Infant Feeding Practices: A Global Perspective

Abstract

Infant nutrition is a primary determinant of growth and development, with long-term impacts on health. The World Health Organization (WHO) offers guidelines for infant feeding, however practices vary by geographical location, culture, and biopsychosocial factors. This chapter provides a comprehensive overview of peer-reviewed and gray literature on the current infant feeding guidelines and cultural practices across the globe. The findings draw attention to the multiple drivers and barriers to exclusive breastfeeding in various regions. This chapter can serve as a building block to inform future public health initiatives and research. By addressing these barriers, we can improve maternal and infant health and reduce the burden of malnutrition and associated health consequences for infants globally.

1. Introduction

According to the World Health Organization (WHO), undernutrition is associated with the deaths of 2.7 million children annually, which is 45% of all child deaths [1]. WHO recommends early initiation of breastfeeding within 1 h of birth, exclusive breastfeed (EBF) for the first 6 months of life, and introduction of nutritionally adequate, safe complementary foods at 6 months with continued breastfeeding up to 2 years of age [1]. Breastfeed of infants is associated with higher cognitive development, reduced risk of infections in both childhood and adulthood, reduced risk of obesity in adulthood, reduced serum cholesterol levels in adulthood, and a small reduction in systolic blood pressure in adulthood [2]. Breastfeeding also significantly reduces the risk of developing type 2 diabetes mellitus [2]. However, only 44% of infants under 6 months of age are exclusively breastfed, indicating that significant barriers exist to providing nutrition to infants [1]. Identifying and reducing these barriers is critical to improving infant nutrition globally, thus improving health outcomes in all populations.

Adequate nutrition is necessary in maintaining overall health for all populations, but is especially important in the infant population. Infant malnutrition is associated with growth stunting, developmental delays, and increased mortality, especially from diarrheal and respiratory illness [3]. Poor nutrition in infancy, particularly in the first year of life, is associated with negative health outcomes across the full lifespan. Malnutrition in the first year of life is associated with significantly elevated incidence of impaired IQ in adulthood, causing a nine-fold increase in adults with disability-range IQ relative to those with sufficient nutrition in the first year of life [4]. Furthermore, adult offspring of parents who were malnourished in the first year of life also demonstrate reduced IQ , even accounting for socioeconomic status (SES) and parental IQ [5].

Significant barriers to meeting infant nutrition guidelines exist globally. Economic factors such as poverty can limit access to healthcare, food, and other resources which are critical to both maternal and infant health. Similarly, geographic isolation reduces access to critical resources. Social factors such as a mother’s need to work outside the home, availability of family support networks, availability of community healthcare workers, and maternal autonomy are also influential on infant nutrition. Additionally, many cultural factors influence perceptions of breastfeeding and introduction of other foods. Family systems are essential in promoting maternal and child nutrition; all family and close community members play a role in the care of infants, particularly grandmothers and nuclear household members [6]. The dyadic relationship between mother and infant is particularly important, as it is well understood that infant health thrives where mothers are well-supported and healthy; infants also take nutritional cues from mothers, including maternal diet during pregnancy [7]. Education about infant nutrition and maternal-infant health is also of critical importance, because lack of maternal knowledge about infant feeding guidelines is associated with earlier cessation of breastfeeding and early introduction of solids [8]. Across the globe, infant nutrition faces significant challenges, which vary in nature by region and community. In this chapter, we explore infant feeding practices across different regions of the globe and specific barriers in different communities to better understand what progress must be made to improve global infant nutrition.

2. North America

Infant nutrition guidelines in North America recommend EBF for the first 6 months of life, followed by continued breastfeeding alongside complementary foods until 12 months of age. However, adherence to these guidelines is not always consistent due to various cultural and societal influences within countries. Unfortunately, early weaning can lead to a range of issues including increased risk of infections, malnutrition, allergens, and chronic diseases later in life [1, 9].

A mother’s close network, such as her spouse, grandmother, and close friends, play a critical role in infant feeding decisions and is associated with an increased likelihood of following medical guidelines for longer durations [10]. Interestingly, a mother’s distant network, including neighbors and relatives, have been found to encourage earlier introduction of family foods than recommended by medical professionals [11]. In Mexico, the Mexican Social Security Institute (IMSS) recommends the integration of family diet reflecting cultural practices between six and 12 months [12]. Despite high initial breastfeeding rates among Mexican mothers at 86%, 92% of infants are fed complementary food before reaching the recommended weaning age [13]. Factors such as maternal employment, maternal education, and maternal age all affect the recommended timeframe for introducing complementary foods [14]. Interestingly, Indigenous Mexican mothers are found to be more compliant with IMSS and WHO infant feeding recommendations than non-Indigenous Mexican mothers [13].

Cultural perspectives play a crucial role in infant feeding within North America. In some African American communities, the decision to breastfeed can be rooted in generational trauma of wet nursing during slavery and, for some, a preference for formula feeding [15]. Unfortunately, negative connotations of wet nursing (woman who breastfeeds and cares for another’s child) and slavery create a cultural barrier that denies African American women and infants the many benefits of breastfeeding [15]. Conversely, in many indigenous communities, the act of breastfeeding is highly valued and an essential cultural practice [16]. The rate of breastfeeding among Chinese Canadian mothers was 68%, lower than the overall rate of breastfeeding in British Columbia, Canada, which is 85–87% [17]. This difference in rates may be attributed to Chinese beliefs of yin-yang theory and a focus on protecting the mother’s body from illness postpartum, while Western medicine places emphasis on the baby’s body [17]. Chinese immigrant populations in Canada report mothers following the traditional postpartum practice of zuo yuezi, which involves new mothers staying at home, avoiding contact with cold items, and increasing the consumption of hot food [17]. This highlights the importance of understanding how cultural context can impact infant feeding practices and deviate from the guidelines provided within the region.

Furthermore, obesity’s impact on North American society is a critical factor that contributes to infant feeding practices. Approximately 30% of children in the United States are overweight or obese, with this trend consistently increasing for the past 20 years [18]. During an infant’s first 6 months of life, rapid weight gain has been associated with later obesity and related comorbidities [19]. Interestingly, mothers who had not previously breastfed or those who experienced higher stress levels tended to feed their infants more out of concerns about hunger [20]. One element of increased stress may be attributed to the timing of a mother’s return to employment. In the United States, employment has little to no impact on breastfeeding initiation. The literature suggests that in the United States, employment has little to no impact of breastfeeding initiation, however, the return to employment is a central factor influencing breastfeeding duration [21]. Therefore, the development of institutional and fiscal policies that offer employed mothers, especially in low-income groups, the support related to breastfeeding is vital for infant health.

3. Australia

Australia has similar breastfeeding guidelines are also in agreement with WHO recommendations and breastfeeding initiation rates however, at 3 and 6 months of age, breastfeeding rates fall below global standards [22]. For instance, in New South Wales, only 17.5% of infants are being exclusively breastfed until 6 months of age and there is a trend towards earlier introduction to complementary feeding [22]. This difference is more extensive in rural communities where 96% of Australian infants were breastfed at birth, 39% exclusively breast to 4 months, and 15% were breastfed for the recommended 6 months [23]. Although there are numerous factors impacting infant feeding decisions, maternal breastfeeding intention is a significant predictor of exclusivity and duration [24].

A particular concern in Australia from a recent study, highlights the exposure to breastmilk substitutes while in hospital. It is reported that 29% of infants were given breastmilk substitutes while in hospital [25]. This is in part due to the lack of antenatal education at the time of birth and the need for more support for breastfeeding continuing on in the early neonatal period. Almost one third of infants lose their EBF status as a result of the early introduction of breastfeeding substitutes, therefore changing the landscape of infant feeding practices in Australian neonates [26].

4. South America

The South American region faces many challenges to achieving WHO recommendations for infant feeding practices, including social, economic, and cultural barriers. Both urban and rural communities face specific difficulties, in both cases associated with low income and education levels [27]. Low access to nutritionally high-quality food is a common theme across the region, which is associated with nutritional inadequacies in infants and children, as well as higher intake of ultraprocessed foods [28]. Additionally, many communities hold cultural beliefs surrounding breastfeeding which decrease both the length of time infants are breastfed and the period of EBF [29]. Many studies show that women in South American low-income communities report having access to community healthcare workers and pediatricians who they have positive relationships with, while others report cultural barriers between healthcare workers and mothers [29, 30]. Mothers generally report a positive opinion of breastfeeding, but report struggle to meet WHO guidelines and the recommendations of local healthcare workers, indicating a strong need to address existing barriers to improving both maternal and infant health [30].

In Latin America, 75% of people live in urban settings, in contrast to 47% of the global population; this is associated with a rise in the number of people living in urban poverty, which has significant consequences for infant nutrition [27]. Childhood malnutrition in Latin America has declined in recent years, but the burden of malnutrition has shifted toward the urban setting, particularly where women must work outside of the home for income [27]. The need to return to work reduces maternal ability to maintain EBF, thus encouraging the use of infant formula and other complementary food products prior to the end of the recommended 6-month exclusivity window. In urban settings, more than 90% of infants are initially breastfed, but are much less likely to be exclusively breastfed, as milk-based complement foods are much more prevalent in urban communities [27]. While urban mothers are more likely to need to return to work outside the home, rural mothers are more likely to lack access to a variety of nutrient-rich supplementary foods, leading to an overall lower nutritional status for rural infants [27]. Thus, both urban and rural mothers in Latin America face geographic challenges to meeting WHO recommendations.

Access to high-quality nutrition is an ongoing struggle described across the South American region, which impacts both mothers and infants. In a Brazilian cohort study on infant feeding practices in 9- to 24-month-old infants, the percentage of children who met minimum standards for diet was significantly increased relative to past studies, but this improvement appears to be mediated by the use of ultraprocessed, high-sugar foods [28]. At 24 months of age, 76.1% of infants had met the minimum acceptable diet, and 80.1% met minimum dietary diversity, compared to approximately 50% in previous studies [28]. However, 99.4% of infants were consuming ultraprocessed foods at 24 months of age, while 30.5% were consuming no fruits or vegetables; by 15 months of age, all participants were consuming sweetened beverages [28]. Additionally, only 45.1% of infants were still breastfeeding at 24 months [28]. There was a reduction in breastfeeding alongside earlier consumption of sugar and lower consumption of eggs and pulses than previous studies, suggesting that women in Brazil are relying on ultraprocessed and sugar-rich foods to fill in existing nutritional gaps, rather than a closure of food disparities.

One of the significant cultural beliefs impacting breastfeeding practices in South America is the belief that breast milk is a cause of diarrheal illness in children [29]. Diarrhea is a leading cause of morbidity in children under 5 years of age, and is a significant aspect of health risk in small children, which in many communities in South America is at least partially attributed to breast milk [29]. In a study of cultural factors surrounding breastfeeding conducted in rural Peru, 85% of women reported ceasing breastfeeding before their infants reached the age of 2 years, citing four main factors: low breast milk supply, need to return to work and chores, belief that breast milk lacks nutritional value after 6 months, and belief that breast milk causes diarrheal illness [29]. Specifically, women reported the belief that breast milk can cause illness if exposed to heat or sun, if produced during a time of maternal physical or emotional unwellness, or if a subsequent pregnancy took place before the first child was weaned [29]. The same cohort also reported a poor relationship with local healthcare workers on a background of inappropriate understanding of these cultural beliefs and practices, likely causing distrust of advice given by healthcare workers [29]. This study describes how cultural beliefs can disrupt successful breastfeeding and create barriers between healthcare workers and local communities, worsening these communities access to reliable healthcare information.

Culturally aware advocacy from community health teams could improve understanding of the role of breastfeeding in infant health and nutrition. Many studies across South America have shown that women who have positive relationships with their local healthcare workers continue to seek advice, and report having positive perceptions of breastfeeding [30]. One study of Brazilian mothers’ perceptions of breastfeeding and complementary foods reported common beliefs that breastfeeding benefits both mother and child, improves mother-child bonding, and is economically beneficial and practical [30]. This population of women cited both their mothers and healthcare workers as supports for continued breastfeeding, and the majority of women continued to breastfeed exclusively until 6 months of age, before introducing complementary foods such as rice flour, milk, fruit juices, and banana [30]. Mothers who began complementary feeding before the recommended 6-month window cited the infant “looking too skinny” or being “unsatisfied” with breast milk alone, while mothers who delayed introduction of foods beyond 6 months cited financial burdens; women who were unable to follow healthcare workers’ recommendations reported frustration with being unable to comply, suggesting that having a well-received healthcare body does improve education and health literacy, but is potentially insufficient in addressing barriers to meeting WHO recommendations such as low income and inaccessibility of food [30].

Grandmothers of infants in South American communities are an important source of stability and advice, especially where mothers are adolescents [31]. In a Colombian study on the role of grandmothers in infant feeding practices, grandmothers were household decision makers in most households, and regularly advocated for breastfeeding and high-quality maternal diet, such as advocating for culturally significant, healthier meals over sugar-rich, ultraprocessed foods [31]. Mothers reported that this role is “essential to [the infant’s] upbringing”, and relied on grandmothers for guidance, advice, and support during times of illness or stress [30]. This suggests that by encouraging strong family support systems, the security and stability of mother-infant dyads can be improved, especially where adolescent mothers are involved.

Another study in Colombia examined modifiable risk factors in failure to initiate early breastfeeding and failure to exclusively breastfeed among a group of mother-infant dyads, and found that C-sections, lack of skilled attendant at birth, prelacteal feeding, and maternal overweight or obesity were all factors in non-adherence to recommendations [32]. Prelacteal feed refers to food given to newborns prior to initiation of breastfeeding, and includes provisions such as sugar and sugar juices, as well as honey, ghee (refined butter), and water or milk-based supplements [33, 34]. Improvements to patient education, pre- and perinatal healthcare, and postnatal follow-up are important to reduce the impact of these factors on mothers and their ability to successfully follow WHO guidelines regarding infant feeding practices.

In summary, the South American region faces a number of cultural, social, and economic challenges to the promotion of WHO-recommended infant feeding practices, but research suggests that this has improved in recent years. Continued improvement of healthcare advocacy and culturally aware community healthcare work, alongside a reduction in community poverty levels, are goals which will continue to improve maternal and infant health and nutrition.

5. Europe

A widespread phenomenon-emerging in many European countries is the effect of what is considered high health literacy on the impact of infant feeding practices. Many mothers from European countries have the education and accessibility to cultivate what they deem acceptable timelines and food group introductions for infant weaning.

The diet introduced to infants and children can greatly impact the overall health of the child, thus creating a window of time in which parents have the opportunity to influence their child’s future eating behaviors [35]. In many countries where the literacy level is high such as France, this creates a strain for the mother who can experience increased levels of stress in order to try to implement the best habits in her child [36]. Information in many European countries such as France, Germany, Spain, and Hungary comes in the form of the internet, social media, healthcare professionals, friends, and family. Studies have shown however, the various avenues of information are not especially significant without understanding the parent’s financial situation and education level [37]. French parents predominantly utilize healthcare professionals as their primary source of advice on childcare feeding due to the fact that consultations for children between the age of 0 and 16 are free and mandatory [38]. This is in contrast to mothers in England and Finland who were not as influenced by doctors in their infant feeding practices due to the disparity in the role of the health care professional. Mothers from Sweden in particular, are the most active in looking up information on the internet and thus are able to comprehend that information in a way that is safe and effective in child rearing [39]. Previous studies have found many correlations between the use of written sources and the number of years of formal education and higher incomes for mothers. Mothers in Sweden who have experienced more years of formal education may choose the written source as this involves searching and reading in contrast to mothers from Spain who rely on passive and informal methods such as family and friends for infant feeding information [40].

France is a model for the effect of immigrant-dominant cultural practices on the effect of breastfeeding as well. In Paris and its surrounding suburbs, women who were born in foreign countries have higher breastfeeding rates compared to other French regions. This is in part due to the fact that many of these women represent first-generation mothers who despite moving to a new country still identify with their traditional values, many of which are from middle eastern or African countries that place a greater value on breastfeeding [41]. This favorable attitude toward breastfeeding can be observed intergenerationally as well between first and second-generation mothers, many of whom are greatly influenced by the cultural practices of their foreign-born mothers before them [41].

A study that focused on Italy reports that women are more likely to breastfeed longer if they are more educated, a trend seen in central to northern Italy where literacy rates are higher [42]. Higher levels of education correlate to more demanding jobs and the subsequent effect of maternity leave then plays an important role in breastfeeding for Italian mothers. Studies conducted in northern Italy have found the longer the leave, the longer mothers breastfed their children [43]. These results are consistent with studies conducted in Norway as well, where such societies have many women employed in various professional jobs that therefore shape the workforce in developed nations to accommodate mothers and infant feeding [43]. Maternity leave is an important construct that shapes the first few months of both the infant’s and the mother’s life, and even after resumption of employment, Italian mothers still reported high motivation to continue breastfeeding [43]. Women in professional jobs have more control over their work and schedule and this allows them to develop a positive relationship between balancing employment and infant feeding.

Developed countries have guidelines for infant feeding practices that influence the parent’s decision on what foods to provide and at what times. These guidelines, however, do not necessarily guarantee optimal health for a newborn, as seen in Sweden in the 1990s. National recommendations during this time for Sweden caused many infants to be introduced to disproportionately large amounts of gluten without ongoing breastfeeding and thus a coeliac disease epidemic emerged [44]. The food content at this time also changed, with many infant cereals manufactured with almost double the amount of gluten and the usage of less protein-rich flour [44]. This provides an example of how the national guidelines can shift from unfavorable to favorable currently based on public health research and the ability of nations like Sweden to rectify infant feeding practices in a political manner.

In Greece, a national breastfeeding promotion program named ‘Alkyoni’ introduced breastfeeding awareness and educational activities for parents and healthcare professionals [45]. Along with this program, a baby-friendly initiative was introduced which created baby-friendly hospitals, and businesses including restaurants, shops, and pharmacies [45]. This provides an example of a nation taking proactive steps to ensure that the stigma surrounding breastfeeding is removed and that mothers are encouraged to breastfeed their babies longer. As numerous other local initiatives continue to become baby-friendly in Greece, higher rates of breastfeeding contribute to the overall health of babies and the shift of the national ideologies to become more cognisant of infant feeding practices [45].

6. Asia

Breastfeeding is a crucial tenant of infant nutrition in Asia. While the importance of this practice is well recognized, rates of EBF for up to 6 months, prior to the introduction of supplements, have steadily declined [46]. In South Asia, the early introduction of milk supplements have been attributed to a rise in inadequate nutrition for infants aged 6–24 months [46]. The premature use of such supplements reduces suckling, and thus milk volume, a negative cascade which promotes early cessation of breastfeeding [46].

There are several factors that impact breastfeeding trends. In Bangladesh and Iraq, maternal education and high familial SES were inversely associated with duration of breastfeeding [33, 46]. These trends are consistent with those in North America and Australia but were not found to impact the duration of breastfeeding in Japan [47]. Contrary to common belief, access to health and nutrition care was also linked to a shorter time span of breastfeeding in several states across India [46]. This highlights the need for appropriate education for not only the mother, but also for the post-natal healthcare team. Furthermore, returning to work was not found to be a detriment to the continuation of breastfeeding in Japan. However, the reason for this relationship is an area for further study [47].

Early initiation of breastfeeding, specifically within 1 h postbirth, is linked to a significant decrease in infection-specific infant mortality [34]. This may be attributed to the high protein and nutrient rich colostrum that is often produced soon after birth and substantially contributes to an infant’s immune system.

However, despite the well-established benefits of early Breastfeeding, in 2013, only 23.4% of infants in India were reportedly breastfed within 1 h of birth [34]. Preventing infants from consuming colostrum is a widespread practice in parts of Asia often prompted by a lack of education regarding the benefits offered by colostrum, in addition to a misconception that colostrum is unhygienic [34]. In West Bengal, India, villages often delay breastfeeding based on the misbelief that post parturition breast milk requires a few days to be ready for consumption [34]. Research also indicates that familial dynamics, specifically in South Asia the lack of decision-making power provided to the mother can hinder prompt initiation of breastfeeding [48].

Furthermore, early breastfeeding is also found to be 9 times lower in caesarean section versus vaginal delivery, a finding that is consistent across multiple research studies [33]. During caesarean section, the use of anaesthesia, as well as the post-operational recovery often results in a third-party providing care for the infants in the hours following birth [33]. Thus, alternative feeding is commonly used until the mother is well enough to explore breastfeeding [33].

Delaying breastfeeding is strongly associated with prelacteal feeding [34]. This practice has been linked to lower rates of literacy, and out of hospital deliveries [34]. Additionally, prelacteal feeding is also influenced by religion. In Islam, infants are often introduced to sweet provisions prior to breastfeeding [34]. Furthermore, misinformation such as familial beliefs that prelacteal feeding would prevent the development of neonatal illnesses (i.e., jaundice) or provide energy when there is insufficient lactation, also underlie the use of this practice [33].

Unfortunately, the use of prelacteal feed acts as a barrier to the EBF [33]. The use of water or milk-based pre lacteal feeds has been associated with a delay in lactation [34].

A potential mitigator of delayed breastfeeding is maternal education which targets cultural beliefs underlined by false information, as well as the taboos surrounding breastfeeding and colostrum [33]. Further improvements can be made through the inclusion of counselling alongside regular antenatal visits. Such support helps prepare pregnant mothers for breastfeeding prior to birth [34]. The use of counselling to improve early breastfeeding has been a proven model in areas such as Bolivia and Madagascar [34]. It is also important to note that early initiation of breastfeeding is less likely in mother’s who experienced obstetric problems. Therefore, research supports the early identification and support to such high-risk mothers [34].

7. Africa

Despite the global advocacy by the World Health Organization (WHO) for EBF, a significant number of African countries are still experiencing remarkably low rates of EBF that begin as low as 10% [48, 49, 50]. Infant nutrition guidelines in African countries recommend EBF for the first 6 months of life, followed by continued breastfeeding alongside complementary foods until 12 months of age [50, 51, 52, 53, 54]. Breastfeeding is widely acknowledged as the typical and optimal method of feeding infants, and most mothers support the recommendation to exclusively breastfeed their babies for around 6 months [50, 54]. However, in Africa, poor comprehension and cultural attitudes towards EBF, as well as conflicts between traditional beliefs and the promotion of EBF, are the primary impediments to the sustainability of this practice [51, 52, 53].

7.1 Socioeconomic factors

Research results in regards to the association between EBF and the mother’s education and SES has been inconsistent with multiple studies showcasing opposing results. In a Morrocan SES, researchers found a strong association between maternal employment and EBF [55]. Many mothers were aware of the benefits of EBF, with higher levels of awareness among those with higher education and SES [55]. Nonetheless, a study in West Africa found that almost half of the participants believed that formula-feeding was more convenient than breastfeeding, which was especially important for working mothers [50]. Additionally, a study conducted in Congo did not find an association between EBF up to 6 months and the mother’s family income [56]. The researchers suggested this may have been due to a variety of reasons, including limited access to complementary foods and breast-milk substitutes due to a lower income. As a result, EBF may have been the sole choice they had for feeding their babies.

Furthermore, researchers in Cameroon found that women of higher SES preferred the use of infant formula against WHO recommendations [54]. Study participants also admitted that they and their affluent, educated peers sometimes chose formula instead to display their wealth and social status [54]. The contradictory results of the above-mentioned studies suggests that socioeconomic factors may contribute to the low rates of EBF in African countries.

7.2 Social support

Access to healthcare services across the continent have also been found to account for low EBF rates [57, 58, 59]. Although access to a health facility provides an opportunity to receive and respond to health promotion messages, relevant messages about breastfeeding may not have been effectively communicated to mothers during antenatal care. A research study carried out in Tanzania discovered that despite 91% of mothers receiving medical attention during the antenatal period, only 39% of pregnant women and 25% of postpartum mothers received counselling on breastfeeding [59]. Previous studies from Ghana and Nigeria reported that mothers who used traditional healthcare services were more likely to practice optimal breastfeeding; however, a more recent study discovered that mothers who frequently attend antenatal visits (ANC) were more likely to bottle-feed their babies than those who did not attend ANC visits [57, 60, 61]. This is also a critical issue in regards to mothers with HIV whose fear of HIV transmission and status disclosure are among reasons for the low prevalence of EBF in South Africa [62, 63].

In rural areas of Egypt, mothers were found to be more likely to initiate breastfeeding within the first hour after delivery compared to Egyptian urban mothers [58]. Additionally, mothers with no education were found to be more likely to initiate breastfeeding within the first hour after delivery compared to educated mothers [58, 64]. However, the results of the 2008 EDHS indicate that health providers did not provide proper advice to pregnant women about breastfeeding [58]. Surprisingly, similar to findings mentioned previously, mothers who received regular antenatal care or delivered with the assistance of a trained health provider were less likely to initiate breastfeeding within the first hour after delivery than those who received no medical or antenatal care [58]. In fact, 52% of mothers who received regular antenatal care initiated breastfeeding within the first hour of delivery, while the percentage was 67% for mothers who did not receive any antenatal care [58].

The impact of marketing and unethical marketing tactics used in the baby formula industry also plays a role in infant feeding in North Africa [65]. A study by WHO found that 38% of Moroccan mothers were offered recommendations for specific milk brands by health professionals [65]. Additionally, 19% of mothers were offered free milk samples inside the hospital, 20% were offered samples outside the hospital, and 26% were offered samples both inside and outside of the hospitals [65]. The promotion of baby formula decreases the likelihood of adherence to EBF.

7.3 Sociocultural factors

There is a common belief in numerous cultures that breastfeeding alone is insufficient for nourishing a child, and that it is necessary to provide complementary solid foods or liquids in order to address thirst and promote healthy growth and development. This is prelacteal feeding and it is one of the most significant practices that hinder proper infant nutrition in African culture [66]. It can lead to lactation failure, insufficient milk production, infection, diarrhea, and short duration of breastfeeding [66, 67, 68]. Moreover, there is a vicious cycle between prelacteal feeding and delayed breastfeeding initiation, which may delay the production of breast milk and further encourage the use of prelacteal feeds [66, 69]. A study conducted in Egypt which included 647 mother-infant dyads found that about 58% of newborns receive prelacteal feeds [66]. The primary reasons for giving prelacteal feeds were tradition (61.0%) and mother’s/mother in law’s advice (58.3%) [66]. A study conducted in Kenya reported that the belief that prelacteal feeds protect the baby from stomach problems was common not only among breastfeeding mothers but also among community health or social workers [70]. Some communities believe that prelacteal feeds are necessary to clean the baby’s bowels, keep the mouth and throat moist, keep the baby warm, soothe the baby, relief pain, and allow stool to be passed [66, 67]. In East African countries, some cultures believe that a male infant needs solid foods immediately after birth in order to be strong and healthy and that if practicing EBF, the bones will weaken [50, 71]. Other various explanations for prelacteal feeding can be explained by a study conducted in rural areas of Cameroon [59]. Firstly, breastfeeding mothers experienced societal pressure from their elders to follow this customary practice and were hesitant to cause any disagreements [59]. Secondly, the women believed that all members of the family should benefit from the highly treasured farm produce, including infants [59]. Lastly, they were prohibited from engaging in sexual activity while breastfeeding [59]. More recently, East Africa and various non-governmental organizations have collaborated and formed groups to tackle the shortcomings in EBF and come up with solutions to enhance its positive health effects [50]. This includes efforts to improve EBF at healthcare centers and in the community, while also partnering with the media as a primary tool to raise awareness [50].

EBF practices can be influenced by a mother’s perception of her own breast milk production. Multiple studies conducted in Tanzania and Kenya have found that the main reason for introducing complementary food early was the belief that the amount of breast milk produced by the mother is insufficient for the child’s growth [59, 72, 73]. As a result, these mothers perceived their child to be thirsty, leading them to introduce herbal medicine for cultural reasons, which was identified as one of the key factors for early mixed feeding [59]. Additionally, Indigenous African people commonly use herbal and medicinal preparations, which are believed to protect infants from evil spirits and improve their chances of survival [56, 59]. As a result of this belief system, EBF is often considered not only an impractical idea but also a “harmful practice” that endangers the lives of infants [56]. In Cameron, a study found that participants with low education and low occupations believed that one should wait to breastfeed only after the colostrum has passed [54]. Other studies found that participants of various religions discarded the colostrum because it was regarded as impure, unhealthy, or harmful and subsequently, they delayed the first breastfeeding for a few hours or even days [59, 66].

Additional research has highlighted the cultural expectations and social norms that encourage women to breastfeed. Qualitative research conducted in Benin showed that mothers perceived breastfeeding as a daily and on-demand activity, often initiated by the infant’s cries [74]. In Nigeria, some women regarded breastfeeding as a religious privilege because breastmilk was considered a natural gift from God [70, 74]. Researchers from Nigeria explained how breastfeeding is a crucial part of African women’s maternal identity and is deeply ingrained in their psyche [74, 75]. In other studies from DRC and Mali, breastfeeding was considered a child’s right and a necessary aspect of a mother’s duty [76, 77]. Deviating from this norm could lead to sanctions; resistance to breastfeeding in Ghana and Nigeria has been found to result in negative reactions, such as family disapproval, anger, or stigmatizing allegations that the mother or child was HIV-positive or illegitimate [75, 78, 79].

Another study in Nigeria found that awareness (95.3%) and knowledge (82.0%) of EBF was high among surveyed mother but the practice of EBF (33.5%) was very low [62]. Socio-cultural beliefs in Nigeria, such as the perception babies continued to be hungry after breastfeeding, the fear of babies becoming addicted to breast milk, lack of family support and the need to return to work were found to influence the mothers’ decision to breastfeed or bottle-feed [60, 63, 80]. In Nigerian communities, new mothers typically do not have the autonomy to make infant feeding decisions, as these decisions are often made by the father or grandmother [60, 63]. Grandmothers, who usually provide significant support to nursing mothers, are knowledgeable in infant feeding practices, but their skills are often based on traditional belief systems [60, 63]. Based on their role, grandmothers can influence a mother’s decision to breastfeed or bottle-feed, which may be an additional reason for suboptimal feeding practices among mothers in Nigeria [60, 63, 81].

8. Conclusions

In conclusion, infant feeding practices are crucial for ensuring the health and well-being of infants globally, but adherence to recommended guidelines for EBF and complementary feeding is influenced by a variety of cultural, societal, and environmental factors. These factors vary across regions, with each region facing unique challenges and barriers to achieving optimal infant feeding practices.

High-income countries like those found in North America, Europe, and Australia face similar challenges in adhering to guidelines for EBF and complementary feeding, including cultural and societal influences. However, in Australia, breastfeeding rates fall below global standards, and the exposure to breastmilk substitutes in hospitals is a particular concern. In Europe, high health literacy among mothers influences their infant feeding practices, creating a need for more support for mothers in implementing the best practices for their children.

South America faces numerous challenges in achieving the WHO recommendations for infant feeding practices, including social, economic, and cultural barriers. Both urban and rural communities face specific difficulties, with low access to nutritionally high-quality food being a common theme across the region, leading to nutritional inadequacies in infants and children. Breastfeeding rates have been declining in Asia, with early introduction of milk supplements being attributed to inadequate nutrition for infants. Various factors influence breastfeeding trends, including maternal education, familial SES, access to health and nutrition care, and returning to work. In Africa, poor comprehension, and cultural attitudes towards EBF, conflicts between traditional beliefs and promotion of EBF, and inadequate communication and understanding about breastfeeding are the primary impediments to the sustainability of this practice. Socioeconomic factors, social support, and sociocultural factors also play a role in the low rates of EBF.

Overall, there is a need for increased support for mothers, especially in low-income groups, to ensure that all infants have access to the health benefits of EBF and appropriate complementary feeding practices. This support should be tailored to the unique challenges faced by each region and should involve advocacy from community health teams, maternal education, counseling, and early identification and support for high-risk mothers. By addressing these barriers, we can improve maternal and infant health and reduce the burden of malnutrition and associated health consequences for infants globally.

Conflict of interest

The authors declare no conflict of interest.