Prevalence of Exclusive Breastfeeding Practice and its Association with Maternal Employment in Ethiopia: A Systematic Review and Meta-Analysis, 2020


 Background: Exclusive breastfeeding is defined as the practice of providing only breast-milk for an infant for the first 6 months of life without addition of any other food or water, which recommends initiation of breastfeeding within one hour of life and continued breastfeeding for up to 2 years of age or more. There are highly variable findings regarding the prevalence of exclusive breastfeeding in Ethiopia. Maternal employment is the most important factor contributing to the low practice of exclusive breastfeeding. The purpose of this review was to estimate the pooled prevalence of exclusive breastfeeding and its association with maternal employment in the context of Ethiopia.Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was used in this systematic review and meta-analysis. The databases such as; PubMed, Google Scholar, Science Direct, Cochrane library, Scopus, CINAHL, and Web of Science were systematically searched. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal. Results: Forty-five studies were included in the final analysis after reviewing 751 studies in this meta-analysis yielding the pooled prevalence of EBF 60.42% (95% CI: 55.81-65.02%) in Ethiopia. The subgroup analysis showed the highest prevalence reported in a study conducted in SNNP and Tigray( 87.84%), a study published during (2015-2016) (64.60 %), and among studies with a sample size of less than 500 (64.15%). Those employed mothers were 57% less likely to practice exclusive breastfeeding in comparison to unemployed mothers in Ethiopia [OR] 0.43; 95% CI (0.31, 0.61).Conclusions: Maternal employment was significantly associated with the practice of exclusive breastfeeding in comparison to their counterparts. The prevalence of exclusive breastfeeding in Ethiopia is low in comparison to the global recommendation. Based On our findings, we recommended that the Ethiopian government should increase legislated paid maternity leave after delivery beyond current paid maternity leave and implement policies that empower women and create a conducive environment for mothers to practice exclusive breastfeeding in the workplace.

Inadequate rates of exclusive breastfeeding result from different factors such as inadequate maternity and paternity leave and other workplace policies that don't support a woman's ability to breastfeed when she returns to work, caregiver and societal belief which favor nonexclusive breastfeeding before 6 months of age. To attain progress on the global exclusive breastfeeding target by 2025 women should be empowered to practice exclusively breastfeed, by providing 6 months of mandatory paid maternity leave and Countries are expected to make policies that create a conducive environment for breastfeeding in the workplace and help women to breastfeed their children exclusively for the rst6 months and thereafter [27][28]. Some Evidence showed that longer paid maternity leave helps the mothers to practice exclusive breastfeeding effectively. Indian and Viet Nam government have been successfully protecting exclusive breastfeeding by the implementation of supportive policies that guarantee mothers to get six months' paid maternity leave and by prohibiting the use of marketing breast milk substitutes with legislation before 6 months of infant's age. Contrary to WHO recommendation, the Constitution of Ethiopia and Labour Proclamation, recommends employed mothers to get fully paid maternity leave of 120 working days only (30 days antenatal and 90 days postnatal) and the proclamation doesn't support women to breastfeed in the workplace and the public area after they return to work [29][30][31][32].
In Ethiopia, many studies have been conducted to determine the prevalence of exclusive breastfeeding (EBF) and its associated factors between January 1/2015 to December 1/2020. These studies showed that different maternal and health service-related factors in uenced the practice of exclusive breastfeeding. Maternal employment [33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50]118],Mode of delivery [34,39,41,42,43,45,[50][51][52][53][54],Marital status [33,34,41,42,47,55,56,57],colostrum feeding [35,37,38,43,58,59,60,61],Prelacteal feeding [ 34,38,43,55,57,62],age of mother [63,64,65,66,67], place of delivery [34,39,56,68] were some of the associated factors which affects practice of EBF.We selected one factor (maternal employment) from the above to investigate its effect on the practice of exclusive breastfeeding (EBF) because of the following reasons: The rst reason is that maternal employment was the most important factor, which ultimately in uencing EBF, especially in our country where the legislation of civil Service give only 4 months of paid maternity leave and enforce mother to return quickly to their job before 6months after delivery. The second reason is that the primary studies conducted previously showed that controversial ndings regarding the effect of maternal employment on EBF, [33][34][35][36][37][38][41][42][43][44][45][46][47][48][49][50]118]showed a negative association of maternal employment with EBF with the presence of grate variation among them and [39,40] showed a positive association of maternal employment with EBF. Due to these, we intended to undertake this meta-analysis and as far as our knowledge is concerned, even if there were small and fragmented studies, there is no published systematic review and meta-analysis in Ethiopia, which investigated the pooled prevalence of exclusive breastfeeding and its association with maternal employment using primary studies published between January 1/2015 to December 1/2020, which is in line with 3rd target of sustainable development goal by 2030. So, the objective of this systematic review and meta-analysis was to estimate the pooled prevalence of EBF and its association with maternal employment in the context of Ethiopia. This Systematic review will generate concrete evidence that helps policymakers and program planners to make an appropriate intervention and remold some policies concerning maternal employment and the practice of exclusive breastfeeding for the best bene ts of mothers and infants in Ethiopia.

Methods
Research question/Hypothesis according to CoCoPop(Condition, Context, Population)criteria: What is the prevalence of Exclusive breastfeeding (EBF) and its association with maternal employment among mothers with infants less than 59 months age in the context of Ethiopia?
Searching strategies: The current systematic review and meta-analysis was reported by using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [69] guideline to determine the pooled prevalence of exclusive breastfeeding practice and its association with maternal employment.
The international databases, including PubMed, Google Scholar, Science Direct, and Cochrane library, Scopus, CINAHL, and Web of Science were systematically searched. The search was conducted using the following keywords: "Prevalence", "Exclusive Breastfeeding", "Feeding, Breast", "Breastfeeding", "Breastfeeding, exclusive", "Factors", "Determinants", "Maternal employment", and Ethiopia. The search terms were used separately and in combination using Boolean operators like "OR" or "AND" and the search was conducted from November 6/2020 to December 1/2020. All papers published until December 1/2020, were included in this review.

Eligibility criteria
Inclusion criteria: Study area: Only studies conducted in Ethiopia.
Publication condition: Articles published in peer-reviewed journals.
Study design: All observational study designs (Cross-sectional, case-control, and cohort) reporting the prevalence of EBF or associations between maternal employments with EBF were considered.
The outcome of interests: Studies reported data on the prevalence of EBF or the association between EBF and maternal employment were considered.
Language: Articles reported in the English language were considered.
Publication year: only studies published from January 1/2015 to December 1/2020 were considered.
Exclusion criteria study Conducted in women with HIV/AIDS, preterm newborn, and newborn in an intensive care unit Study with abstracts without full text and Qualitative studies, symposium/conference, case reports.
Articles, which were not fully accessed, after at least two Email contact of the primary author was excluded and Experimental, intervention, and review articles were excluded.

Outcome measurement
This systematic review has two main outcomes. The rst one is the Prevalence of Exclusive Breastfeeding practice, which is de ned as the practice of providing only breast-milk for an infant for the rst 6 months of life without the addition of any other food or water, except for vitamins, mineral supplements, or medicines [6]. The prevalence was calculated from each primary study by dividing the number of women breastfeeding exclusively by the total number of women who had ever breastfed multiplied by 100. The second outcome was to investigate the association between maternal employment and exclusive breastfeeding and we calculated the log odds ratio based on the primary studies that examined the relationship between maternal employment and exclusive breastfeeding.
Data extraction: Data was extracted using a standardized data extraction format, which was adopted from the JBI data extraction format. Two authors (GE and YM) independently assessed the quality of each original study using the JBI data extraction tool. Any disagreements at the time of data abstraction were resolved through discussion and consensus. The data extraction format included primary author, publication year, and study Area, study design, sample size, the prevalence of exclusive breastfeeding, the quality score of each study, the association between maternal employment and exclusive breastfeeding with their respective odds ratio(OR), characteristics of study participants and Response rate.
Quality assessment: The Joanna Briggs Institute Critical Appraisal tools for use in JBI Systematic Reviews (JBI-MAStARI) was used for critical appraisal of studies [70]. The tool has 8 major criteria for critical appraisal of each primary study. Accordingly, primary studies with a score of equal or greater than 50% and above were included in the Meta-analysis research.
Statistical analysis: Data were extracted in Microsoft Excel format and analysis was done using STATA version 11software.We calculated the standard error for each original study using the binomial distribution format. Heterogeneity regarding reported prevalence was assessed by computing p-values for Cochrane Q-statistics and I2 tests. I2 test statistics of 25%, 50%, and 75% were declared as low, moderate, and high heterogeneity respectively [71]. The test statistic showed that there was signi cant heterogeneity among the included studies (98.8%, p = <0.001), because of this a random-effects meta-analysis model was used to estimate the DerSimonian and Laird's pooled effect. To minimize the random variations between primary studies subgroup analysis was done by region in Ethiopia, sample size, and publication year of primary studies. Besides to the above, univariate meta-regression was conducted by considering the sample size, year of publication, and region in Ethiopia as covariates to identify the possible sources of heterogeneity, but none of them were found to be statistically signi cant.
We checked Publication bias by funnel plot subjectively and Egger's and Begg's tests objectively and a p-value less than 0.05 was used to declare the statistical signi cance of publication bias [72]. The pooled prevalence of exclusive breastfeeding with a 95% con dence interval (CI) in this meta-analysis was presented with the Forest plot. Accordingly, the size of each box corresponds to the weight of the study, the crossed line refers to a 95% con dence interval of the study, and the Ln odds ratio was applied to examine the association between maternal employment and EBF in Ethiopia.

Results
As described in Fig.1, 751 studies were identi ed regarding EBF in Ethiopia through PubMed, Google Scholar, Science Direct, Scopus, CINAH, Web of Science, and others in the rst step. Then 200 studies were excluded because of duplication. From the remaining 551 studies, after duplication was removed, 299 articles were excluded after reviewing their titles based on assessment since they were not relevant to this review. The remaining 252 studies were screened by abstracts yielding an additional 189 studies to be excluded. Moreover, 63 full-text articles were assessed for eligibility based on the preset inclusion criteria. From these 18 articles were excluded due to the inclusion criteria. Among excluded studies, three of the studies were excluded because they didn't report our outcome of interests [73,74,75]. Two studies were conducted among HIV-infected mothers [76,77]. The rest 12 articles were excluded because of publication year; one Study published in 2009 [78], two studies were published in 2012 [79,80], three of the studies were published in 2013 [81,82,83], six studies were published in 2014 [84,85,86,87,88,89] and one study excluded by quality assessment criteria [124]. Finally,45 studies ful lled the inclusion criteria and included in the systematic review and meta-analysis.
As shown in Table1, all of these 45 studies were published between January 1/2015 to December 1/2020. A total of 33000 breastfeeding women were included to estimate the pooled prevalence of exclusive breastfeeding in the current Meta-analysis. Regarding study design most 42 of the studies are cross-sectional study design. The sample size of the studies ranges from 226 -5,227. The lowest prevalence (29.29%) of EBF was observed in a study conducted in Addis Ababa, Ethiopia [54] whereas the highest prevalence (87.84%) was observed in a study conducted SNNP and Tigray region, among rural mothers in Ethiopia [123]. From nine regions of Ethiopia, seven regions and two council cities were represented in this meta-analysis.

Meta-analysis
Pooled Prevalence of exclusive breastfeeding in Ethiopia The pooled prevalence of EBF in Ethiopia from 45 included studies is 60.42% (95% CI: 55.81-65.02%). The I2 test result indicated high heterogeneity among included studies (I2 98.8%, p = <0.001), and because of this high heterogeneity the random effect meta-analysis model was used. In this meta-analysis research, Hagos et al (87.84%) and shiferaw et al (29.29%) reported the highest and lowest prevalence of exclusive breastfeeding respectively (Fig.2).
Besides, we conducted a Univariate meta-regression by considering the year of publication, sample size, and region in Ethiopia as covariates to identify the possible sources of heterogeneity, and unfortunately, none of them were found to be statistically signi cant(Table2). Besides, publication bias was assessed subjectively and objectively using funnel plot and Begg's and Egger's tests respectively. Even if the funnel plot showed the presence of publication bias (Fig.3), Begg's and Egger's tests showed no statistical signi cance for estimating the prevalence of EBF (p = 0.304) and (p = 0.314) respectively.

Subgroup analysis
A subgroup analysis was done by an administrative area (region) in Ethiopia, the year of publication, and the Total sample size of primary studies to compare the prevalence of exclusive breastfeeding across different studies. Accordingly, this systematic review and meta-analysis showed that the highest prevalence reported in a study conducted in SNNP and Tigray 87. Association between maternal employment and exclusive breastfeeding in Ethiopia: We examined the association between maternal employment and EBF practice using 19 studies [33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50]118] in this meta-analysis and the nding showed that the practice of EBF was signi cantly associated with maternal employment. Those employed mothers were 57% less likely to practice exclusive breastfeeding in comparison to unemployed mothers [OR] 0.43; 95% CI (0.31, 0.61).High heterogeneity (I2 = 85.0% and p-value < 0.000) was observed across the included studies and a random effect meta-analysis model was applied to examine the association between maternal employment and EBF in Ethiopia (Fig.4). We also assessed publication bias subjectively using the funnel plot and objectively using Begg's and Egger's tests. While the funnel plot showed the presence of publication bias, Begg's and Egger's tests showed the absence of signi cant publication bias (p-value=0.363 and p=0.684) respectively (Fig.5).

Discussion
This systematic review and meta-analysis research was conducted to determine the pooled prevalence of exclusive breastfeeding and its association with maternal employment in Ethiopia using a study published between January 1/2015 and December 1/2020. Breastfeeding is a core part of the 2030 agenda for Sustainable Development goal (SDG) which is linked with many targets (SDGs), especially with the 3rd target which deals with ending preventable maternal and neonatal death [8]. This type of meta-analysis plays a great role for program planners and policymakers to make all mothers practice optimum breastfeeding practice in Ethiopia according to WHO recommendation and helps to end preventable maternal and neonatal death.
According to the results of 45 studies included in this meta-analysis, the pooled prevalence of exclusive breastfeeding in Ethiopia is 60.42% (95% CI: 55.81-65.02%). The overall prevalence of exclusive breastfeeding in this study is almost similar to the result of the 2016 Ethiopian demographic and health survey (EDHS) result (58%) [19], and the result of a meta-analysis conducted in Ethiopia (59.3%) [90]. This similarity could be attributed to similarities in socio-demographic, methodological, and the characters of individual studies included in both review and EDHS reports. But, the overall reported prevalence of EBF in this review is higher than the result of meta-analysis result conducted in Iran(49.1%) [91] and 29 sub-Saharan African countries, which showed the prevalence of EBF (23.70% in Central Africa) and (56.57% in Southern Africa) [92]. The pooled prevalence of exclusive breastfeeding in this review is also higher than the results of the study conducted in 27 sub-Saharan African countries (SSA) (36%) [93], the Demographic and health survey of Tanzania (22.9%) [94], demographic and health survey of Madagascar (48.8% [95] and study conducted in developing countries (39%) [96]. This variation might be because of methodological differences, differences in infants and maternal socio-demographic characteristics, economical, health service utilization, the gap of the year at which the study was conducted, and the number of studies included in the review. Again the pooled prevalence of exclusive breastfeeding in this research is much higher than the results of primary study conducted in Bangladesh(5%) [97], Southern Brazil (43.7%) [98], Lebanon (27.4%) [99], Al Hassa, Saudi Arabia (12.2%) [100], Tamil Nadu India (34%) [101], Canada (15.3%) [102],Tabuk Saudi Arabia (31.4%) [103] and this difference might be because of methodological differences and differences in health service utilization and health service coverage. But the overall prevalence of exclusive breastfeeding in our review is lower than the result of the primary study conducted in Indian regains, which indicated the prevalence of exclusive breastfeeding was (79.2% in southern India and 68.0% in northeastern India )respectively(104), Nepal demographic and health survey result (66.3%) [105], and the result of the study conducted in Ghana (64%) [106].
Besides, we performed sub-group analysis based on the study areas or Regions in Ethiopia where the studies were conducted, sample size, and year of publication of the primary studies. Accordingly, the highest (87.84%) and lowest (36.64%) prevalence of exclusive breastfeeding was reported in a study conducted among rural mothers of SNNP and Tigray region and Addis Ababa City respectively. This regional difference in the prevalence of exclusive breastfeeding might be because of differences in socio-demographic, the difference in numbers of the studies included in the two regions during analysis. In addition to the above, the participants of a study conducted in SNNP and Tigray region are rural resident mothers, and according to different kinds of literature being rural in residence for breastfeeding mothers is associated with a high prevalence of exclusive breastfeeding practice [56,119,125]. We also performed a subgroup analysis using a year of study publication. Accordingly, the highest (64.60%) and lowest (58.74%) prevalence of exclusive breastfeeding were reported in the study published during 2015-2016 and 2017-2020 respectively. This difference could be attributed to the difference in coverage of health information regarding exclusive breastfeeding and effective utilization of health extension workers, adherence to the national and international policy by health institutions [107]. Also, this difference might be attributed to the number of studies included in each category during analysis.
Besides, we conducted subgroup analysis using the total sample size of the study, and the highest (64.15%) and lowest (47.38%) prevalence of exclusive breastfeeding was reported among studies with sample size less than 500 and greater than or equal to 1000 respectively. This difference might be associated with a difference in the number of the study included in each category during data analysis. One of the greatest threats to the validity of meta-analytic results is publication bias which generally leads to effect sizes being overestimated and the dissemination of false-positive results [126,127,128], and because of this, we assessed publication bias and possible sources of heterogeneity using Begg's and Egger's tests and univariate meta-regression respectively, unfortunately, the tests showed no statistical signi cance for of both parameter.
Maternal employment was signi cantly associated with the practice of exclusive breastfeeding in this systematic review and meta-analysis research. Accordingly, Employed mothers were 57% less likely to practice exclusive breastfeeding as compared to unemployed mothers. This result is in line with the results of the primary study conducted in Lebanon [99], a study conducted in Iran [108], a study conducted in Malaysia [109], a study conducted in Saudi Arabia [103], and the study conducted in Somalia [110]. This similarity could be attributed to Mothers who returned to work at an earlier time before 6 months have less frequency of contact with their baby and employed mothers begin liquid and solid based supplementation of food before the expected age of starting weaning food which will end up with the decreased practice of exclusive breastfeeding [111]. Some evidence showed that employed mothers face unique barriers to practice exclusive breastfeeding and returning to work too early after birth has been shown to affect the practice of exclusive breastfeeding. Different literatures showed that the more we increase the legislated duration of paid maternity leave, the more the mothers practice exclusive breastfeeding and this will result in the higher prevalence of exclusive breastfeeding [112,113,114].

Limitations Of The Study
This review has certain limitations. Majorities of the primary study included in the review were cross-sectional study which might affect the outcome variable because of other confounding factors. Studies published in a language other than English were not included in the review and the review addressed only one associated factor (maternal employment) with exclusive breastfeeding. The review included some studies with a small sample size which might affect the pooled report of exclusive breastfeeding and the last limitation is that the study protocol was not registered at the International prospective register of systematic reviews (PROSPERO).

Conclusions
Maternal employment was signi cantly associated with the practice of exclusive breastfeeding in comparison to their counterparts. The prevalence of exclusive breastfeeding in Ethiopia is low in comparison to the global recommendation. Based On our review ndings, we recommended that the Ethiopian government should increase legislated paid maternity leave after delivery beyond currently paid maternity leave and implement policies that empower women and create a conducive environment for employed mothers to practice exclusive breastfeeding at the workplace. Authors' contributions GE: Conception of the research protocol, study design, literature review, data extraction, data analysis, interpretation, and drafting of the manuscript.YM: data extraction, quality assessment, data analysis, and reviewing the manuscript. Both authors have read and approved the manuscript.

Funding
No, any funding was received from any organization.

Availability of data and materials
Datasets used for this study and other supplementing materials are available from the corresponding author on request.    Figure 1 Flow diagram of studies included in systematic review and meta-analysis, 2020.

Figure 1
Forest plot displaying the pooled prevalence of exclusive breastfeeding of 45 studies in Ethiopia, 2020.

Figure 1
Funnel plot for publication bias, LNOREMP represented in the x-axis and standard error of LNOREMP on the y-axis, 2020.

Figure 1
Funnel plot for publication bias, PREPOP represented in the x-axis and standard error of SEPOP on the y-axis, 2020.

Figure 1
The pooled odds ratio of the association between maternal employment and exclusive breastfeeding in Ethiopia in 2020.

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