was provided (either directly at the breast or by expression). VLBW newborns who were late preterm and more clinically stable but unable to suck at the breast were fed expressed breastmilk using a NG tube in the KMC/NICU. Mothers with these newborns highlighted the key support from health workers on how to feed their infant using the NG tube.

“Currently, I am trying to breastfeed if my breast produces milk. Sometimes she sucks and gets milk, and other times she tries to suck but doesn't. If she cannot get milk from my breast, I provide expressed milk through a syringe in the NG tube way. Therefore, I am using both direct breastfeeding and pumping to provide expressed milk.. . Furthermore, the doctors and nurses also showed us how to feed my child through an NG tube. I had no idea how to feed my child for the first time, so the doctors helped me by showing me how to do it.” (Participant 9, VLBW with BFD)

Mothers with multiple births (twins and triplets) were unable to meet their infants' breastfeeding needs due to self-reported insufficient milk (SRIM) production and supplemented their newborn feedings with formula. Hospital staff support for formula feeding was quite variable; while some neonate nurses expressly advised mothers with multiple births to adopt formula feeding, others forbade the use of the formula for LBW neonates, and when inevitable, they encouraged mothers to breastfeed first before supplementing with formula. A 23-year-old mother of 2 shared her experience feeding LBW twins:

“My breasts were not producing enough milk... Hence, I feed my children utilizing both bottle feeding and breastfeeding. I breastfed the first time, then use infant formula the second time. However, I must breastfeed since it was my most significant feeding.” (Participant 10, twin LBW with BFD)

The experience of eighteen of the twenty mothers with LBW newborns was similar to those with VLBW delivery, regardless of whether they had breastfeeding difficulty or not. The neonates were admitted to the NICU for clinical stabilization and were either reportedly unable to feed at the breast or were preemptively bottle-fed for the first few days of life. After stabilization in the NICU, mothers without feeding difficulty reported being able to directly breastfeed or provide sufficient expressed milk to their neonate while those with feeding difficulty still lamented about their inability to produce sufficient milk. After clinical stabilization in the NICU, newborns were transferred to the KMC wards where they had unrestricted access to their mothers. At the KMC ward, they were breastfed, fed their mothers’ expressed breastmilk or infant formula. Most mothers without feeding difficulties were satisfied with their breastmilk production and were able to exclusively breastfeed their newborns breastmilk. Only a few had issues with inconsistent suckling, latching, and an overall lack of breastfeeding knowledge and experience. Hence, they expressed a lot of milk and achieved some success through bottle or nasogastric (NG) tube feeding their infant. A 22-year-old uneducated mother of 1 summarized her breastfeeding experience:

“Currently, the baby doesn’t suckle well, so I feed him using a feeding bottle of extracted milk. My body trembles when the baby touches my breast because it is my first child and I have no experience with feeding. I progressively overcome the problem with the help of advice and direction from others and the good fortune of experience.” (Participant 16, LBW without BFD)

Whether newborns were directly breastfed at the breast or through a NG tube in the KMC unit, mothers reported a feeding every 3 hours and a latch time ranging from 2–10 minutes. These feeding experiences were consistent across the 3 groups of mothers after newborns were clinically stable (those with LBW with and without feeding difficulties and those with VLBW newborns). Among newborns who were VLBW and preterm, mothers reported a higher feeding frequency “I am providing the expressed milk (at least) once an hour and more than 12 or 13 times per day.” (Participant 9, VLBW with BFD). However, once the infants were discharged from the NICU and enrolled in the KMC care, direct breastfeeding was initiated and feeding frequency was reduced to “once every 3 hours”—like most mothers.

Challenges when initiating and continuing feeding

The primary challenge experienced by all mothers who had difficulty initiating breastfeeding is SRIM. Regardless of whether a neonate can suckle effectively, most mothers in the study reported that their breastmilk volume was insufficient to meet the nutrient needs of their newborn. This SRIM problem was widely reported among all mothers with VLBW newborns and most mothers of LBW newborns with feeding difficulty. Newborns in this category were immediately separated from their mothers after birth and placed in the NICU, making it more difficult for mothers to establish and maintain breast milk flow. Further, some mothers were only asked to express breastmilk 2–3 days after delivery. Most mothers in these 2 categories gave birth to preterm newborns—some as early as 7 months. These newborns still struggled to breastfeed after discharge from the NICU because of developmental problems. Some believed the forced separation may have contributed to delays in breast milk flow even after multiple hand expressions.

“There were two major problems I faced: my breast was unable to produce milk for my child and the newborn child could not suck my breast because he was a pre-term child.” (Participant 6, VLBW with BFD)

“…this time, I could not feed my child directly because the doctors fed her. By the way, my breast still does not provide enough milk, so if she had been with me, I could not breastfeed her. However, if she were with me, maybe my breasts would produce milk if she tried to suck.” (Participant 9, VLBW with BFD)

Despite mothers’ hesitance to solely breastfeed due to their concern about insufficient milk production, healthcare workers in one facility encouraged mothers to exclusively breastfeed and that led to some positive breastfeeding experiences.

“The physicians assisted me in resolving the problems since they admitted my child to the NICU and encouraged me to begin breastfeeding and feed my newborn with expressed milk. They are still working with me to get my breasts to produce adequate milk. They also encouraged me to eat a well-balanced diet and drink plenty of liquids to produce adequate milk for my child.” (Participant 9, VLBW with BFD)

Another important challenge faced by LBW neonates’ mothers who had breastfeeding difficulty was expressing breastmilk, particularly among first-time mothers. Since most mothers did not have prior experience with breastmilk expression, a few had “wounds at the tip of their breast” and/or “inverted nipples”, and most of the mothers who expressed milk did so by hand. They experienced pain during the process, and this made the expression of breastmilk more challenging than they anticipated.

“Unfortunately, I felt pain in my breast when I expressed my breast when the doctor asked me to give milk to feed my child.. . and the top of my breast also became wounded.” (Participant 2, LBW with BFD)

A few mothers noted that they had significant psychological stress, primarily because of their newborn’s low weight and inability to breastfeed (unable to suckle). Most mothers who adopted formula feeding reported that purchasing formula presented significant financial stress. While discussing her biggest challenge a 35-year-old mother who is a teacher states:

“My blood pressure was very high and it had several negative effects on my child’s feeding. As well, stress and worry were a problem for me, especially when I see my preterm baby and his very small size. It was very troubling to me; It makes me feel very confused.” (Participant 6, VLBW with BFD)

Feeding support after delivery

Feeding support after delivery varied by facility. Most mothers highlighted the lack of breastfeeding education and support during ANC and Postnatal Care (PNC) visits. Many mothers were unaware of the risks of giving birth to a LBW or premature infant, and most had difficulty coping with a LBW newborn’s needs when they arrived. A few mothers highlighted the tremendous support they received from health workers while they struggled to breastfeed. However, this was not the case for most participants, who lamented that neonate nurses seemed to lack the skills or knowledge needed to support mothers struggling to breastfeed, were reluctant to help, or lacked the adequate number of staff needed to provide individualized breastfeeding support. These mothers who were in facilities where staff provided ‘helpful assistance’ and ‘compassionate care’ were able to return to exclusively breastfeed their infant after discharge from the NICU. They reported newborns who were able to suckle and attach better compared to mothers who received limited support at facilities. Mothers who received support were also more able to establish and maintain feeding at the breast and reported less milk expression. Most of these mothers attributed the survival of their newborns to the “attention and support of all hospital staff.”

“The hospital staff provides me with all the support I need to care for my child, including medication and glucose for the infant…No, I do not express breastmilk… Depending on the baby's satiety, the time frame at the breast can range from 20 to 30 minutes.” (Participant 12, VLBW with BFD)

Furthermore, most mothers who were able to successfully breastfeed reported synergy between their family members—primarily friends, mothers, and husbands—and healthcare workers made their breastfeeding experience much more successful as time progresses. Instrumental familial and peer counseling and support often came from sharing experiences and stories about those family members who had overcome breastfeeding difficulties themselves.

“My family and doctors are still supporting me in breastfeeding my child. I am also supported by the nurses at [deidentified] Hospital in feeding my child effectively. My husband is always by my side when I express my breast milk and provide it to the doctors. Furthermore, the doctors and nurses also showed us how to feed my child through an NG tube. I had no idea how to feed my child for the first time, so the doctors helped me by showing me how to do it” (Participant 10, VLBW without BFD).

“I am grateful to my family since they continue to support me by reassuring me that there is no need to be concerned about anything.” (Participant 15, LBW with BFD)

Furthermore, all mothers who reported having insufficient breastmilk volume reported receiving similar advice on how they can address the problem: “Drink enough water, consume hot liquid food, and eat a balanced diet.” Liquid foods like porridge, tea, coffee, and ‘atmite’ (Amharic for soup) were highly recommended. In addition, some mothers were encouraged to adopt formula feeding by health professionals, indicating that the reported breastmilk insufficiency was confirmed by healthcare workers. Yet, only a few health workers educated their clients on the proper way of feeding newborns with formula and the risks involved.

“When my breast was unable to flow, they (doctors and nurses) advised me to eat a variety of liquid foods, pump milk frequently, and stroke my nipples. My breast produced enough milk after I began to eat these liquid foods.” (Participant 19, LBW without BFD)

“Despite the doctors' advice that breastfeeding is healthy for children and you should feed your child this, my breasts did not produce milk. Therefore, I was unable to feed my newborn child. For this reason, they consulted me before buying the formula food. Currently, I am providing this food for my child. My doctor helped me purchase this formula milk for my child.” (Participant 5, VLBW with BFD)

The findings from exploring mothers' experiences before and after delivery revealed several barriers and facilitators to breastfeeding at the individual and health systems levels. These barriers and facilitators fell into three categories—counseling and support, resources and supplies, and technical concerns (Table 1).

The present study describes the breastfeeding experiences of mothers with LBW newborns from the Amhara Region of Ethiopia. We identified several context-specific barriers and facilitators to breastfeeding including self-reported milk insufficiency, suboptimal maternal nutrition, limited breastfeeding-specific counseling at ANC and PNC clinics, inadequate breastfeeding and milk expression support after delivery, absence of breast milk pumps, and the lack of a standardized protocol and practices to ensure rapid initiation of direct milk feeding or hand expression of breastmilk after birth.

Before delivery, all the mothers in this study had the intention to exclusively breastfeed for the first 6 months of life as recommended by the WHO. Most mothers had a remarkable understanding of the benefits of breastfeeding to improve newborn health outcomes; however, they had less familiarity with the potential risks of other alternative feeding option such as infant formula and some reported that cow’s milk can be provided after 6 months—contrary to WHO’s recommendation of only providing cow milk when infants are > 12 months³⁰. This strong intention to breastfeed primarily stemmed from mothers’ personal experiences, observations of peers/friends, the influence of key family members, advices from health worekers and social media. This finding parallels evidence that mothers’ social network influences their intention to initiate and continue breastfeeding^31,32. The intention to breastfeed was least influenced by health workers' recommendations before delivery, despite the fact that health workers often mentioned the importance of breastfeeding for newborns. However, breastfeeding-specific counseling and effective techniques to employ should mothers experience feeding difficulties was limited and inconsistent during prenatal visits and across the health facilities used for this study. The historically low uptake of ANC in Ethiopia may further exacerbate the problem, as facilities that provide adequate counseling are unable to reach their coverage target of at least 4 ANC visits. At present, only 27% of Ethiopian pregnant women attend four or more ANC visits³³. We found that prenatal counseling on EBF is not standardized —particularly for LBW newborns. This Amhara finding aligns with other global studies³⁴ and highlights a missed opportunity for health workers to provide evidence-based education that may support EBF among vulnerable newborns—especially for LBW newborns.

Despite women’s high intentions to exclusively breastfeed during pregnancy, most mothers with LBW newborns did not exclusively breastfeed after delivery due to extensive barriers. The primary barrier to breastfeeding initiation, continuation, or exclusivity in this study was mothers’ perception that their breastmilk volume was inadequate to meet the nutritional requirement of their vulnerable newborn. Globally, SRIM is the most cited reason for introducing formula; concerns for SRIM are especially common among mothers with LBW or preterm newborns^13,35,36. Although SRIM is often interpreted as an outcome solely based on mothers’ perceptions, evidence suggests that this phenomenon is influenced by biological factors specific to mothers and newborns, sociocultural factors, and hospital-level factors³⁷. In a comprehensive systematic review of 120 studies conducted across varying country income levels globally, four key risk factors of SRIM were reported: delayed initiation of breastfeeding, separation of mother and child in NICUs, suboptimal and non-specific breastfeeding counseling, and in-hospital formula feeding³⁸. Although in-hospital formula feeding was less prevalent in this study, the other SRIM drivers were common in this study context. They present a unique opportunity to design interventions targeting these four drivers of SRIM in Amhara.

Furthermore, we observed that most mothers with reported milk insufficiency noted that this condition was acknowledged by the healthcare workers in their facility. Consequently, some report being supported by health workers to consume foods that can increase breastmilk volume—primarily hot liquid soups—and in extreme cases of insufficiency (especially among mothers with multiple births), some mothers reported being explicitly advised by health workers to supplement breastmilk with formula. Hence, dismissing reported milk insufficiency as merely a mother’s ‘perception’ may be a rather simplistic approach—particularly based on evidence from the 120 study systematic review³⁸. Rather, juxtaposing the breastfeeding experiences of mothers with LBW newborns with the health worker perspectives may provide a powerful and unique opportunity to more deeply explore the causes and potential solutions to SRIM for LBW mothers in Amhara.

In line with extensively-documented evidence, we found that mother-newborn separation in NICUs greatly limited breastfeeding initiation in this study^39–42. The WHO recommends initiating breastfeeding within the first hour of birth; it decreases the risk of all-cause mortality, infection from pathogens in foods, and maternal postpartum hemorrhage^15,16,43,44. Nevertheless, it is still very commonplace for NICUs to separate mothers and their newborns for prolonged periods globally and in Ethiopia^41,45. Separation is known to influence mother-infant bonding and may promote psychological stress that may hinder optimal breastfeeding outcomes—especially among mothers with VLBW infants with substantively higher rates of postpartum depression compared to mothers of healthy-term infants^25,45,46. Despite this, there was no standardized protocol across all health facilities selected for this study to ensure that mothers of LBW newborns immediately initiate breastfeeding or express breastmilk after delivery.

Early initiation and frequent on-demand feeding or breastmilk expression are associated with increased milk production⁴³. Specifically, early research has shown that expressing breastmilk before 6 hours postdelivery and for ≥ 5 times per day substantially increases breastmilk volume among mothers with preterm and VLBW neonates^47,48. Average daily breastmilk volume at 8 weeks postpartum was 96 ml greater for mothers who expressed breastmilk ≥ 5 times/day compared to those who expressed breastmilk < 2 times per day^47,49. In addition, daily breastmilk production of ≥ 500 ml among mothers of VLBW newborns within the first 2 weeks of birth is a strong predictor of sustained lactation⁵⁰. Mothers in these studies, however, were provided efficient double electric breast pumps which pump milk more quickly compared to manual pumps and hand expression. In this study, only 3 of the mothers had access to manual pumps. Hence, there is an opportunity to further support lactation for mothers with vulnerable LBW newborns—particularly those separated from NICU care—with manual or electric pumps to improve milk production and sustained breastfeeding.

In addition to the delayed initiation of breastmilk feeding among mothers with LBW newborns, there was inconsistent support for breastfeeding or breast milk expression in facilities. In the early days after delivery, many were not supported to express breastmilk or provide EBF. Some mothers did not receive EBF assistance until after their newborns were clinically stable and discharged from the NICU. These findings are consistent with previous studies highlighting the challenges encountered by mothers of LBW and preterm neonates in establishing regular and routine breastmilk feeding strategies^36,45,51. This separation challenge was more profound among mothers with multiple births, who require additional time and effort to care for multiple newborns in the hospital and would likely be expected to fulfill household responsibilities upon discharge from the hospital⁵².

The feeding support provided to mothers with vulnerable newborns after delivery varied greatly between facilities. In hospitals where mothers received targeted postnatal care, breastfeeding challenges were more readily addressed and some mothers were able to continue breastfeeding exclusively. Furthermore, healthcare workers in these facilities were less likely to suggest the introduction of formula compared to facilities with limited postnatal support. Mothers with multiple births whose breastmilk supply was deemed inadequate to meet the needs of the newborns were supported to provide mixed milk feeding—breastfeeding first before providing formula as a supplement. However, this is not recommended by WHO and ironically is associated with decreased breastmilk production and early cessation of breastfeeding^53,54. By contrast, in situations where mothers were unable to produce sufficient breastmilk and in facilities with more limited support, health workers did little to encourage exclusive breastfeeding among mothers experiencing feeding difficulties; some recommended formula as the sole solution to the problem. This can result in the medicalization of newborn feeding problems—a situation that heavily favors formula marketing⁵⁵. In Ethiopia, healthcare workers have numerous opportunities to interface with pregnant and lactating mothers. The health extension workers (HEW) provide antenatal and postnatal services at health posts (the lowest level of the primary health system (PHS)) and during community-level outreach services while the maternal and child health (MCH) nurses provide complementary services in MCH clinics at health centers (HCs are one level above health posts) and hospitals. Hence, strengthening the health systems to be more effective in reaching mothers with LBW and vulnerable newborns with targeted support such as educational messaging and in-facility support may be targeted system strategies to improve breastfeeding uptake, duration, and sustained practice. These system-level supports may enable mothers to more effectively handle any EBF challenges experienced after birth.

Strengths and limitations

This is the first known research to explore the breastfeeding experience of mothers of vulnerable LBW infants in Ethiopia by recruiting mothers with varying degrees of breastfeeding difficulties. It is strengthened by documenting these experiences across the country’s clinical continuum of care (primary, general, and referral hospitals). Thus, the study documents diverse experiences from the Amhara region. The separation of mothers into three categories enabled us to explore the challenges mothers face and provide insights into interventions that can be targeted to specific groups of mothers based on their degree of breastfeeding difficulty. Furthermore, the use of highly-skilled local interviewers ensured that the in-depth interviews generated detailed information about breastfeeding experiences, challenges, and perspectives of mothers in this context.

However, our study has a few limitations. We collected data from facilities taking part in the government’s national SLL initiative within the Amhara Region. Hence, the breastfeeding experience of mothers and the support provided by healthcare workers may differ from those at other health facilities outside the SLL program, facilities in other regions, or private hospitals. As with many qualitative studies, there is potential for recall and social desirability bias since data were self-reported. However, given that mothers were selected based on the degree of feeding difficulty they had and were interviewed a few days after delivery, it is plausible that the experiences shared are accurate and minimally impacted by social desirability. Furthermore, we explored the breastfeeding experience based on the mothers’ perspective alone. Further research is needed to triangulate mothers' experiences with the perspective of health workers to thoroughly understand the factors affecting breastfeeding initiation, continuation, and exclusivity in Ethiopia, Amhara, and similar contexts. More investigation is warranted to comprehensively explore maternal perspectives on optimal breastfeeding support mechanisms or interventions required for the successful initiation and continuous sustenance of breastmilk feeding among vulnerable newborns. In addition, there is a need to conduct more research to comprehensively describe the barriers to ANC attendance in the region so that potential mothers can be targeted with timely breastfeeding education and support.

This research provides information on the contextual barriers and facilitators of breastfeeding among mothers with LBW infants in Amhara Ethiopia and provides valuable insights for the development of context-specific interventions and support programs at government hospitals. During pregnancy, the intention to breastfeed exclusively was high. However, this intention did not become a reality for most mothers given the various maternal- and hospital-related barriers to breastfeeding initiation and continuation. Regardless of the degree of breastfeeding difficulty experienced or whether a mother had a LBW or VLBW newborn, the primary challenges reported by mothers were consistent. These included individual factors (limited knowledge of breastfeeding a LBW newborn) and health system factors (limited education on LBW feeding during prenatal visits, prolonged separation from newborns admitted to NICU, delayed initiation of direct milk feeding or hand expression of breastmilk while in hospitals and poor breastfeeding support from hospital staff) and multifactorial drivers (SRIM). Based on these findings, it may be most critical to strengthen breastfeeding counseling and support strategies for LBW newborns at hospitals. Additionally, concrete strategies for EBF could be introduced during prenatal visits. Ideally, standardizing the support provided to mothers of vulnerable LBW newborns across facilities at the regional level may improve breastfeeding uptake. Further, timely initiation of breastfeeding or hand expression within 1 hour of birth reducing/eliminating mother-infant separation in the NICUs, offering practical strategies to address SRIM, and reassuring mothers about the normal variations in milk production may be powerful next steps to strengthen EBF in Ethiopia, Amhara, and similar government hospitals in similar contexts.

Table 1

Barriers and facilitators of breastfeeding among mothers of vulnerable newborns in Amhara region, Ethiopia
Category	Barriers	Facilitators	Potential Solution
Counseling & support	Inadequate prenatal counseling on breastfeeding and measures to take to ensure greater success with breastfeeding a LBW newborn during ANC visits.	Comprehensive prenatal education on breastfeeding and lbw newborn care during anc visits. This was reported among 3 of the thirty mothers.	Incorporate counseling services on LBW breastfeeding during ANC and educate on potential problems they might experience with breastfeeding after delivery.
	Self-reported insufficient milk (SRIM) and insistence on using formula.	Strong insistence on exclusively breastfeeding by health workers while also providing support on effective feeding techniques (positioning, latching)	Mothers should be effectively targeted prenatally and postnetal and educated on the sufficiency of breastmilk. Health workers can be encouraged to provide targeted feeding support and only revert to formula feeding as a last resort.
	Absence of effective postnatal counseling services and hands-on breastfeeding support after delivery and discharge, particularly in health centers.		Intensify breastfeeding support when mothers transition to PNC, particularly for those with VLBW newborns who experience severe feeding difficulties.
	Lack of structured breastfeeding support within and across health facilities.	The counseling and support from health workers, mothers’ peer-counseling and the support from family members’ encourages breastfeeding initiation and continuation despite the difficulties encountered.	Culturally appropriate, evidence-based breastfeeding protocols for vulnerable newborns are needed. Health workers counsling and support, mothers’ peer-counsling and family members support should be greatly encouraged.
Resources and supply
	Limited counseling, lack of practical support, and lack of access to breast milk pump for milk expression.	Health workers' education on hand-expression techniques that are effective and less painful.	Incorporate counseling and practical support on breastmilk expression to mothers and work with critical stakeholders on strategies to incorporate hand pumps as an additional tool.
	Inadequate finances to purchase formula milk, particularly for mothers with multiple births and/or severe breastfeeding difficulty.	Education and feeding support to first provide as much human milk as possible before supplementing.	Provide demand-side support at facilities to mothers with vulnerable newborns and family members with financial difficulties. This could include newborn formula for those unable to breastfeed and concomitant education on safe feeding.
Technical
	Lack of a standardized protocol to ensure mothers begin breastfeeding within one hour of birth or expressing breastmilk immediately after they recover from Caesarean section or expressing breastmilk immediately when separated from newborns in the NICU		Direct breastfeeding or hand expression should be encouraged within the first hour of birth (even when mothers and newborns are separated)
	Low health worker knowledge on how to support vulnerable newborn breastfeeding.		Provide on-the-job training and capacity building to improve neonate nurses’ and other care providers' skills and knowledge on effective facility-based newborn breastfeeding strategies specific to vulnerable newborns

Funding statement

This study was nested within the Saving Little Lives(SLL) project (Reference Number: NoH/R/T/T/D/5/9, Date:12/13/2021)—funded by the Global Financing Facility(GFF) through UNICEF. Additional support was provided by the Emory Global Health Institute (EGHI).

Ethical statement

The Research Ethics Committee (REC) of the Amhara Public Health Institute (APHI) approved the study (Reference Number: NoH/R/T/T/D/5/9, Date:12/13/2021). The Institutional Review Board of Emory University granted an exemption for this research study as it falls under the category of non-human subject research.

Author contributions

Conceptualization;

AG, JC, MYF

Data curation;

MCE, YAT, DA, MA

Formal analysis;

MCE, YAT, MYF

Funding acquisition;

AG, JC, MYF

Investigation;

MCE, YAT, AG, JC, MYF

Methodology;

AG, JC, MYF

Project administration;

MLB, YAT, MA, DA

Resources; Software; Supervision; Validation; Visualization;

MYF

Roles/Writing - original draft; and Writing - review & editing

MCE, YAT, MYF, JC, AG

Declaration of competing interest

The authors declare that there is no conflict of interest.

Acknowledgements

Mothers, APHI, Hospitals and Hosp, Amhara Regional Health Bureau, Amhara Public Health Institute, Emory Ethiopia Bahir Dar staff, Emory Amhara team, participating hospitals, nurses working in the project facilities, mothers and their parents

Data availability

The data are available from the senior authors (AG and JNC) upon reasonable request.

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No competing interests reported.

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Breastfeeding experience, barriers, and facilitators among mothers of vulnerable low birth weight infants in Amhara Region, Ethiopia: a qualitative exploratory study

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Abstract

Introduction

Methods

Study Design, Setting, and Participants

Data collection

Data analysis

Results

Before delivery

Mothers’ feeding plans before delivery

Breastfeeding counseling at prenatal visits

Mother’s knowledge of different neonate feeding options and practices

After delivery

First-day feeding practices

Challenges when initiating and continuing feeding

Feeding support after delivery

Discussion

Strengths and limitations

Conclusion

Declarations

Funding statement

Ethical statement

Author contributions

Declaration of competing interest

Acknowledgements

Data availability

References

Additional Declarations

Status:

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