Assessing pooled prevalence of exclusive breastfeeding practice and addressing principal barriers to its practice in North African countries: A systematic review and meta-analysis

Introduction

Exclusive breastfeeding (EBF) during the first six months of an infant’s life is strongly recommended by the World Health Organisation (WHO) due to its numerous benefits for both infant and mother’s health.¹

Numerous advantages of breastfeeding for both the mother and child have been extensively researched and reported by several studies.^2–4 Breastfeeding is an ideal, safe, and ecological source of nutriments necessary for child growth.⁵ Breast milk provides optimal nutrition, essential antibodies, and protection against infections, making it a complete and beneficial option for babies’ health.^6,7

It is one of the most effective ways of child health and survival. Infants who are breastfed have been found to have lower rates of infectious diseases, childhood obesity, and better cognitive development compared to those who are not breastfed.^8–10 Furthermore, breastfeeding offers protection to mothers against breast and ovarian cancers, type 2 diabetes, and cardiovascular diseases.^3,7 These benefits are heightened when breastfeeding is exclusive during the first six months of life and continued for an extended period.^4,8,11

It has been demonstrated that promoting the EBF is the most cost-effective intervention among all interventions to reduce infant mortality.^12–14

According to the WHO, to be considered exclusively breastfeed, it is required that children initiate breastfeeding within the first hour of birth and be exclusively breastfed for minimum the first 6 months of life, meaning no other foods or liquids are provided, including water.¹⁵

According to the WHO, about 44% of infants 0–6 months old are exclusively breastfed.¹

However, the prevalence of EBF in the first 6 months of life remains low, with only 41% globally and 37% in low- and middle-income countries (LMICs).^4,16 Therefore, there is an urgent need to improve and promote this practice in these disfavoured areas.

Given the geographical proximity of North African (NA) countries (Tunisia, Morocco, Algeria, Libya, Egypt, and Sudan), the similarities of dietary and nutritional habits, socio-economic conditions, religious beliefs, and social practices, we thought about the relevance of conducting a systematic review (SR) regarding the pooled global prevalence of breastfeeding practice in these countries. Aggregating and summarizing all the breastfeeding relating data, will enable us to get a global idea on the prevalence of this practice among mothers and understand the principal barriers to its practice in NA countries.

Through this SR and meta-analysis (MA), we aimed to firstly assess the global pooled prevalence of EBF, among mothers in NA by synthesizing available published studies; and secondly to estimate the pooled odds ratios (OR) of principal associated factors of practicing EBF (mother educational level, maternal employment, and mode of delivery).

Methods

Results

Findings of the search strategy

We conducted our search during February 2023. Out of the 2680 articles identified in the systematic search, 2110 remained after the exclusion of duplicates and removing for other reasons. A further 1769 articles were excluded upon screening the title. The next screening step was based on a review of the abstracts. In this stage we only retained 341 articles which were thoroughly assessed for eligibility. The most common reasons for excluding articles were for non-availability of the full text, not conducted in NA countries, not eligible population, incomplete data. After this stage, 16 studies were found to fit our inclusion/exclusion criteria and were selected to be included in the SR and the MA. The flowchart of the literature search according to the PRISMA guidelines is represented in Figure 1.

Figure 1. PRISMA flow diagram for the selection of included studies.

Pooled effect sizes

Forest plot for pooled prevalence of exclusive breastfeeding practice during the first 6 months

In total, 16 studies were included with an overall sample size of 7849. The overall pooled effect size (prevalence) was 29% with 95% CI [18 %- 42 %] (Figure 2). The heterogeneity was high (I ² = 99%; 95% CI [99-99] and Tau ² = 1.4; 95% CI [0.7 – 3.5] with p<0.01).

Figure 2. Forest plot of the pooled prevalence of exclusive breastfeeding during the first 6 months (among children aged of 6 months or younger).

The prediction interval for EBF prevalence ranged from 3% to 85%, with 95% confidence. This prediction interval represents the range of expected EBF prevalence in 95% of settings.

A funnel plot of the estimates is shown in Figure 3. Regression test (p=0.09) and Rank correlation test (p=0.19) for funnel plot asymmetry showed no evidence of publication bias.

Figure 3. Funnel plot of the 16 included studies.

To identify outliers studies, Influence and Baujat plots were plotted (Figure 4 and Figure 5).

Figure 4. Influence plot to identify outliers studies among the 16 included studies.

Figure 5. Baujat plot to identify outliers studies among the 16 included studies.

Eleven (11) studies were identified as outliers and were removed from the overall analysis. The estimated pooled prevalence for the remaining studies (N=5 studies from Tunisia, Libya, Morocco, and Egypt) was 40.0% (CI 95% [38.0-42.0]), prediction interval [34%- 48%] with homogenous results (Tau²= 0.0053, I² = 31%, p=0.22) (Figure 6).

Figure 6. Forest plot of the pooled prevalence of exclusive breastfeeding during the first six months with homogenous results (N=5 studies).

The pooled prevalence of the remaining 11 studies was 24.0% (CI_95% [12.0; 42.0]), prediction interval [0.01;0.9] with heterogenous results (Tau²=1.95, I²=99%, p<0.01) (Figure 7).

Figure 7. Forest plot of the pooled prevalence of exclusive breastfeeding among children aged 6 months or younger than six months (N=11 studies).

To identify outlier studies among these 11 studies, Influence and Baujat plots were plotted (Figure 8 and Figure 9).

Figure 8. Influence plot to identify outlier studies among the 11 included studies.

Figure 9. Baujat plot to identify outlier studies among the 11 included studies.

Seven (7) studies were identified as outliers (among these 11 studies), and after removing them from the overall analysis, the estimated pooled prevalence was 14.0% (CI95% [12.0; 15.0]), prediction interval [0.11;0.17] with homogenous results (Tau²= 0.0, I2=0%, p=0.91) (Figure 10).

Figure 10. Forest plot of the pooled prevalence of exclusive breastfeeding during the first 6 months with homogenous results (N=4 studies).

Subgroup analysis

Table 3 shows the results of the subgroup analysis according to the country of studies and sample size of included studies (<500; 500-1000; >1000). Tunisia had the lowest prevalence of EBF (11%) while Sudan (63%) and Morocco (48%) had the highest prevalence rates (Table 3).

Table 3. Meta-analysis of the prevalence of exclusive breastfeeding stratified by study country and by study size (N=16 studies).

Factors		Number of studies	Total size	EBF prevalence % [CI95%]	Heterogeneity
					Tau2	I2 (%)	p
By country	Tunisia	2 Bouanene and al 2008 Ben Slama and al 2009	614	11 [ 0-80]	6.26	99	<0.01
	Libya	2 Abdulmalek 2017 Salem Berdan and al 1988	525	42 [34-50]	0.04	72	0.06
	Morocco	3 Hamada and al 2016 Habibi and al 2016 Laamiri and al 2016	2030	48 [37-60]	0.15	95	<0.01
	Egypt	6 El Shafei and al 2012 Al Ghwass and al 2010 Abou ElWafa and al 2017 Mohamed NafeeElsayed and al 2016 El Gilany 2003 Khamis Hassan and al 2013	2619	18 [11-29]	0.54	97	<0.01
	Algeria	2 Abla and al 2014 Kadi and al 2015	1677	36 [5-86]	3.10	100	<0.01
	Sudan	1 Warille 2014	384	63 [58-68]	-	-	-
By study size	<500	9 Bouanene and al 2008 Ben Slama and al 2009 Abdulmalek 2017 Salem Berdan and al 1988 Habibi and al 2016 El Shafei and al 2012 Mohamed NafeeElsayed and al 2016 El Gilany 2003 Khamis Hassan and al 2013	2363	26 [14 – 45]	1.55	97	<0.01
	500-1000	Laamiri and al 2016 Abou ElWafa and al 2017 Abla and al 2014 Kadi and al 2015 Warille 2014	3403	38 [17 – 64]	1.52	99	<0.01
	>1000	Hamada and al 2016 Al Ghwass and al 2010	2083	21 [4 – 59]	1.54	100	<0.01

The forest plots of the 16 included studies by country and by study sample size are represented, respectively, in Figure 11 and Figure 12.

Figure 11. Forest plot of the pooled prevalence of exclusive breastfeeding stratified by study country (N=16 studies).

Figure 12. Forest plot of the pooled prevalence of exclusive breastfeeding stratified by sample size (N=16 studies).

To determine potential sources of heterogeneity and to predict the EBF practice, univariate and multiple meta-regression analysis was conducted by considering the country, sample size, and year of study conduct as covariates, but no factor was identified as statistically significant (Table 4).

Table 4. Identifying heterogeneity factors for the estimation of exclusive breastfeeding global pooled prevalence using univariate and multiple meta-regression analysis (N=16 studies).

Univariate meta-regression
Factors	Adjusted R-squared	F-statistic	P-value
Country	0.4924	1.94	0.1743
Study size	-0.06874	0.03517	0.8539
Year of study conduct	-0.06874	0.03517	0.8539
Multiple meta-regression
All covariates	0.22	1.604	0.2606

Pooled prevalence of EBF up to 6 months

The pooled prevalence of EBF until the first 6 months of life (eight included studies from all 6 countries except Algeria, with an overall sample size of 3564) was 30.0% (CI_95% [14.0; 52.0]), prediction interval [0.01;0.93] with heterogenous results (Tau²=1.8, I²=99%, p<0.01) (Figure 13).

Figure 13. Forest plot of the pooled prevalence of exclusive breastfeeding up to 6 months of infants’ lives (N=8 studies).

Barries to EBF practice

Mother educational level

A total of 10 studies were included in the analysis. The analysis was carried out using the log odds ratio as the outcome measure. The estimated average of observed log odds (OR) ratio based on the random-effects model was equal to 0.42 (95% CI: −0.44 to 1.29) with a prediction interval at 95% of the OR [−2.3-3.1]. Therefore, the average outcome did not differ significantly from zero (z=0.9604, p=0.3369). According to the Q-test, the true outcomes appear to be heterogeneous (p<0.0001) and I²=94.1%. The Forest and Funnel plots are shown in Figure 14 and Figure 15 respectively.

Figure 14. Forest plot showing the pooled OR of mother educational level on practicing exclusive breastfeeding using the random-effects model.

Figure 15. Funnel plot of the 10 included studies to assess the mother educational level on practicing exclusive breastfeeding using the random-effects model.

Maternal employment

A total of 10 studies were included in the analysis. The estimated average of the log odds ratio (OR) based on the random-effects model was equal to 0.25 (95% CI: −0.57 to 1.07) with a prediction interval at 95% of the OR [−2.1-2.6]. Therefore, the average outcome did not differ significantly from zero (z=0.58, p=0.5567). According to the Q-test, the true outcomes appear to be heterogeneous (p<0.0001) and I²=94.7 %. The Forest and Funnel plots are shown in Figure 16 and Figure 17 respectively.

Figure 16. Forest plot showing the pooled OR of maternal employment on practicing exclusive breastfeeding using the random-effects model.

Figure 17. Funnel plot of the 8 included studies to assess the maternal employment on practicing exclusive breastfeeding using the random-effects model.

Delivery mode: (vaginal or cesarean section)

A total of 5 studies were included in the analysis. The estimated average of the log odds ratio (OR) based on the random-effects model was equal to 0.24 (95% CI: −0.08 to 0.57) with a prediction interval at 95% of the OR [−0.28; 0.76]. Therefore, the average outcome did not differ significantly from zero (z=1.4555, p=0.1455). According to the Q-test, there was no significant amount of heterogeneity in the true outcomes (p=0.1760) and I²=33.2%. The Forest and Funnel plots are shown in Figure 18 and Figure 19 respectively.

Figure 18. Forest plot showing the pooled OR of delivery mode on practicing exclusive breastfeeding using the random-effects model.

Figure 19. Funnel plot of the 5 included studies to assess the effect of the delivery mode on practicing exclusive breastfeeding using the random-effects model.

Neither the rank correlation nor the regression test indicated any funnel plot asymmetry (p=0.483 and p=0.327, respectively).

Discussion

We reviewed the current evidence on the prevalence and determinants of EBF during the first six months of life among 16 studies with an overall sample size of 7849. Overall, the pooled prevalence of EBF during the first six months of life in the NA countries was 29% (CI95% [18 %- 42 %]). Subgroup analysis (of the 16 studies) revealed that the prevalence was the lowest in Tunisia (11%). The pooled prevalence of EBF up to 6 months of life was 30% (CI95% [14.0; 52.0]).

The global pooled prevalence of EBF during the first six months in our SR was comparable to the reported prevalence in most West and Central African countries.⁴⁸ However, it is lower compared to prevalence in most East and Southern African countries.⁴⁸ Our estimated pooled prevalence of EBF in the NA countries did not reach the 50% which is the World Health Organisation’s target of prevalence of EBF in the first six months, listed among the six global nutrition targets by 2025.⁴⁹

The result of the estimated pooled prevalence of EBF during the first six months of life in our SR was heterogenous (Tau²= 1.41, I² = 99%, p<0.01). A more in-depth data analysis was carried out by eliminating studies that could be a source of heterogeneity, in order to find more homogeneous results. Eleven outlier studies were removed from the overall analysis. The estimated pooled prevalence of 5 studies from Tunisia, Libya, Morocco, and Egypt was about 40.0% (CI95% [38.0-42.0]) with homogenous results (Tau²= 0.0053, I² = 31%, p=0.22). This pooled prevalence was greater than some middle and low-income countries. For example, the EBF prevalence was 1% in Jordan,⁵⁰ 6.6% in Brazil,⁵¹ 19% in Nigeria,⁵² and 27.2% in Iran.⁵³ However, our prevalence was lower than most West and Central African countries.⁴⁸

The results of EBF prevalence during the first 6 months by country from our MA were compared in Table 5, to the rates reported in the latest MICS surveys, for each country except for Libya (no results from MICS surveys were available). According to the United Nations of International Children’s Emergency Fund (UNICEF) data,⁵⁴ the EBF rates during the 6 first months of life are collected through household surveys like DHS, MICS, and other national nutrition surveys, using specific indicators such as “exclusive breastfeeding” for infants aged 0–6 months.

We notice after this comparison a variability of rates between countries and within the same country.

Our results highlight the low rates of EBF prevalence in NA countries. Here are some factors that may explain the low adherence and practice of EBF in these countries^55,56:

Comparing our fundings to other African countries, here are some insights about EBF rates in African region. A systematic review and meta-analysis of EBF in Ghana revealed that half (50% (95% CI 41.0–60.0% among children aged 0–6 months) of all infants in Ghana are exclusively breastfed during the first six months of life.⁵⁷ EBF is a public health priority in sub-Saharan Africa. However, there is variability in EBF rates within the region. Some countries have shown increases in EBF over time, while others have experienced declines. For example, Sierra Leone is expected to meet the WHO’s EBF of 70% by 2030 at the national level, but there are disparities in EBF rates at the province- and district-levels in other countries like Chad, Nigeria, Niger, and Somalia.⁵⁵

The prevalence of EBF also varies widely within all African countries. Some regions or districts may have significantly higher or lower rates than the national average. For example, Lesotho, Burundi, and Rwanda are predicted to meet the WHO’s exclusive breastfeeding target at all their province and district levels, while Chad and Somalia have some of the lowest levels of EBF prevalence. Geographic inequalities in EBF prevalence are also evident, with countries like Nigeria showing a six-fold or greater difference in exclusive breastfeeding rates between districts.⁵⁵

The Global Breastfeeding Scorecard 2021 revealed that 27 African countries had EBF rates below the 50% target set by the World Health Assembly for the year 2025.⁵⁸ The report emphasizes the need for scaling up breastfeeding in Africa through multisectoral approaches, investments, and systemic changes to achieve the global targets for EBF.

It is important to note that the prevalence of EBF may vary across different African countries due to various factors. These disparities and inequalities may be attributed to a combination of factors, including sociodemographic, cultural, economic, and healthcare-related influences. Here are some possible explanations^55,58,59:

Figure 20. Geographical distribution of the status of different African countries regarding their degree of compliance with the International Code of Marketing of Breast-Milk Substitutes’ recommendations.

Source: Marketing of Breastmilk substitutes WHO 2022Middle East and African Region.⁶⁰

Moreover, among children younger than 6 months in LMICs, 36.3 million (63%) were not exclusively breastfed at the time of the most recent national surveys. The corresponding percentages (of non EFB) were 53% in low-income countries, 61% in lower-middle-income countries, and 63% in upper-middle-income countries.⁶¹

These findings indicate a wide difference in the prevalence of exclusive breastfeeding (EBF) both across countries and within countries over time. It should be noted that variations in the methodologies used to estimate the EBF rate can also impact the results, as suggested by previous studies.^62–64

Otherwise, the low adherence to EBF among women in low- and middle-income countries can be explained by some barriers to its practice. To explain barriers to EBF practice, we analysed the effect of the educational level of mothers, the maternal employment, and the mode of delivery. This was not an exhaustive list of barriers to EBF practice, but it was widely and commonly described in previous published literature. It should be noted also that our analysis was dependent on quality of information provided in the selected articles and we were not able to extract and find all factors related to EBF in our selected articles. There is evidence to support the fact that women with higher levels of education are more likely to engage in exclusive breastfeeding compared to those with limited formal education.^65–67 In the past, in the USA, breastfeeding initiation was more prevalent among mothers with lower levels of education until the 1960s, but there has been a shift in this social pattern since then.⁶¹ Furthermore, a higher level of education is also consistently associated with an extended duration of breastfeeding.^68,69 Based on the literature, it has been observed that mothers who opt for EBF tend to be more proactive in educating themselves about nutrition and dietary choices. They also consult with healthcare professionals more frequently and have better access to information regarding the health of their breastfed infants, in comparison to mothers who do not practice EBF.⁷⁰ It is possible that mothers with higher levels of education are more aware of the benefits of EBF, leading to greater motivation in implementing it.

Subgroup analysis (10 studies) revealed that the prevalence of EBF in NA countries was not affected by mothers’ educational level (p=0.3369). This observation could be explained by the limited number of studies included in this meta-analysis.

As for maternal employment, a total of 8 studies were analysed in the present study. We didn’t find a significant impact of this parameter on EBF prevalence in NA countries (z=0.5878, p=0.5567). The variation in the duration of paid maternity leaves among countries in the region, raging from less than 12 weeks in Tunisia and Libya to 14 to 17 weeks in Algeria, could potentially explain this observation.⁷¹ Indeed, the International Labour Organization recommends that mothers should be provided with a minimum of 18 weeks of maternity leave with full salary coverage during that period,⁷² this practice is yet to be enforced in North Africa.

Previous studies have indicated a higher likelihood of breastfeeding discontinuation before the age of 6 months when mothers are employed full-time.^73,74

In their survey of 15 maternity hospitals in the “Pays de la Loire” region in France, Branger et al. considered that factors related to work (parity, socio-occupational category, timing of the decision to breastfeed) were more significant than work itself in terms of weaning. However, around 16 weeks, after returning to work, a shift was observed in the probability curves of breastfeeding.⁷⁵

Hence, it is important to consider providing psychological support to breastfeeding mothers who are employed, particularly from their partners and employers, to help create a supportive environment for them. There is also a need extend maternity leave and provide support facilities in the workplace.

We also considered the mode of delivery as a potential risk factor in the EBF practice. After analyzing five relevant studies, no significant difference was found regarding the prevalence of EBF in relation to the mode of delivery.

We examined a considerable body of literature regarding the relationship between delivery mode and breastfeeding. While there are variations in how delivery types are categorized, vaginal delivery consistently shows significant increases in both the initiation and continuation of breastfeeding, and therefore, a portion of the observed effect of delivery mode on breastfeeding outcomes is likely influenced by the confounding effects of maternal body size.⁷⁶

According to Sheehan et al.,⁷⁷ vaginal deliveries were associated with higher odds of exclusive breastfeeding at 6 months. The pain and discomfort experienced after cesarian section may hinder breastfeeding. Interestingly, mothers who gave birth at home were five times more likely to exclusively breastfeed compared to those giving birth at hospitals. This correlation can be attributed to the negative impact of formula supplementation and reduced breastfeeding initiation due to the disruption of the mother-infant dyad. Women who undergo cesarian deliveries may experience disruptions in lactogenesis, which can be attributed to decreased oxytocin secretion or maternal stress. These factors can result in decreased milk production.⁷⁸

However, in contrast to previous studies, Violet Naanyu’s research in Kenya did not find a significant association between exclusive breastfeeding and the mode of delivery.⁷⁹ It is worth considering that the widespread use of spinal anesthesia in cesarian deliveries may contribute to enabling mothers to initiate breastfeeding within an hour of birth. Additionally, the misconception that a cesarian delivery may negatively impact the shape of the mother’s belly could motivate mothers to prioritize EBF, as it promotes rapid uterine involution and helps maintain a smaller abdomen later.

Although our analysis did not differentiate between different types of cesarian deliveries (planned or emergency), previous research has indicated that the type of cesarian delivery does influence breastfeeding initiation and duration. Mothers who undergo emergency cesarian deliveries face greater difficulty in initiating breastfeeding compared to those who have vaginal deliveries.^80,81 However, several studies have shown that planned cesarian deliveries, in particular, are associated with a significant decrease in breastfeeding initiation.^81,82 Women undergoing planned cesarian deliveries are less likely to have the intention to breastfeed, initiate breastfeeding, or seek lactation support.⁸¹ Infants born through planned cesarian deliveries are more likely to encounter factors associated with lower gestational age, which can affect breastfeeding initiation, such as poor sucking skills and decreased alertness.^81,83,84

Conclusion

In conclusion, this SR and MA has assessed the pooled prevalence of EBF among mothers in NA countries and explored the key risk factors associated with EBF practice.

Our findings indicate that the practice of EBF in NA countries falls below the recommendations of the WHO and requires further attention and improvement. Our results highlight the importance of targeted interventions and support programs to promote optimal breastfeeding practices in these regions. EBF rates in NA vary widely, and efforts to promote and support this practice need to be context-specific and tailored to each country’s unique challenges and opportunities. While some countries have made progress in increasing EBF rates, others still face barriers and disparities that hinder the achievement of the WHO’s EBF target. To improve EBF rates, investments in time, resources, education, and policy support are crucial. Implementing policies and programs that provide skilled lactation support, breastfeeding counseling in health facilities, raising awareness among mothers, improve maternal education and sensibilization and paid longer maternity leave could help alleviate the burdens of related complications and health impact of lower EBF rates. It is crucial to work together to create an enabling environment for this optimal infant feeding practice and to provide adequate support to overcome potential barriers and challenges faced by mothers in sustaining EBF practices. Inappropriate and exaggerate marketing of breast-milk substitutes play a very important role in decreasing the practice of EBF among mothers. The adoption of legal measures to combat the influence and the rapid and powerful evolvement marketing tactics adopted by baby food manufacturers is crucial.

Appropriate interventions are needed at both the national and subnational levels. More research on socio-economic, cultural, and healthcare factors, and country-specific data are needed to provide a comprehensive overview of the rates of EBF in all NA countries.

Finally, breastfeeding is primarily a mindset and a practice to be ingrained in future generations for its preservation. Concerted efforts are required to promote and support EBF practices. Overall, a multi-dimensional approach involving families, healthcare systems, non-governmental social organizations, societal commitment, and policymakers is needed to promote and sustain EBF practices in NA countries, ultimately leading to improved health outcomes and well-being of infants and mothers in the region.