Breastfeeding Practices in Sierra Leone: Progress, Inequalities, and Influencing Factors
Breastfeeding, a universally acknowledged cornerstone of infant and maternal health, gains even more prominence with the concept of early initiation of breastfeeding. This term refers to the crucial act of breastfeeding within the first hour of birth, which is pivotal in achieving the Sustainable Development Goals (SDGs). Sierra Leone, a West African nation emerging from a period of significant challenges, has made strides in improving breastfeeding practices. This article examines the progress, inequalities, and factors influencing breastfeeding practices in Sierra Leone, drawing on data from multiple sources, including the Sierra Leone Demographic and Health Survey (SLDHS).
The Importance of Early Initiation of Breastfeeding
Early initiation of breastfeeding, defined as placing a newborn to the breast within the first hour of birth, is vital for improving neonatal survival, strengthening the mother-child bond, and ensuring the delivery of essential nutrients and antibodies. As the World Health Organization (WHO) and UNICEF recommend, early initiation of breastfeeding is essential for optimal infant health and survival. It ensures that newborns receive colostrum, the nutrient-rich “first milk” particularly beneficial for the infant’s immune system. Moreover, early skin-to-skin contact between mother and infant, which facilitates early initiation of breastfeeding, has been shown to increase the likelihood of exclusive breastfeeding for the first one to four months of life and extend the overall duration of breastfeeding.
Progress in Early Initiation of Breastfeeding in Sierra Leone
Between 2008 and 2019, Sierra Leone saw a significant increase in early initiation of breastfeeding within the first hour of birth, rising from 48.7% to 75.2%. The most notable progress occurred between 2013 and 2019, likely driven by targeted interventions, increased public awareness campaigns, and improvement in healthcare practices. By 2019, the prevalence of early initiation of breastfeeding among women in Sierra Leone exceeds the recommended target of 70%. This rate was also higher than previously reported studies conducted in Sierra Leone, which found a rate of 55.14%. It also exceeds the approximately 50% average reported in LMICs, as well as the 55.1% rate reported in a study across multiple sub-Saharan African countries. However, in a multi-country study, these findings were lower than those reported in Burundi (85.0%), Rwanda (80.5%), Mozambique (76.7%), and Malawi (76.3%). These gains may be partly attributed to policy actions such as the Breast Milk Substitutes Act enacted in 2021. As noted by the WHO and UNICEF (2023), this legislation was designed to protect breastfeeding amidst rising use of substitutes, and likely contributed to the upward trend in this study.
Disparities in Early Initiation of Breastfeeding
Despite the overall progress, inequalities persist across various socio-demographic factors.
Age: Contrary to previous studies that reported lower rates of early initiation of breastfeeding among young mothers, this study found that young mothers aged 15-19 years consistently exhibited the highest rates of early initiation of breastfeeding across all years, with a significant increase observed particularly between 2013 and 2019. This might be attributed to health interventions and educational campaigns that have effectively reached younger mothers. Improved access to healthcare and support systems, as well as socioeconomic and cultural shifts might also have contributed to these higher rates. Additionally, policy changes to improve maternal and child health may have disproportionately benefited younger mothers.
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Economic Status: From 2013 to 2019, mothers in the richest quintile consistently had the lowest early initiation of breastfeeding rates. In contrast, mothers in the poorest quintile showed significant improvement, reaching rates similar to those in the middle quintiles by 2019. The observed improvement in the poorest quintile suggests that targeted community-based health education programs could have effectively increased early breastfeeding rates. These strategies may include outreach and the provision of breastfeeding support to economically disadvantaged groups. The low rates in the richest quintile highlight the need for tailored strategies to address their potential barriers, such as workload or misconceptions about breastfeeding due to previous experiences.
Education and Residence: Mothers with no education and those living in rural areas had the highest initiation of breastfeeding rates, with improvements observed across all education levels by 2019. This aligns with previous studies in Bangladesh, which reported relatively higher early initiation of breastfeeding rates among less educated women. The findings is also linked to the observation that rural women, who typically have lower educational attainment, exhibited higher rates of early initiation of breastfeeding compared to their urban counterparts. These patterns underscores the potential influence of educational and geographical factors on breastfeeding practices. Educational interventions targeting rural areas and less educated mothers might be an effective approach to further increasing early initiation of breastfeeding rates. Strategies could involve community leaders and healthcare workers to ensure the message reaches women with limited formal education. However, these findings differ from previous studies in underserved areas of Sierra Leone, which reported low rates of early initiation of breastfeeding.
Regional Disparities: Notable regional disparities exist in early initiation of breastfeeding rates, with the Eastern region consistently lagging across the study periods. Significant disparities were also found in Ethiopia and Bangladesh studies. The low prevalence of early initiation of breastfeeding in the Eastern region could probably be due to the increased Caesarian section rate among women. A previous study in West Africa shows delays in breastfeeding initiation due to cesarean delivery. It is suggested that mothers face considerable discomfort after a cesarean section, leading to a delay in starting breastfeeding. The cultural norms of the community, as well as access to healthcare facilities and information, may also explain the disparities.
Factors Influencing Exclusive Breastfeeding
Exclusive breastfeeding (EBF) is the practice of giving the baby only breast milk and no other liquids, foods, or even water aside from syrups or drops that include vitamins, minerals, supplements, or medications during the first six months of life. Understanding the factors influencing exclusive breastfeeding practices among children aged 0-5 months is essential for developing effective interventions to increase exclusive breastfeeding rates.
Prevalence of Exclusive Breastfeeding: The prevalence of exclusive breastfeeding among children aged 0-5 months was 54.1% in Sierra Leone. This figure aligns with global trends, although it is greater than in some sub-Saharan African nations and lower than in others.
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Age of the Child: Children aged 2-3 months and 4-5 months had significantly lower odds of being exclusively breastfed compared to those aged 0-1 month. This finding highlights the decline in EBF rates as infants grow older, a trend that reflects challenges in sustaining EBF over time. A possible reason might be that women start giving their babies more food as they get older because they believe that breast milk is insufficient to satisfy their needs for nourishment and water. Another cause might have to do with mothers’ perceptions that their breast milk production has declined over time, making it insufficient for the infant’s growth. Additionally, it can be connected to mothers’ inadequate understanding of the value of EBF and the negative effects of starting supplemental feeding before the child is six months old.
Skilled Birth Attendance: Contrary to global trends and expectations, the study found that children with skilled birth attendance had lower odds of EBF compared to those without skilled birth attendance. This suggests potential gaps in postpartum care and breastfeeding counseling within health facilities, emphasizing the need for improved support for breastfeeding mothers during and after delivery.
Place of Residence: Children in rural areas had higher odds of EBF compared to those in urban areas. This is consistent with studies conducted in Ethiopia Gozamin District, Azezo District, Tigray Regions, Hawassa, and Sheka Zone, Myanmar, Cambodia, and Malawi. This may be explained by the fact that mothers who give birth in medical facilities have a greater chance to receive postnatal and obstetric care, as well as better access to breastfeeding resources such as connection, appropriate positioning, nutritional information, and counseling on the positive benefits of breastfeeding.
Parental Practices and Child Feeding
In Sierra Leone, breastfeeding continues to play a vital role in improving maternal, newborn, and child health. However, several challenges remain in ensuring optimal child feeding practices.
Early Feeding Practices: The majority of children in the sample received their very first feeding from their mother as breast milk. Among the children aged 6 months to 6 years of age who were breastfed for whom information is available, only 31.8% still suckled on the day of the survey. Exclusive breastfeeding for the first six months of a child’s life could save 12- to 20% of child deaths. Hence, awareness must be increased in communities, inclusive of women and men, on the importance of breast feeding.
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Meal Frequency and Adequacy: Slightly over half of children had three meals the day before the survey. Nearly three-quarters of mothers think their child has enough to eat. Mothers in rural areas versus urban areas felt that the food eaten by their children is sometimes or not sufficient enough. Children are at least expected to have 3 meals a day. This calls for further analysis to determine why children are given at least 3 meals a day. Income level of the family but also the geographical location (urban/ rural) affects adequacy of food provided to children. This may be related to poverty levels in the country.
Dietary Diversity: A significant number of children consume only one or two types of food in a day. Children whose diet is already little diversified represent the majority of those who consume no fruits and vegetables, while a large percentage of them do not consume protein and a considerable percentage of those do not eat meat. The daily diet of young children is considered as diversified if it includes foods from at least four different food groups. Based on this definition, alot of children in the study do not have a diversified diet. Consumption of non-diversified meals and consumption of meals with no meat, fruits and/or vegetables may be a cause for poor nutritional outcomes in children in Sierra Leone.
Access to Food: Only slightly over half of mothers had no difficulties in accessing food. This is quite a low figure if the child related nutritional problems in Sierra Leone are to be addressed. The scenario is worse in rural areas.
Recommendations for Improving Child Feeding Practices:
- Parental Education: There is need for attention to breast feeding practices, child feed, caregiver feeding support, dietary diversity and access to food.
- Community-Based Programs: Nutrition outcomes in Sierra Leone would be improved by developing a comprehensive community based early childhood development programme to improve feeding related parental practices.
- Further Research: Future studies in this area should collect data on dietary intake, disaggregated by age. In addition, future research of this type should collect anthropometric data to triangulate findings from caregiver practices data. This will enable further assessment of food and dietary intake by age as recommended by WHO.
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