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 benefits for mothers and it plays a great role in improving public health [1-3].
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 first 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) defined as the practice of providing only breast-milk for an infant for the first 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 first 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.
But still, we are far behind to make exclusive breastfeeding during the first 6 months of life the norm for infant feeding. Currently, the worldwide prevalence of EBF for infants aged 0-6months 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 specified six global nutrition targets for 2025 and from this, the fifth target states that, to increase the rate of exclusive breastfeeding in the first 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 Pacific, South Asia, Central America and the Caribbean, eastern and southern Asia, least developed countries and worldwide respectively.
During the years between 1985 and 1995, global rates of exclusive breastfeeding raised by 2.4%. Twenty-five 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) .
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% .
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 .
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 .
According to a study conducted In Latin America and the Caribbean countries, exclusive breastfeeding for the first 3 months of life can prevent 55% of infant deaths related to diarrheal disease and acute respiratory infection .
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 . Globally, more than 1.45 million lives were lost due to suboptimal breastfeeding in developing countries .
A study conducted in Ghana showed that the risk of neonatal death was fourfold higher in children given milk-based fluids or solids in addition to breast milk in comparison to those fed breast milk exclusively according to WHO recommendation .
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 .
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 .
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 .
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 first6 months and thereafter. Some Evidence shows that longer maternity leave helps the mothers to practice exclusive breastfeeding more as per WHO recommendations .
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 .
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 findings 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.
Concerning associated factors, these studies showed that different maternal and health service-related factors influenced EBF;
Maternal employment [33-50],Mode of delivery [34,39,41,42,43,45,50-54],Marital status[33,34,41,42,47,55,56,57],colostrum feeding[35,37,38,43,58,59,60,61],prelacteal feeding[ 34,38,43,55,57,62],age of mother[63,64,65,66,67], place of delivery [34,39,56,68] were some of the associated factors with practice of exclusive breast feeding(EBF).
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 first reason is that maternal employment was the most important factor, which ultimately influencing 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 findings regarding the effect of maternal employment on EBF. among those primary studies some of them showed a negative association of maternal employment with exclusive breastfeeding with the presence of grate variation among them[33-38,41-50]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 benefits of mothers and infants in Ethiopia.