August 8, 2022

FACTS Spotlight: National Breastfeeding Month

Breastfeeding Knowledge, Attitudes, and Practices in East Africa

By Liseli W. James, MD

Editor’s Note: To continue National Breastfeeding Month, we are highlighting a review of breastfeeding attitudes and practices in East Africa. Dr. Liseli James summarized a 2020 literature review published in the International Breastfeeding Journal, when she completed the FACTS elective as a 3rd year family medicine resident. At FACTS, we welcome any medical resident or health professional student to participate in our FACTS elective, as well as our Ambassador program.  Learn more here.



Attitudes related to exclusive breastfeeding (EBF) are widely varied. EBF is defined as “feeding your baby only breast milk, not any other foods or liquids (including infant formula or water), except for medications or vitamin and mineral supplements” [1]). Despite the numerous benefits of EBF to the infant and mom, only 38% of women worldwide exclusively breastfeed for the first six months [2]. Some barriers include a lack of education and breastfeeding counseling, as well as misconceptions about breast milk quality and its benefits for the infant. In truth, breastfeeding supports bonding between a mother and her baby, prevents SIDS in the infant and diabetes in the breastfed adult [3], and it can even be used as a form of natural family planning.

“Exclusive breastfeeding supports bonding between a mother and her baby, prevents SIDS in the infant and diabetes in the breastfed adult, and it can even be used as a form of natural family planning.”

The Lactational Amenorrhea Method (LAM) is a form of contraception that can be used by women with an infant less than six months old, who is exclusively breastfeeding and has not yet had the return of menses after giving birth. Researchers Dukuzunuremyi et al. sought to survey the knowledge, attitude, and practice of EBF among mothers in East African countries in order to discern barriers to EBF and ways to increase EBF among mothers in the study population [2].


A literature review was conducted across several databases using keywords: “exclusive breastfeeding,” “knowledge,” “attitude,” “practice,” and “East Africa.” Studies published from January 1, 2000 to June 25, 2019 were included in the study.  After an exclusionary process, only 15 studies spanning Ethiopia, Kenya, Uganda, Rwanda, Tanzania, and South Sudan were included in the review. These studies used questionnaires, interviews, and focus groups to assess mothers’ knowledge, attitude and practices in regards to EBF. To assess knowledge, specific questions were asked: “Do you know that breast milk alone is enough for infants?” “Do you know that breast milk alone can sustain the baby for six months?” “Do you think starting complementary foods before six months is important?” “When did you start breastfeeding after delivery?” The researchers then analyzed the percentages of the common answers to these questions in order to quantify the raw data.


Some key results from this study showed marked differences among mothers when it came to knowledge, attitude and practice regarding EBF. This is underlined by the fact that the lowest and highest prevalence of EBF was found in Ethiopia. On average, 49% of mothers knew that infants should exclusively breastfeed for the first six months, but the percentages varied from as low as 21% to as high as 90% in two different cities in Ethiopia. Most mothers did not appreciate the importance of breastfeeding immediately after birth; 66% disagreed or strongly disagreed that breast milk within the first hour after delivery is important.

Only 55.9% of mothers surveyed in this study practiced exclusive breastfeeding. Notably, only 41% of women knew that EBF could prevent pregnancy, and just 55.1% knew that EBF could protect their babies from respiratory illnesses.


The studies included in the review span six countries with sample sizes ranging from 90 to 630 participants. The authors took a unique but effective approach in summarizing the data into a comprehensive format. However, it was difficult to condense the volume of data collected into concrete, usable conclusions. This difficulty is exacerbated by the wide variety of questions posed to the participants, as well as the wide variety of answers given.

The authors did an excellent job identifying the strengths and gaps in this population’s knowledge about breastfeeding. Per the results, women identified as being highly knowledgeable (operationalized as scoring >70% in the knowledge test) were aware that babies only need breast milk in the first six months of life, and that breastfeeding within one hour of delivery is important. However, their knowledge is more limited about the many benefits of EBF, including LAM, as well as important topics, such as breastfeeding on demand and ways to promote milk formation. The study also showed that some mothers may not fully appreciate the benefits of EBF. Almost half of participants believe that formula-feeding is more convenient than breastfeeding and only half of mothers recognize that EBF increases infant-mother bonding. Finally, only 55.9% of mothers were actually exclusively breastfeeding.

“Women identified as being highly knowledgeable were aware that babies only need breast milk in the first six months of life, and that breastfeeding within one hour of delivery is important.”

What this study does not adequately address is the important “why” question: Why are inadequate knowledge and negative attitudes pervasive in this population? Additionally, although the authors successfully identified some gaps in knowledge, they have not identified the barriers that prevent the population from adopting more positive attitudes towards breastfeeding.  The study does briefly mention previous research conducted in east Africa by Maonga et al., which discussed a cultural belief that babies need solid food early in life to prevent weak bones.  Inevitably, other prevailing cultural and religious beliefs exist within this population that may also hinder breastfeeding [2].

The research by Dukuzemuremyi et al. provides helpful snapshots of individual concepts related to EBF within a sample population, but we still lack a broader conclusion regarding the knowledge, attitude and practice of EBF in East African countries. Greater understanding of traditional beliefs which influence newborn care will be a valuable start, but the authors note that education about EBF is critical within these populations — not to erase cultural beliefs, but to better inform them. Mothers and babies both stand to benefit from targeted education about the importance of EBF, from its use as an effective family planning method to the health benefits for mothers, such as decreased cancer rates, and to disease prevention and healthy brain development in children. [2]


[1] Infant and Toddler Nutrition: Definitions. Centers for Disease Control and Prevention. Updated April 11, 2022. Accessed August 7, 2022.

[2] Dukuzumuremyi JPC, Acheampong K, Abesig J, Luo J. Knowledge, attitude, and practice of exclusive breastfeeding among mothers in East Africa: a systematic review. Int Breastfeed J. 2020;15(1):70. Published 2020 Aug 14. doi:10.1186/s13006-020-00313-9

[3] James RS. Breastfeeding Disparities in African American Women. NIMHD Insights Blog. July 6, 2020.


Liseli W. James, MD

Dr. Liseli James is a board-certified family medicine physician, caring for patients at Valley Health Family Medicine | Spring Mills. Dr. James received her bachelor’s degree in biology from Howard University and  attended medical school at Howard University College of Medicine. Dr. James then completed her residency at MedStar Health in Washington, D.C. through the Georgetown-Washington Hospital Center Family Medicine Residency Program. While there she was a Global Health Scholar and also showed interest in Women’s Health. As part of her work in Global Health she worked on a research project involving assessment of the utilization of Natural Methods of Family Planning in global communities.

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