Poor access to breastfeeding counseling services and associated factors among lactating mothers who had optimal antenatal care follow-up in Sub-saharan Africa: a multilevel analysis of the recent Demographic and Health Survey | BMC Health Services Research

This study aimed to assess the magnitude and determinants of poor access to breastfeeding counseling services among women who had optimal ANC follow-up in Sub-Saharan Africa using 22 Sub-Saharan African Demography and Health Surveys from 2015 to 2022. In this study, the magnitude of poor access to breastfeeding counseling services among women who had optimal ANC follow-up in Sub-Saharan Africa was found to be 43.08% (95% CI: 42.8, 43.39). The magnitude of poor access to breastfeeding counseling services in this study was lower than in the studies conducted in Saudi Arabia (68.1%, 52.5%) [27, 28], and Bahir Dar in Ethiopia (76.4%) [29] and Pakistan (72.3%) [30]. On the other hand, poor access to breastfeeding counseling services in this study was higher than the studies conducted in Somali region Ethiopia (39.5%) [31] and Nigeria (33.3%) [32]. The discrepancy could stem from variations in the study population and sample size and the differences in data collection methods. The present investigation employed a larger sample size than earlier research conducted in the above-mentioned countries, which utilized a smaller sample size. Moreover, these discrepancies could be explained by variations in health policies, healthcare quality, and socioeconomic and cultural differences between countries, and the higher percentage of poor access to breastfeeding counseling services in our analysis indicates that this issue needs to be given more attention in sub-Saharan Africa.

In multivariable multilevel logistic regression analysis, sex of household head, maternal educational status, husband educational status, maternal work, distance to health facility, media exposure, wealth index, place of delivery, health insurance coverage, postnatal checkup, mode of delivery, birth interval, residence, community poverty, and country category were significantly associated with poor access to breastfeeding counseling service among women who had optimal ANC follow-up in Sub-Saharan Africa.

The odds of poor access to breastfeeding counseling services were 1.18 times higher among women whose age was 15–19 years compared to women 20–34 years. This finding is consistent with previous findings in Bangladesh [33], Norway [34], and the USA [35]. One possible explanation is a lack of awareness: some young women may not be aware of the benefits of breastfeeding counseling or may not know where to access it [36, 37]. Societal norms and stigmas surrounding breastfeeding can discourage young mothers from seeking counseling, particularly as they may face judgment or bias from healthcare providers [38]. Additionally, young mothers often face challenges in balancing work, education, and childcare, making it difficult to find time for counseling sessions [39]. Barriers such as limited access to healthcare facilities, a lack of trained counselors and the impact of the COVID-19 pandemic, which disrupted health services globally, further contribute to these disparities. During the pandemic, restrictions on in-person care and the redeployment of healthcare workers reduced the availability of breastfeeding counseling services, especially in low-resource settings. Fear of infection also deterred mothers from seeking healthcare services [40,41,42].

In addition to societal norms and healthcare barriers, the aggressive marketing of commercial formula and human milk substitutes also contributes to poor access to breastfeeding counseling services. The widespread and targeted promotion of formula products, particularly in low- and middle-income countries, undermines breastfeeding efforts by influencing maternal decisions and diminishing confidence in breastfeeding. This marketing creates confusion about the benefits of breastfeeding versus formula feeding, especially among young and less educated mothers, who may be more susceptible to such campaigns. Furthermore, formula feeding companies often exploit regulatory gaps to market their products directly to mothers, health professionals, and through digital platforms, reinforcing the perception that formula feeding is a socially acceptable or superior alternative to breastfeeding [43].

The odds of poor access to breastfeeding counseling services were 1.28 times higher among women who had no formal education compared to women with secondary and higher educational attainment. It is in line with the previous studies conducted in Zimbabwe [44], Nigeria [45], China [46], and Italy [47]. The reason for this is that women with no formal education may have difficulty reading, writing, or understanding written or verbal information about breastfeeding [48]. In addition, women without a formal education may face social and economic disadvantages, poverty, and restricted access to counseling, nutrition, and health care. Without any official guidance, women may adhere to cultural or religious traditions and beliefs that affect their decision to breastfeed, such as avoiding colostrum, using herbal remedies, or introducing complementary foods early. When it comes to making decisions about nursing, women without formal education may lack confidence and self-worth and rely on their husbands, mothers-in-law, or other elders [49].

The odds of poor access to breastfeeding counseling services were 1.17 times higher among women whose distance to a health facility was a big problem compared to women whose distance to a health facility was not a big problem to access health care services. It is consistent with studies in Malawi [50] and Scotland [9]. The possible explanations for the poor access to breastfeeding counseling services might include several interrelated factors. Transportation costs and availability can be a major barrier: lactating women may not have the means or options to travel to a health facility, facing challenges such as high costs, long distances, poor roads, or limited public transportation. Time constraints and opportunity costs also play a role, as women may have competing responsibilities such as household chores, childcare, work, or education, which make it difficult to attend counseling sessions. Furthermore, the quality of care and trust in the services are critical factors: women may not receive adequate or respectful care at the health facility, encountering long waiting times, staff shortages, a lack of privacy, or negative attitudes from health workers [50, 51].

Among women with media access, the likelihood of having poor access to breastfeeding counseling services was 1.12 times higher among women who were not accessing media than that of women who were accessing it. This is supported by the previous study conducted in Bangladesh [52]. Media access can be a critical source of information and motivation for lactating women to seek and use breastfeeding counseling. However, several barriers may hinder this access. Women in rural or isolated areas may face challenges due to poor infrastructure, limiting their access to media devices like the internet, radio, or television. Furthermore, the high costs of media devices or subscription services may prevent some women from utilizing these resources. In addition, low literacy levels, especially in remote regions, can make it difficult for women to comprehend media content, particularly if it uses technical language or is presented in a foreign language. Lastly, even when media is available, the relevance of the content to women’s cultural needs or preferences can influence its effectiveness in motivating behavior change [7, 53, 54].

The odds of poor access to breastfeeding counseling services were 1.05 times higher among women who had middle wealth quantiles compared to women who had rich wealth quantiles. This finding is in line with the studies conducted in Bangladesh [55, 56] and South Asia [57]. A poor wealth index can be a major obstacle for lactating women to receive breastfeeding counseling, as it can affect their access to and utilization of health services. Some of the reasons are: Poor women may not be able to afford the costs of traveling to, staying at, or receiving care at a health facility that offers breastfeeding counseling. Women from poor and middle wealth quantiles may also face indirect costs, such as loss of income, childcare expenses, or opportunity costs. Poor women may live in areas where there are no or few health facilities that provide breastfeeding counseling or where the quality of care is low. They may also face shortages of trained and skilled counselors or a lack of essential supplies and equipment. Moreover, poor women may not trust or feel comfortable with the health system or the counselors due to perceived or experienced discrimination, disrespect, or abuse. The lactating women may also have different preferences, beliefs, or expectations regarding breastfeeding counseling, which may not be met by the available services [7, 9, 55].

Poor access to breastfeeding counseling services was 4.31 times more likely to occur among women who gave birth at home compared to women delivered at health institutions. This finding is consistent with previous finding in Iran [58]. This is likely due to several factors: Women who deliver at home may have limited contact with health workers, resulting in missed opportunities for breastfeeding counseling during the antenatal, delivery, and postnatal periods. Additionally, home deliveries often lack proper referral and follow-up, which can hinder access to continued breastfeeding support. Women who choose home births may also have lower confidence and trust in the health system due to negative past experiences, such as perceived poor-quality care or mistreatment. As a result, they may turn to family or community members for breastfeeding advice instead of trained professionals [9, 58].

The odds of poor access to breastfeeding counseling services were 3.92 times higher among women who had no postnatal checkup compared to women who had. This finding is in line with the WHO 2014 Postnatal Care for Mothers and Newborns report [59], Bangladesh [60], and India [61]. The lack of postnatal care may reflect a lack of awareness about the importance of breastfeeding counseling and postnatal services, as well as difficulties accessing these services due to factors like cost, distance, or transportation barriers [58, 62].

Poor access to breastfeeding counseling services was 1.88 times higher to occur among women who gave birth vaginally compared to women delivered via caesarean section. This finding is consistent with the study done in Scotland [9]. The possible reason could be women who deliver vaginally may receive less attention and support from health workers, who may assume that they are more capable and experienced in breastfeeding than women who deliver by cesarean Sects. [7, 9]. Women who had ≤ 24-month pregnancy intervals had 1.12 times higher odds of poor access to breastfeeding counseling services compared to women who had > 24-month pregnancy intervals. This could be because women may not be aware of the importance and benefits of breastfeeding for themselves and their babies. They may also not know when and where to access breastfeeding counseling services due to a lack of time [63].

The odds of poor access to breastfeeding counseling services were 1.14 times higher among women whose place of residence was rural as compared to women from urban areas. This finding is consistent with previous studies in Haiti and Malawi [50]. This may be because rural areas may have fewer health facilities or health workers that can provide breastfeeding counseling services. Women may also face challenges in accessing these services due to distance, cost, or transportation. Moreover, rural women may have less exposure to health information or education that can raise their awareness of the importance and benefits of breastfeeding for themselves and their babies. They may also not know when and where to access breastfeeding counseling services [64].

Women who reside in a community with high poverty had 1.09 times higher odds of poor access to breastfeeding counseling services compared to women who had low community poverty. It is in line with study findings in United Kingdom [65]. The possible explanation could be women living in poverty may have limited access to health facilities or health workers that can provide breastfeeding counseling services. They may also face challenges in affording the cost or transportation to reach these services [9]. Additionally women living in poverty may receive poor quality of breastfeeding counseling services, if they are available at all. They may encounter health workers who are not trained, friendly, respectful, or professional in providing breastfeeding counseling. They may also receive insufficient, inaccurate, or inconsistent information or advice on breastfeeding [65]. The odds of poor access to breastfeeding counseling services were 1.06 times higher among women who had low community institutional delivery compared to women who had high community-level institutional delivery. This finding is supported by the study conducted in Ethiopia [66]. The reason could be women who deliver at home or in non-institutional settings may have less access to health facilities or health workers that can provide breastfeeding counseling services. Additionally women who deliver at home or in non-institutional settings may have less social or community support for breastfeeding, especially if they face cultural or traditional norms, beliefs, or practices that discourage them from doing so [7, 67].

Compared to women from East Sub-Saharan Africa, breastfeeding women in central Sub-Saharan Africa had 2.23 times a higher likelihood of having poor access to breastfeeding counseling services. This may be because Central Sub-Saharan Africa has the lowest proportion of births attended by skilled health personnel in the world, with only 59% of births occurring in health facilities in 2019. This means that many women miss the opportunity to receive breastfeeding counseling during antenatal, delivery, and postnatal care [68]. On the other hand breastfeeding women in southern Sub-Saharan Africa were 16% times less likely to have poor access to breastfeeding counseling services compared to women from eastern Sub-Saharan Africa. The explanation could be Southern Sub-Saharan Africa has a higher literacy rate than East Sub-Saharan Africa, with 75% of adults able to read and write in 2018. This may increase the exposure of women to health information or education that can raise their awareness of the importance and benefits of breastfeeding for themselves and their babies [69].

The study’s strength was the utilization of recently conducted large-sample national demography and health surveys from 22 sub-Saharan African countries. Moreover, this study used multilevel logistic regression to determine two-level factors, which could not be done using classical logistic regression. However, the study did not consider the potential impact of the COVID-19 pandemic, which may have influenced breastfeeding practices and access to counseling due to healthcare disruptions and changes in maternal behaviors. Additionally, while multilevel logistic regression was used, it may oversimplify breastfeeding behaviors, and more advanced methods could offer deeper insights. Another limitation is the absence of breastfeeding outcome data, such as intention, initiation, and duration, which restricted the analysis the outcome data determination into breastfeeding counseling during the first two days after delivery. Lastly, the DHS dataset lacked important variables like maternal psychological factors, limiting the exploration of other potential determinants.

Conclusions and recommendation

Poor access to breastfeeding counseling services among lactating mothers who had optimal ANC follow-up in Sub-Saharan Africa was high. Both individual and community-level variables were determinants of poor access to breastfeeding counseling services. The ministry of health in Sub-Saharan Africa should give attention to those women who have not had a postnatal check-up and give birth at home while designing policies and strategies.