MCSP Nutrition Brief: Addressing Barriers to Exclusive Breastfeeding: Evidence and Program Considerations for Low- and Middle-Income Countries

Optimal breastfeeding practices have long been known to reduce neonatal and child mortality and morbidity, including respiratory infection, diarrhea, and otitis media. Breastfeeding also has maternal benefits, contributing to birth spacing, and longer durations are associated with reductions in ovarian and breast cancer. Three key barriers to EBF in the first 6 months of life have been identified through analysis of available Demographic & Health Survey (DHS) data. These barriers include prelacteal feeding, delayed initiation of breastfeeding beyond 1 hour after childbirth, and early introduction of foods and liquids. Prelacteal feeding varies widely across countries, ranging from 5.2% to 70%, and up to 64% of newborns are not put to the breast within 1 hour of childbirth. A systematic review of barriers to EBF identified 16 barriers, which were divided into three sections: prenatal barriers, birth through the first day, and through the first 6 months. Key maternal barriers to EBF practices include lack of or late attendance at antenatal care, poor knowledge of EBF, and maternal health and attitudes. Women who attend antenatal care visits are more likely to practice EBF, and those with knowledge of EBF are also more likely to practice it. Maternal health and attitudes, such as personal frustrations, confidence in one's ability to breastfeed, stress, and maternal illness, may also impact EBF practices. Key barriers to initiating and maintaining EBF within the first day of life include deliveries outside of the facility, delivery by cesarean section, and delayed initiation of breastfeeding beyond 1 hour after birth. Women who deliver outside of a health facility are less likely to exclusively breastfeed, and those who deliver by cesarean section are also less likely to EBF. Delayed initiation of breastfeeding beyond 1 hour after birth is also associated with a higher risk of ceasing EBF. Prelacteal feeding is another key barrier to EBF, with common prelacteal feeds including glucose water, infant formula, honey, cow or buffalo milk, and water. Women who breastfeed their babies as a first feed are more likely to practice EBF, and those who discard colostrum are less likely to EBF. The reasons for discarding colostrum include receipt of advice from elders and the perception that it is not good for health. The World Health Assembly target is to increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% by 2025, specifically in USAID's ending preventable child and maternal deaths (EPCMD) priority countries. Addressing the barriers to EBF is essential to reaching this target and improving the health and well-being of mothers and children in LMICs.