Qualitative Studies of Infant and Young Child Feeding in Lower-Income Countries: A Systematic Review and Synthesis of Dietary Patterns

Continued high rates of both under- and over-nutrition in low- and low-middle-income countries highlight the importance of understanding dietary practices such as early and exclusive breastfeeding, and dietary patterns such as timely, appropriate complementary feeding—these behaviors are rooted in complex cultural ecologies. A systematic review and synthesis of available qualitative research related to infant and young child dietary patterns and practices from the perspective of parents and families in low income settings is presented, with a focus on barriers and facilitators to achieving international recommendations. Data from both published and grey literature from 2006 to 2016 was included in the review. Quality assessment consisted of two phases (Critical Appraisal Skills Program (CASP) guidelines and assessment using GRADE-CERQual), followed by synthesis of the studies identified, and subsequent thematic analysis and interpretation. The findings indicated several categories of both barriers and facilitators, spanning individual and system level factors. The review informs efforts aimed at improving child health and nutrition, and represents the first such comprehensive review of the qualitative literature, uniquely suited to understanding complex behaviors leading to infant and young child dietary patterns.


Introduction
Early nutrition is crucially important for children to survive, grow and develop into healthy adults who can lead rewarding lives and productively contribute to their communities, and improving nutrition among young children has widely been recognized as an international priority [1]. Nonetheless, almost half of all childhood deaths (those under age 5) continue to be linked to nutritional causes [2]. In addition to morbidity and mortality, the impacts of poor nutrition, both in the form of under-and overnutrition, include strong, negative intergenerational health consequences for descendants [3]. Alongside maternal nutrition and intrauterine exposures [4], nutritionally-based caring behaviors of families, including breastfeeding and complementary feeding, form the basis of child nutrition. As a result, the potential impact of improved dietary practices on child nutrition has been extensively studied and subsequently promoted for potential to greatly improve health [5][6][7][8].
The United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) concur that optimal nutrition practices for childhood include early initiation of breastfeeding, exclusive breastfeeding for the first 6 months of life, followed by the addition of nutritionally adequate, safe, and appropriate complementary foods with continuation of breastfeeding for 1 year and longer [9,10]. Markers of appropriate infant and young child feeding include these practices, as well as the timely introduction of solid and semi-solid foods, adequately frequent provision of daily meals, dietary diversity, and consumption of iron rich foods. In response to the need for simple, practical indicators of appropriate feeding practices in children aged 6-23 months, WHO published a set of population-level indicators that could be obtained from large-scale survey data on feeding practices in varied international settings [11].
However, characterizing feeding practices through quantitative methods such as large-scale surveys can be challenging, particularly because these practices constitute multidimensional and often interrelated behaviors rooted in family systems and socioeconomic conditions, and feeding patterns also change rapidly within short intervals of age [12,13]. Nonetheless, information on infant and young child feeding (IYCF) practices is required to improve nutrition and health during the first 2 years of life. Over the last decade, numerous studies on improvement of nutrition-related behaviors for infants and young children have relied on qualitative research methods, well-suited to exploring complex behaviors and their underlying psychosocial and cultural drivers, to investigate infant and young child feeding [14][15][16][17][18]. This body of research is likely to contain useful information to further the understanding of behavioral approaches to improve child nutrition. A comprehensive summary of qualitative data on feeding practices in this age group from lower-income settings, including a synthesis of barriers and facilitators to recommended practices, is currently lacking in the biomedical literature.
The primary objective of the proposed study was to systematically review qualitative literature related to family experiences (particularly parental ones) of infant and young child feeding in low-income countries, synthesizing information on the barriers and facilitators that may relate to interventions to impact nutrition, survival, growth and development. The results provide an overview of qualitative studies relating parental perspectives on infant and child dietary patterns, in the interest of providing insights for developing, improving, and scaling nutrition interventions.

Materials and Methods
This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO): registration number CRD42016035677. The review followed guidelines from the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. Due to the exclusive focus on qualitative research, the review employed the ENTREQ guidelines [19] in lieu of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, which are more specific to the requirements of quantitative literature reviews [20]. The Supplementary Material to this article contains the full ENTREQ checklist.
Studies were only reviewed if their results were directly obtained from participants who were parents or close family members of an infant or young child (0-2 years of age) at the time of the study. Family members, for the purposes of this review, were defined to include mothers, fathers or other caregivers living in the child's household who routinely engage in infant or young child feeding. Infant and child feeding practices were defined as all actions taken to meet the physiological nutritional needs of children in this age group, including but not limited to: breast feeding; introduction of solid, semi-solid, and/or family foods (known as complementary feeding); and continued breastfeeding of children alongside provision of solid/semi-solid food.

Inclusion and Exclusion Criteria
Included studies used widely accepted qualitative data collection methods, with well-described methodology, including for example: interviews, focus groups, direct observation, and participatory action research. Included studies also needed to have provided a clear description of recognized qualitative data analysis methods (e.g., Grounded Theory, narrative analysis, content analysis, thematic analysis).
Excluded studies were those for which it was difficult to extract qualitative data, e.g., mixed methods studies without clearly labeled data, or studies in settings where perceptions of parents or caregivers around infant and young child feeding could not be clearly identified, such as summaries or aggregated data. Commentaries, protocols, and systematic reviews were not included in the analysis. Additionally, as the focus was on research from resource limited settings, studies from countries other than those defined by the World Bank as low-income countries and lower-middle income countries (which have a Gross National Income per capita of less than $4125) were excluded [21].

Search Strategy
The following electronic databases were considered to be the most relevant for the topic and were searched: MEDLINE (PubMed); Embase; Cumulative Index to Nursing and Allied Health Literature (CINAHL: EBSCOhost). A health sciences librarian was consulted in the development of the database searching strategy.
The initial search strategy was developed for MEDLINE and then adapted for the other databases. Medical Subject Headings were initially used followed by free-text terms using controlled vocabulary (see Appendix A for a detailed description of the search strategy). Results were restricted to English language publications from the last 10 years, due to potential difficulties in translating and interpreting foreign language qualitative data by native English-speaking reviewers, and to ensure that the review identifies literature relating to the most current infant and young child feeding practices. In addition, reference lists of included studies were manually searched to identify any additional studies that fit the inclusion criteria.
The included grey literature was initially identified through listing of relevant websites to search for organizations working in nutrition in lower-income countries (in consultation with experts working in the field who use and disseminate data through websites for related nutrition research). A custom search engine was created using Google Custom Search. Within the Custom Search Engine, the relevant websites were searched using search strategies adapted from those used in the databases to reflect relevant keywords related to qualitative studies of infant and young child feeding practices.
The review also included documents identified through a manual review of organizational reports and reports from relevant meetings related to nutrition of young children in low income countries. Results were similarly limited to publications in English from the last 10 years.
A flow diagram using PRISMA guidelines for reporting of systematic reviews is presented in Figure 1 in reporting of the selection process and results [20]. For organization of initial search results, Endnote reference management software (EndNoteX8, Clarivate Analytics, Boston, MA, USA) was used, and results of searches imported to the software. At the first stage, duplicates and irrelevant studies were removed. Two independent reviewers then screened study titles and abstracts for suitability against inclusion and exclusion criteria. The decision to include or exclude a study was required to be agreed on by both reviewers. If after consultation a decision was not reached by the two reviewers, a third reviewer made the final decision.

Quality Appraisal
Each selected document was initially assessed for quality and internal validity according to the Critical Appraisal Skills Program (CASP) checklist for qualitative research [22]. The CASP checklist includes 10 questions to appraise the quality of qualitative research. These assessments for each study can be seen in the final column of Table 1 with reference to the CASP appraisal question number where the study presented potential quality limitations. Selected studies met minimum criteria defined through the checklist including domains such as appropriateness of study design, data collection techniques, and analysis methods used. CASP questions include the following: 1. Was there a clear statement of the aims of the research? 2. Is a qualitative methodology appropriate? 3. Was the research design appropriate to address the aims of the research? 4. Was the recruitment strategy appropriate to the aims of the research? 5. Was the data collected in a way that addressed the research issue? 6. Has the relationship between researcher and participants been adequately considered? 7. Have critical issues been taken into consideration? 8. Was the data analysis sufficiently rigorous? 9. Is there a clear statement of findings? 10. How valuable is the research?

Data Extraction
For organization of extracted data, a unified matrix was utilized to record specific characteristics of included studies. Extracted data included: reference details (author, year, title, journal/publisher); country/region of study; objectives or aims of the study; study design including methodological approaches (e.g., interviews/focus groups) and conceptual basis underlying the study (e.g., Grounded Theory); analysis method(s); sampling methodology and sample size; and initial assessment of the methodological limitations of the study. The initial results of the selection process and data abstraction are presented in Table 1.
Additional steps were taken in the data extraction phase that involved expanding the matrix (Table 1) to include participant characteristics, summaries of key outcomes/results reported, and the emergent review findings for which the study contributes evidence. These details are given in Appendix B. To explore and describe mothers' perception of baby feeding and approaches to support for baby feeding & to describe and explore mothers' experiences of support for baby feeding, with a focus on the transition from exclusive to non-exclusive breast feeding, in suburban Dar es Salaam, Tanzania.

Quality Appraisal
Each selected document was initially assessed for quality and internal validity according to the Critical Appraisal Skills Program (CASP) checklist for qualitative research [22]. The CASP checklist includes 10 questions to appraise the quality of qualitative research. These assessments for each study can be seen in the final column of Table 1 with reference to the CASP appraisal question number where the study presented potential quality limitations. Selected studies met minimum criteria defined through the checklist including domains such as appropriateness of study design, data collection techniques, and analysis methods used. CASP questions include the following: Was there a clear statement of the aims of the research? 2.
Is a qualitative methodology appropriate? 3.
Was the research design appropriate to address the aims of the research? 4.
Was the recruitment strategy appropriate to the aims of the research? 5.
Was the data collected in a way that addressed the research issue? 6.
Has the relationship between researcher and participants been adequately considered? 7.
Have critical issues been taken into consideration? 8.
Was the data analysis sufficiently rigorous? 9.
Is there a clear statement of findings? 10. How valuable is the research?
At the second level of appraisal, the GRADE-CERQual (Grade Conidence Evidencerom Reviews Qualitative research) guidance [23] was used to differentiate emergent findings strongly supported or less well supported. Two reviewers independently reviewed studies. Reviewers used guidance derived from GRADE-CERQual to reach consensus of the quality of findings emergent from included studies. The results of this appraisal are presented in Table 2. During this process, methodological limitations of emergent findings were considered and categorized as minor, moderate or major. These categorizations were based on the presence or absence of description of key elements in methodology (guided by the CASP assessment in Table 1) in the document(s) which support the finding, including the following: approach used to recruit or sample participants, how potential for researcher bias was addressed, how analysis was done or, in the case of mixed methods research, how statistical sampling and analysis was done. Minor methodological limitations were those with one element missing, moderate limitations were those with two elements missing, and major limitations were those with three or more missing. Full details of which elements were missing from each document are available in Appendix C. Additional assessments of emergent findings were conducted based on the quality of the studies or documents supporting the finding. These included assessments of relevance, coherence and adequacy guided by the GRADE CERQual methodology. Assessments of relevance and coherence were not conducted for emergent findings with minimal (usually one) studies or grey literature contributing to the finding. These assessments for each emergent finding are given in Table 2 with full details of the how assessments were made found in Appendix C. The overall assessment of confidence in emergent findings was based upon the assessments of methodological limitations, relevance, coherence and adequacy and was guided by the GRADE CERQual method. These are given for each emergent finding in Table 2 along with an explanation of judgment describing how the level of confidence was reached.    No concern about adequacy of data

Moderate confidence
This finding was graded as moderate confidence because of minor concerns about coherence, moderate concern about relevance and methodological limitations.

52
Mothers concern about over-feeding their child (which might cause them to be hungrier in future) 16 Moderate methodological limitations NA NA No concern about adequacy of data NA NA Moderate concern about adequacy of data

Moderate confidence
This finding was graded as moderate confidence because of moderate concerns about methodology, adequacy of data, relevance and minor concern regarding coherence.   NA: not applicable.
Following abstraction and grading of evidence, the final step involved data from the results, discussion, and conclusion sections of the included studies, being extracted and entered into NVivo 11 qualitative software (QSR International Pty Ltd., Version 11, 2015, Burlington, MA, USA), wherein thematic analysis was employed to identify domains descriptive of the data for investigation and presentation.
This thematic analysis led to a more interpretive phase in order to understand how the themes identified may represent barriers and facilitators to change infant and young child feeding; for this we used an approach similar to that of Thomas et al. [24].

Results
After a narrative summary of themes identified through the initial analysis was available, three reviewers met jointly to consider these and produce a consensus-based listing of barriers and facilitators. This step evaluated all emergent findings in light of the summary of themes wherein several emergent findings were often merged into one synthesized finding, or individual emergent findings were discarded due to weak assessments of confidence or minimal support from the included studies. Table 3 presents the synthesized review findings of barriers and facilitators generated through the data synthesis exercise and subsequently agreed on by reviewers.
Four categories of barriers to recommended breastfeeding practices were identified, and three categories of barriers to recommended complementary feeding practices were identified. None of the studies included in the final review disclosed funding from food manufacturers, nor disclosed any related conflicts of interests. Barriers to breastfeeding included factors specific to infant or mother, and cross-cutting beliefs and perceptions, as well as a pervasive lack of support for breastfeeding, from families, health workers and due to time poverty. Several categories of facilitators were also identified from the literature reviewed, including food security, social support, and individual infant and maternal factors. Table 3. CERQual summary of qualitative review findings. Objective: To systematically review qualitative literature related to family experiences (particularly parental ones) of infant and young child feeding in low-income and lower-middle income countries, synthesizing information on the barriers and facilitators that may relate to interventions to impact nutrition, survival, growth and development.
Perspective: Experiences, beliefs, attitudes and perceptions of parents/caregivers who routinely engage in infant and young child feeding.
Included studies: Included studies involved participants from low-income or lower-middle income countries who were parents or close family members of an infant or young child (0-2 years of age) at the time of the study; used widely accepted qualitative data collection methods; and provided a clear description of recognized qualitative data analysis methods.

Conclusions
The findings contribute to the expanding literature on family experiences related to breastfeeding and complementary feeding of young children and infants in low-income settings and constitute the most comprehensive summary of findings to date. Previous systematic reviews of qualitative literature related to infant feeding have not included as broad an approach to the topic as the current review, having focused rather on specific areas such as bottle feeding [25] and obesogenic dietary intake. [26] Another qualitative review, undertaken in 2008, focused solely on maternal support for breastfeeding mothers [27] and one carried out in 2013 considered the psychosocial correlates of exclusive breastfeeding [28]. Neither of those included a comprehensive approach to assessing the quality of included studies.
Strengths of the current review included the use of multiple reviewers experienced in qualitative research and data collection and analysis, a comprehensive search strategy, assessment and scoring of quality and confidence placed in the findings based on guidelines, and inclusion of grey literature. Limitations of the study were the exclusion of documents not available in the English language and date limitations. Two authors of the present review, who conduct research in this topical area, have authored or co-authored articles included in the review, which inclusion was based solely on having met the eligibility criteria.
Overall, this review focused on identifying qualitative and ethnographic studies that related the experiences and first-hand accounts of family members responsible for providing for the care and nutritional needs of young children under 2 years of age. Through this systematic qualitative review and synthesis, hypothesized barriers and facilitators to improving infant and young child feeding have been identified. The findings presented in this review are directly applicable to social and behavioral change initiatives in low resource settings aimed at improving dietary patterns and practices for better health and nutrition of young children.

Acknowledgments:
No funding was provided for this study. All authors have read and approved the final manuscript.
Author Contributions: A.N.B. conceived and designed the study. All authors jointly contributed to the implementation of the research, to the analysis of the results, and to the writing of the manuscript.

Conflicts of Interest:
All authors declare that they have no competing interests.

Appendix A
Details of search strategy.  Mothers' ages ranged from 16 to 45 (mean age = 25), "The highest educational level attained was as follows: one had attended university (did not graduate), two had graduated from secondary school, one had completed eighth grade, three had completed sixth grade, two had completed fourth grade, and one had never attended school. When asked how well they spoke and/or understood English, two said "a little," and the other eight answered "not at all." The estimated yearly income for the entire family was reported by all 10 participants as less than 28,500 pesos ($868 U.S. dollars)."

Date of Search Search Terms Total Articles Returned
From abstract: "The women who participated in the focus group all breast fed their babies with the belief that breast milk is better for infants than formula. Cereal, fruits, and vegetables are the main diet for children under 3 years old. Typically, "fast foods" and snack foods are not readily available and therefore they are rarely consumed. Obesity was viewed as a health risk for children. These mothers were practicing many healthy feeding behaviors, such as breastfeeding and limiting fats and sweets for young children, and they recognized their importance in promoting the health of children." Additional notes: Participants universally practiced breastfeeding in part because formula is expensive and not readily available. They recognized the association between breastfeeding and the health of their babies. They all learned to breastfeed from their mothers/grandmother/sisters and said that everyone in the DR learns this way. Older mothers mentioned that breastfeeding has a negative effect on the physical appearance of their breasts but that this did not impact their decision to breastfeed because formula is not affordable. Mothers said they avoid giving fast foods and snack foods (which are not readily available), greasy/fatty foods, and sweats to young children. Since they do not give greasy/fatty foods to young children, they do not give much meat until around 3 years because it is greasy. Participants said that 3 years is the age when children eat what everyone else in the house eats in the DR.
(1) (59) (65) (68) 2 Amal Omer-Salim, Lars-Ake Persson, Pia Olsson Whom can I rely on? Mothers' approaches to support for feeding: An interview study in suburban Dar es Salaam, Tanzania Mothers were aged 16-30 years. Four women had no formal education, two had completed primary education and two had completed secondary education. Five of the women were homemakers and three were either formally employed or self-employed From abstract: "The study revealed four categories of mothers' perceptions of baby feeding: (1) baby feeding, housework and paid work have to adjust to each other; (2) breast feeding has many benefits; (3) water or breast milk can be given to quench baby's thirst; and (4) crying provides guidance for baby feeding. Four different themes describing approaches to support emerged from the data: (1) adhering to diverse sources; (2) relying wholeheartedly on a mother figure; (3) working as a parental team; and (4) making arrangements for absence from the child." Additional notes: Mothers believed breastfeeding makes babies healthy and prevents diseases. Also, breastfeeding was viewed as a cheap and hygienic option. Some believe colostrum is good for the baby and so initiated breastfeeding soon after birth, but some women did not believe this and discard it. Good nutrition for the mother thought to improve breastmilk output. Some women practice exclusive breastfeeding believing that breastmilk is all a baby needs, but some think the baby also needs water (but they know that the water must be clean to give to baby). It is a traditional practice to give boiled water shortly after birth. Some believe that giving water relieves baby from constipation. Initial crying was recognized as a prompt for breastfeeding, but too much crying led mother to give water or porridge and was seen as a sign of hunger (traditional beliefs say porridge will solve this and baby will stop crying). Advice from HWs was sometimes inadequate (too general, or infeasible for mother). Advice from mother/mother-in-law/senior mother figure sometimes refutes the advice given by HWs. Support and agreement from the husband encourages breastfeeding. Praise from partner or HW encouraged mother to continue to exclusively breastfeed. Work interrupted optimal baby feeding for many mothers, but some mothers reported expressing breastmilk into a clean cup while working to continue to breastfeed the baby. From abstract: "The major reasons for delaying initiation of breast-feeding were the perception of a lack of breast milk, performing postbirth activities such as bathing, perception that the mother and the baby need rest after birth and the baby not crying for milk. Facilitating factors for early initiation included delivery in a health facility, where the staff encouraged early breastfeeding, and the belief in some ethnic groups that putting the baby to the breast encourages the milk." Additional notes: Barriers for delayed initiation: The perception of a lack of breastmilk: including physical signs that milk is absent/insufficient, beliefs about colostrum, and traditional beliefs of when the milk comes in (believed to be on the third day for some cultural groups in the study). Some believed colostrum was not good for the baby and so discarded it or delayed initiation until white milk came in.
Delayed initiation of breastfeeding beyond 12 h often led to prelacteal feeding. Facilitators: Delivery at a health facility facilitated early initiation of breastfeeding due to advice of HWs. From abstract: "Almost all of the participants believed that exclusive breastfeeding is the superior infant feeding method and should be practiced for the first 6 months postpartum. However, there was widespread belief that infants can be given water if it is clean. Mothers reported that exclusive breastfeeding was easier when breast milk began to flow soon after delivery. The main obstacles to exclusive breastfeeding identified were maternal employment, breast and nipple problems, perceived milk insufficiency, and pressure from family." Additional notes: Mothers obtained advice on exclusive breastfeeding (EBF) at the antenatal care clinic, during hospital stay, or at the postnatal care clinics. (Nurses advised them of the recommended practices, even if the reasons they gave were inaccurate). Knowledge that "breastmilk is best" was a motivation for women to practice EBF. Facilitators to EBF: Observation that EBF resulted in less frequent and shorter duration of illness in infants was a motivator for EBF. Mothers felt that EBF makes babies grow strong, intelligent, and healthy. Young babies stomachs are not mature enough for anything other than breastmilk (this finding lacks some coherence as some women believed breastmilk alone was not sufficient-e.g., when a baby still cries or remains restless even after breastfeeding it is a sign they need other foods). Mothers believed that her nutrition influences breastmilk production and quality; cultural beliefs influenced what foods they should eat for improved breastmilk production. Mothers' knowledge that poor water and sanitation could cause a child to get diarrhea if child had other water or foods was a motivator for EBF. Some believed water should not be given to babies because of (runoff) from the fertilizers and chemicals used in the agricultural industry contaminating their water supply. Barriers to EBF: Swollen breasts, abscesses, and sore nipples are barriers to breastfeeding. Work interferes with breastfeeding (short maternity leave, followed by inability to find a place to breastfeed when they return to work). Maternal sickness and death prevents breastfeeding (though only two participants said women with HIV cannot breastfeed). Infant sickness impairs breastfeeding (child may lose interest or not latch on), along with weak jaws which impact sucking ability of infant, prompting mother to give other food so baby does not lose weight. Some mothers believe breastfeeding makes their breasts sag and so refuse to breastfeed. Women are hesitant to breastfeed in public, even in their cars because they do not want people to see their breasts. Pressure from mothers/grandmothers to adopt the mixed feeding methods their generation had used impacts EBF (especially if grandmother is around when infant is crying, they assume breastmilk is not enough), then women resort to adding water or not practicing EBF. Lack of support from the baby's father could also hinder breastfeeding.
(1) The women participating ranged from 20 to 33 years of age. Regarding the level of education, one of the women had done university studies, four had completed high school, 5 had not finished high school, and the remaining participants had been in grammar School.
From abstract: "Findings are presented in two parts: practices and beliefs in favor of exclusive breastfeeding and practices and beliefs that do not support exclusive breastfeeding. The prominent practices and beliefs in favor of exclusive breastfeeding are related to the mother´s bond with the child, preparation for breastfeeding during pregnancy, and family support. Among the practices and beliefs not supporting maternal breastfeeding, we must highlight the mother's lack of confidence in her breast milk production." Additional notes: Breastfeeding was associated with providing love to their child and strengthening their bond. Women were convinced that breastfed children will be healthier and smarter in the future. But, exclusive breastfeeding for six months was considered difficult, and required preparation. They want their milk to be of adequate quality and quantity for their child. Some grandmothers or other elders had ideas of ways mothers could improves these milk traits (e.g., consuming fennel water). Mothers, mothers-in-law and grandmothers helped prepare mothers to breastfeed through their own experiences. Some still felt that breastmilk alone would not be enough for their child. Especially if the child continued crying. Pain in the breast was another reason for not exclusively breastfeeding. Some mothers who exclusively breastfed reported their child had become dependent on the breast and it was then difficult to wean. Along this line, mothers believed that weaning would be easier if the child had already had milk from other sources.
There is a belief that children are born with weak stomachs and something must be done to strengthen it and protect them from disease. Home preparations are often given tot eh child within days after birth for this purpose; these included bean tincture, bacon, or a liquid to purge the stomach. There was a gap in knowledge about appropriate complementary foods in terms of quality and quantity and strategies to convert family foods to make them suitable for children. Complementary feeding advice from family members, peers, and health workers, the importance given to feeding young children, and time spent by caregivers in feeding influenced the timing, frequency, types of food given, and ways in which complementary feeding occurred." Additional notes: Children were fed complementary foods prior to 6 months of age primarily due to the perception that breastmilk alone was inadequate as the child got older. Liquids were given to young babies, including formula, which was considered good to maintain the health of the baby. From abstract: "Five categories of breastfeeding attitudes and practices were identified: breast-feeding best but not exclusive, cultural and traditional beliefs, infant feeding as a learning process, factors influencing decision to breastfeed, and intention to feed the child." Additional notes: Mothers recognized that breastmilk is best, but none were exclusively breastfeeding. Many gave water because they think the baby gets thirsty and that water will prevent tongue disease. Most discarded colostrum thinking it is harmful for baby, but a few knew that it was beneficial to baby's health. Some were afraid breastmilk alone is not enough for baby so they also gave formula. Mothers believed that breastmilk quality was linked to health of mother (an ill mother would produce inferior milk), and her ability to consume the traditional postnatal diet. Mothers followed traditional beliefs (e.g., what to eat and not eat; messaging) to improve breastmilk production. Mothers, mothers-in-law, and grandmothers encouraged breastfeeding, told them how to breastfeed and helped with housework to allow mother to rest (after childbirth) and care for infant. The process of learning about breastfeeding from various sources gave them increased knowledge, which lead to improved self-confidence. Husband support gave confidence in breastfeeding. Returning to work shortly after birth (mostly before 6 months) made breastfeeding difficult. Media influenced mother's opinions of formula and baby foods and made them think they are good for baby. Lactation problems (sore and cracked nipples, engorgement, inadequate lactation) interrupted breastfeeding with formula as a replacement. Size of baby influenced breastfeeding: mothers said they would feed baby more if he/she was small. Some mothers fed baby when he/she cried. After 4 months, mothers believed breastmilk alone was not enough so would add formula and/or complementary foods. The initial breastfeeding practice immediately after delivery impeded the mothers' decisions to exclusively breastfeed. For example, some women believed their baby had been given formula by the health provided after birth, so they hesitated to breastfeed exclusively. The belief of insufficient production of breast milk lead mothers to wean their babies early. After weaning their babies, the mothers still had a desire to breastfeed. Mothers kept trying to breastfeed even though they had weaned their baby and reported breastmilk production had decline. Early weaning caused several consequences (e.g., decline in breastmilk, increase in spending, health problems for the baby), which continued to affect the mother's and baby's lives. Some women though their babies grew faster after weaning and they enjoyed the extra time they had to spend on their daily activities. Media promotion of formula, suggestions from peers and family, and the mothers need to work were reported as external factors which impeded exclusive breastfeeding. Internal factors which did this included lack of knowledge about exclusive breastfeeding, techniques to ensure effective breastfeeding (e.g., ensuring baby was satiated), not recognizing baby feeding cues and behaviors, and believing formula can make babies healthier. The majority of them were unemployed and/or housewife (n = 9). Six were employed.
From abstract: "Participants demonstrated positive attitudes towards breastfeeding and recognized its importance. Despite this, breastfeeding practices were suboptimal. Few exclusively breastfed for the first six months of the baby's life and most of the first-time mothers included in the sample had stopped or planned to stop breastfeeding by the time the infant was 18 months of age. Work was named as one of the main reasons for less than ideal breastfeeding practices. Traditional beliefs and advice from health staff and the first-time mothers' own mothers, were important influences on breastfeeding practices. First-time mothers also cited experiencing tension when there were differences in advice they received from different people." Additional notes: Health staff assisted women to introduce breastmilk early, and many reported the importance of the child receiving the colostrum. Breastfeeding was also reported to strengthen the bond between mother and newborn.
Breastfeeding was thought to save money, giving it an advantage. Family elders have important role in decisions related to child feeding and one elder thought it was important to include them to avoid conflicts in advice given by health staff. Some women reported inconsistent advice from these two groups. Some women had trouble managing exclusive breastfeeding and work, with many citing it as the main reason for stopping exclusive breastfeeding early. Support from family and support in the workplace were also cited as reasons for success in exclusive breastfeeding. Insufficient milk supply, compressed (inverted) nipple and the baby just stopping sucking were all reported reasons for ending exclusive breastfeeding early. Fear of breast deformation and embarrassment of breastfeeding at social functions were also cited as reasons for stopping breastfeeding. Elders in the family often advocated for early introduction of complementary foods despite this being contradictory to the advice of health personnel. The range of mothers' ages was between 19 years and 43 years. Years of education attainment ranged from 0 to 13 years.
From abstract: "Mothers described baby care by birth attendants as well as actual and perceived health issues of the mother and child as some of the factors influencing timing of breastfeeding initiation." Additional notes: All 25 mothers believed that breastfeeding, colostrum and mature milk, was good for baby's health and they value providing these health benefits to their baby; baby's health was a priority for mothers. Mothers exhibited comfort with breastfeeding (comfortable feeding in front of others) and had the feeling that breastfeeding was the normal way of infant feeding.  (2) those that are traditionally introduced are not varied and primarily consist of grains and starches." Additional notes: Qualitative data revealed several beliefs that may limit implementation of optimal IYCF practices. Women in some communities felt it was necessary to administer purgatives shortly after birth to cleanse the child's body. A poor diet is believed to weaken breast milk, making it inadequate in terms of quality and/or unsatisfying to the child. Illness is thought to make breast milk "dirty" and unsafe for the child. In addition to these beliefs about breast milk, women view continued breastfeeding as a possible risk for infections among older children and thus prefer earlier weaning. Minimum dietary diversity achievement appears limited by difficulties mothers experience when complementary feedings and the low diversity of traditional, grain-based complementary feeding.
(2) From abstract: "The results provide qualitative evidence about facilitators and constraints to IYC nutrition in the two geographical areas and document their inter-connections. We conclude with suggestions to consider 13 potential nutrition-sensitive interventions. The studies provide empirical ethnographic support for arguments concerning the importance of combining nutrition-specific and nutrition-sensitive interventions through a multi-sectoral, integrated approach to improve the nutrition of infants and young children in low-income, resource-constrained populations." Additional notes: Not having enough money to buy food was commonly reported as a challenge associated with caring for their children. Shortage of water/lack of access to clean water was also a difficulty, both in taking time from mothers in water retrieval and in limiting food preparation. Collecting firewood and food storage limitations were also reported as issues impacting food preparation for young children. Mothers knew the importance of food and nutrition to their child's health and development. Mothers' ages ranged from 21 to 55. The range of education attainment was between 0 and 16 years. Ten mothers were housewives. Other mothers worked as a factory worker (n = 4), farmer (n = 3), or, sewer/weaver (n = 4), The rest of mothers' occupation included small convenience store worker, clothes seller, nighttime guard (father), and high school teacher.
From abstract: "The results revealed knowledge and practice gaps in behavior that likely contribute to breastfeeding barriers, particularly in the areas of infant latch, milk production, feeding frequency, and the use of breast milk substitutes. The predominant theme identified in the research was a dearth of detailed information, advice, and counseling for mothers beyond the message to exclusively breastfeed for 6 months." Additional notes: Women knew to practice exclusive breastfeeding for 6 months and reported following this behavior, however some mothers that reported this also said they used breastmilk substitutes on occasion. Some women described giving prelacteal feeds or waiting for the milk to come in prior to initiating breastfeeding. Some mothers gave water to newborns. Women reported that their own mothers, other female relatives or their midwives advised them on how to breastfeed. One mother reported that the midwife advised her to exclusively breastfeed but did not give her specific instructions to do so. Participants believed milk supply was related to the mother's nutrition. Some felt they did not have enough milk and one was concerned about transferring illness to her newborn via breastmilk. Some felt that newborns required less milk or shorter feedings (or from just one breast) than older babies required. Some also did not want to rouse a sleepy newborn to feed. Many women had concerns that breastfeeding would impact their breast shape and size. They especially felt this could occur if they used both breasts during one feeding session.
Positioning the newborn was also difficult for some mothers. Observations confirmed problems of poor latch, pain from suboptimal infant positioning and the practice of feeding from only one breast per session.
From abstract: "Although breastfeeding was prevalent, few mothers engaged in optimal feeding practices. Barriers included poverty, high work burden, lack of decision-making power in the household, and perceived milk insufficiency. Health provider guidance and mothers' motivation to breastfeed and feed nutrient-dense foods emerged as facilitators to optimal practices." Additional notes: Many women recognized the benefits of colostrum for their newborn and gave it to them. Many said their mothers or grandmothers did not practice this and discarded the colostrum, but advice from health centers has changed this behavior. Common reasons for discontinuing exclusive breastfeeding included the feeling of insufficient milk, clogged milk duct, and the child being ill. These reason led to early introduction of complementary foods, water, or sugar water. The weather being hot was another reason cited for giving water to an infant less than 6 months old. Crying was considered an indication of the child being unsatisfied with breastmilk alone, so also led to early introduction of complementary foods like porridges. They were encouraged to continu this practice when giving other foods led to the baby stopping crying. Women who succeeded in exclusive breastfeeding for 6 months had encouragement during ANC visits. Mothers also reported that their own diets were important to the success of exclusive breastfeeding. Children's diets (older than 6 months) have little diversity, and they eat what the family eats. Families with livestock do not tend to give the meat and milk available to their children as they prefer to sell these products in the market. The little meat the family eats is usually purchased, and milk is not commonly given to children as it is expensive. From summary: "The findings from this study showed that although mothers have basic breastfeeding and complementary feeding information, visible gaps remain, such as not practicing exclusive breastfeeding, the existence of faulty traditional beliefs, and specific misconceptions about breastfeeding and complementary feeding. Among the major misconceptions is the belief of mothers that giving only breastmilk without adding fenugreek juice will expose the baby to intestinal worms. Beliefs also keep mothers from providing extra breastfeeding for a sick child. Some mothers reported the belief that encouraging suckling when the child is ill will only contribute to its illness. In Tigrey Region, mothers, community members, and HEWs alike stressed the unavailability of diverse foods and lack of resources to purchase foods as the major reasons for not following recommended complementary feeding practices. Lack of food was also mentioned in explaining why mothers introduce complementary foods later than 6 months of age, fail to offer children a variety of food types, and are unable to give children extra meals when they are sick or recovering from illness. The study identified misconceptions that affect complementary feeding habits. Mothers, community leaders, and even voluntary community health promoters (VCHPs) hold widespread beliefs that children cannot digest meat or other animal products, that children will choke on thick porridges, that extra food when a child is sick will contribute to illness, that children will refuse to eat during or after sickness, and that bottle feeding is more sanitary than using cups or hands to feed. Mothers and other community members, HEWs, VCHPs, and supervisors all expressed interest in learning about the recommended IYCF practices, as long as they trust that the person providing advice is properly trained and has reliable information. The findings from this study reveal that HEWs have reasonably better knowledge in the area of breastfeeding than in complementary feeding. Regarding their own knowledge and skills related to counseling, almost all of the HEWs are keen to improve those skills." From summary: This study indicates that breastfeeding is widely practiced in the research communities and is expected of all mothers and valued in the community for its contribution towards child growth and healthy development. Mothers in the study areas seem to know the expected breastfeeding requirements such as: on-demand feeding, frequency of breastfeeding, and the need to feed from both breasts. Yet exclusive breastfeeding is not widely practiced in the study communities. Mothers commonly introduce water, fenugreek, or linseed water as early as 2 months. In regards to complementary foods, the study indicates that the age for introduction of additional foods ranges from 2 months to 8 months, with a majority of mothers reporting that they had started giving foods at 6 months or earlier. Certain foods such as kale, enichila, banana, egg, pumpkin, carrot, and green vegetables are considered unsuitable and "too strong" for young children to digest before 1 year of age. Mothers consider meat in particular as too difficult to digest. Most mothers recommend meat for children above 1 or 2 years old. Mothers also expressed that they need to have a good income to buy or feed their children such foods. The study also revealed that HEWs feel they have a need to learn more about child feeding in order to effectively counsel mothers on IYCF. Several pointed out that they need more detailed information about additional foods, types of foods, and best approaches for preparing food for young children, with follow-up mechanism.  Breastfeeding is recognized as extremely important by mothers and other members of the community and remains the first choice for infant feeding. There is widespread awareness about the message of exclusive breastfeeding for six months, and generally mothers, fathers and grandmothers expressed their support for the practice. However, in reality many respondents expressed doubts as to whether breastmilk was really sufficient during the first six months and whether mothers could produce enough breastmilk to meet their child's needs. In particular, families tended to introduce water before six months due to their perception that infants gesture to indicate their needs-and the belief that not responding is cruel to the child. And it is traditional to introduce water and watery foods early. When women are away from their infants, most respondents did not feel it was acceptable to express breastmilk. Many respondents strongly oppose it because it is considered untraditional, unhygienic, and unnecessary if the mother can stay close to her child. Multiple respondents commented that when mothers have an inadequate diet, they do not produce enough breastmilk, and need to introduce foods and liquids before 6 months of age, or must wean their child from breastmilk. The study identified a number of factors that represent barriers to the uptake of recommended infant and young child feeding practices. Respondents noted that cultural beliefs, traditions, and lack of knowledge about the nutritional needs of young children are barriers (e.g., most women give thin unenriched porridges as complementary foods). Many respondents identified lack of food and inability to afford food as a major reason for not providing appropriate foods to young children.
Mothers did not cite grandmothers and fathers as important influencers of IYCF. The media was cited as a source of information on IYCF. Prelacteal feeding of water and sometimes water with herbs was widespread. There were different beliefs regarding colostrum but some believed (with influence by the grandmother) that it was bad and dangerous for the infant. A traditional practice is to give herbal infusions in water to treat and prevent illness, from the time of birth. Being away from baby inhibited breastfeeding, and often results in introduction of water. Many of the women are farmers and it is difficult to breastfeed when they are working on the farm. Breastmilk is not believed to be sufficient in either water or sustenance for babies 3 months and older, so thin gruels are introduced at this age. Some women believed that a mother with HIV could not breastfeed her baby. A sick child with a lack of appetite requires "forced feeding" but some felt concern that this might make the child choke (child sickness impacts child feeding).
Maternal nutrition is recognized as important for pregnant and lactating women, and inadequate nutrition leads to inadequate milk production, but there was a lack of consensus of what foods are best for mothers and affordability may impact their ability to attain good foods. Fathers were supportive of the women and children achieving good nutrition by letting them eat first.  Table 2) 19 United States Agency for International Development Consulting with caregivers-formative research to determine the barriers and facilitators to optimal infant and young child feeding in three regions of Malawi Mothers in both phases were young, with more than half in each sample less than 25 years old. The overall literacy rate of the women in both samples (63.3 percent in Phase 1 and 69 percent in Phase 2) was slightly less than the national literacy average of 70 percent, 19 and in both samples, there was a wide variation in years of schooling, with approximately one-fifth to one-quarter of each group having no schooling at all and another quarter having more than six years of schooling.
Crying after feeding influenced the mother or other family members to give the baby other foods or liquids, assuming that the breastmilk was inadequate to satiate the baby's hunger. Giving water during hot times of the year was thought to be necessary by some mothers, interfering with exclusive breastfeeding. Mothers did not know that breastmilk alone was acceptable for infants less than 6 months; once they were told this and tried it many were successful at transitioning to the improved practice.
Observations identified two suboptimal breastfeeding practices: breastfeeds of very short duration, and breastfeeding from just one breast. When mothers transitions to improved practices, positive outcomes reinforced this behavior, including less crying and better sleep for babies, which give mothers more time for household chores, babies took more milk and did not have an upset stomach. Other family members support also facilitated good practice, for example by identifying that longer duration of breastfeeding indicated mother was showing more love to the child. Fear of HIV transmission was indicated as a reason for stopping continued breastfeeding early, along with having another pregnancy. The study also found that using breastfeeding to prevent pregnancy was also a facilitator of continued breastfeeding, but that mothers need counseling on the use of this method. Families given infants 6 to 8 months thin/watery porridges because they think this is the only food this age child can swallow and digest. Breastfeeding is common, but exclusive breastfeeding remains difficult for most mothers are they are responsible for a lot of work both in and out of the home. They are very busy and have limited access to information, do not have time to prepare special foods for children or exclusively breastfeed for six months (especially for mothers who work in the fields).
Overall, there is a lack of awareness about nutritional requirements for infants and young children. Adding oil to baby food is common, and meat is considered healthy but not given to children under 2 years because it is thought babies cannot digest meat. Thick porridge is also considered to be hard to digest, so thin porridge is given to young children. Eggs are sold in the market rather than given to children because they are expensive; the same applies to milk-if they have a cow they sell the milk in market, and many cannot afford a cow or goat. There was a lack of awareness that different foods provided different nutrients, or that nutrition was related to mental and physical development.
Respondents were not aware of the importance of the first two years of life. In most locations, there is lack of availability of several food categories, especially meat and fish, and they are expensive when they are available. Although infant and young child care are considered primarily the mother's realm, the study found that cultural beliefs also play an important role and grandmothers are largely responsible for propagating these beliefs. Grandmothers influence the early introduction of other foods, as a response to babies crying, indicating to them that breastmilk alone is insufficient. Feeding porridge to young babies also induces longer sleep sessions, which is a motivation for mothers to interrupt exclusive breastfeeding since it allows them to do more other activities. Some mothers' negative connotation regarding exclusive breastfeeding was due to the perceptions that those who exclusively breastfed for 6 months were HIV positive. Reasons for early cessation of breastfeeding included pregnancy, doctor's advice, baby refusing to eat other foods, and reduction in breastmilk supply. Mothers had minimal awareness of best complementary feeding practices. Resulting sub-optimal practices included early introduction of complementary foods, low quality foods in terms of energy and nutrient content, and inadequate feeding frequency. Foods given to young children are limited to what the household can afford (they eat modified family foods usually). Heavy workloads of the primary caregiver impacts complementary feeding behaviors. Force-feeding was reported as a common practice in Western Province. Some caregivers are only able to cook food, usually porridge, for the baby once a day and then store it in a flask the rest of the day, increasing the chance of bacterial growth. Grandmothers in Eastern Province believed that meat should not be given the children before 2 years of age, impacting the quality of diets of children.
The study found that grandmothers and men have inadequate knowledge of recommended IYCF practices. Men listen to the advice of their mothers (the child's grandmother) more than their wives regarding infant and childcare and feeding, since they are considered more experienced. Men may not be clear about their role in IYCF besides providing food. Men are interested in obtaining more information on IYCF but there are no forums to do so besides general community-level initiatives like flyers, radio programs, or messages from church. Men want to learn about best practices form trained experts, and trust those who they perceived as more knowledgeable on the topic. The majority of fathers did not believe exclusive breastfeeding for 6 months would be feasible due to the mother's many responsibilities that require separation from the infant. Men agreed that they must provide mothers with adequate food to allow them to breastfeed successfully. Grandmothers are highly regarded as knowledgeable and experienced caretakers in the communities and so play a large role in infant and child caregiving and feeding. They also often provide financial support to their son's young families. Grandmothers are the main alternative caregivers when mothers are away. They are also central in decision-making regarding food preparation and child feeding, along with other important activities like sick-child care. The majority of respondents (42.2%) were between the ages of 22 and 29 years. The median age was 28 years. More than half of the respondents (56.3%) in the nine districts had little or no education (primary school or less). Only one-third had completed basic education (middle school or junior high school). District-specific data showed a similar result in only three of the districts: Sene, Sunyani West, and Kintampo South having respondents with tertiary level education. The majority were peasant farmers, including a few fishermen (55.2%); followed by petty traders (13.7%) and artisans (12.2%). A little more than 10% (11.5%) reported that they were unemployed. About 85% of the respondents were married. Only 7% of participants were single (never married), and 6.3% were cohabiting. The majority of the study participants reported Christianity as their religion (81.5%). This was followed by Islam (11.5%), with a small percentage being traditionalists.
Note: The majority of findings presented are from the quantitative portions of this study, so are not relevant for this review. Mothers and fathers who believed exclusive breastfeeding was good for baby < 6 months said that it helps a baby grow and protects them from breastfeeding. Those who did not believe exclusive breastfeeding was best said that this was because a baby needs more than just breastmilk to satisfy them (they also need water). From summary: "Delayed initiation of breastfeeding, pre-lacteal feeding, and lack of exclusive breastfeeding were found to be common largely due to a lack of understanding of their importance and confusion about colostrum feeding as well as the definition of EBF. Also, mothers lack support for appropriate infant feeding after delivery. The perception that baby's crying indicates insufficient breastmilk and that insufficient breastmilk is caused by poor maternal diets is widespread and a major barrier to EBF." Additional notes: Perceptions of what foods should be given for complementary feeding of children 6 to 24 months differ from the recommended practices. There is a lack of diversity of type of food available to give children, especially animal sourced foods. Child's poor appetite causes them to reject foods, inhibiting optimal feeding. Mother's time constraints and lack of knowledge of appropriate complementary feeding were viewed as larger barriers than limited food availability. Mothers lack knowledge of how to make family foods appropriate for young babies and therefore do not give them meat because it is presumed to be not appropriate for them. No concern about adequacy of data (the authors provide rich data) Minor concern about adequacy of data (the majority of the studies provide moderately rich data overall, but one study shows only thin data) No concern about adequacy of data (both studies offer rich data)

Moderate confidence
This finding was graded as moderate confidence because of minor concerns about coherence, moderate concern about relevance and methodological limitations Moderate concern about adequacy of data (one study provides moderately rich data overall, but other studies offer only thin data)

Moderate confidence
This finding was graded as moderate confidence because of moderate concerns about methodology, adequacy of data, relevance and minor concern regarding coherence. Moderate concern about adequacy of data (one study provides moderately rich data overall, but other studies offer only thin data)

Moderate confidence
This finding was graded as moderate confidence because of moderate concerns about methodology, adequacy of data, relevance and minor concern regarding coherence. NA: refers to nothing.