Section 3 Mother-Baby Health

### **Chapter 4**

## Supporting and Promoting Breastfeeding: The 10 Steps to Successful Breastfeeding

*Mary Economou and Nicos Middleton*

#### **Abstract**

Since the launch of the BFHI (*Baby-Friendly Hospital Initiative*), the "*Ten Steps to Successful Breastfeeding*" have been the cornerstone of national and international strategies that protect and promote breastfeeding. The aim of the BFHI has been the optimization of maternity care services by focusing on the adherence of maternity care facilities to good practices to support and protect breastfeeding. Numerous studies have evaluated the impact of the "10 Steps," employing both observational or intervention study designs, and established higher breastfeeding initiation and longer breastfeeding duration. Nevertheless, suboptimal implementation of the "10 Steps" has been reported in many countries worldwide.

**Keywords:** breastfeeding, exclusivity, the 10 steps to successful breastfeeding, maternity practices, skin-to-skin, rooming-in

#### **1. Introduction**

The joint WHO/UNICEF *Baby-Friendly Hospital Initiative* (BFHI) was launched in 1990 as one of the main components of the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. It is an international program which aimed in the improvement of maternity care services, mainly focusing on the adherence of maternity care facilities to "good practices" and specifically the implementation of the "*Ten Steps to Successful Breastfeeding.*" The "10 Steps" are the underpinning of the BFHI and describe the optimal maternity practices for supporting mothers to initiate breastfeeding. The BFHI program was reinvigorated for the first time in 2017 since it was first launched in 1989. The updated implementation guidance targets the policymakers and the institution managers at different levels to fulfill nine responsibilities through a national BFHI program. These are (1) the integration of the 10 Steps into the national policies, (2) establishing or strengthening a national coordination body, (3) ensuring the capacity of all healthcare professionals, (4) the use of external assessment to regularly evaluate the implementation of the 10 Steps, (5) providing technical assistance, (6) monitoring of the implementation, (7) continuous communication and advocacy, (8) identification and allocation of sufficient resources and (9) incentivizing change [1].


#### **Table 1.**

*The ten steps for successful breastfeeding.*

#### **2. BFHI designation and the "ten steps"**

A maternity facility is awarded with the designation of Baby-Friendly Hospital when it follows the Global Criteria of the BFHI that were set as the standards for measuring adherence to the 10 Steps for Successful Breastfeeding. The Global Criteria provide guidance on the procedure that maternity care facilities have to undergo in order to be assessed and acquire certification as Baby-Friendly. In 2009, BFHI documents were revised and updated instructions and guidance required for the successful implementation and compliance to the "10 Steps" and the International Code of Marketing of Breast Milk Substitutes were offered [2]. **Table 1** below lists the "10 Steps for Successful Breastfeeding."

A BFHI Self-Appraisal Tool (Section 4) of the ten steps is included in the BFHI package. This tool was developed in order to be used by the maternity care facilities as a means of a preliminary self-assessment of the extent to which they implement the 10 Steps. The self-assessment of maternity care practices which affect successful breastfeeding provides a framework by which a maternity care facility can identify gaps in the implementation to design potential and necessary improvements and modifications. The process follows a triple-A sequence (Assessment, Analysis, and Action). For a maternity facility to acquire the baby-friendly accreditation, it should demonstrate at least 80% compliance to all the maternity practices/Global Criteria as described in the "*Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care*" guide [2]. Accreditation is followed by periodical, predefined reevaluations to assess to the facility's compliance to the Ten Steps.

#### **3. Current status of the BFHI globally**

Since the BFHI was launched, as many as 21,328 maternity care facilities that have been listed as ever been designated as Baby-Friendly in 131 (out of 198; 66%) countries [3]. These represent 27.5% of the all maternity clinics worldwide, ranging from 8.5% in developed countries to 31% in less developed settings [3].

#### *Supporting and Promoting Breastfeeding: The 10 Steps to Successful Breastfeeding DOI: http://dx.doi.org/10.5772/intechopen.113317*

The WHO [4] published an updated report to celebrate the 25th Anniversary since the launch of the initiative. The report provides an analysis of the current status of the BFHI worldwide. Among others, the report describes the global and country program coverage1 , the current designation process as well as reasons of discontinuation of the program in countries that reported its termination. Results of this Report were derived from 2nd Global Nutrition Policy Review (GNPR2), which was distributed to all 194 WHO member states in 2016. The members were requested to ask a series of questions in relation with the implementation of the BFHI. A total of 117 countries completed the questionnaire included in the GNPR2. WHO also obtained information from other sources for countries that did not respond or provided no coverage information to the GNPR2. The additional sources included the 2016 BFHI Network for Industrialized Countries, the 2014 American Health Organization survey on BFHI Implementation in Latin America and the Caribbean, the 2013 UNICEF Nutridash survey. Further, WHO conducted a series of interviews with national leaders in breastfeeding programs and the BFHI in order to receive additional qualitative information of the BFHI [4].

According to the report, 86% of the countries that completed the questionnaire reported that they implemented the BFHI. Overall, 71% reported that they have an operational BFHI program. The BFHI was introduced by almost half (48.8%) of the participating countries in the early 90s, whereas 11 (9.4%) and eight countries (6.8%) have initiated the implementation of BFHI in the period 2000–2009 and 2010–2017 respectively. As many as 16 countries report that they had never implemented the program and for a further 25 countries, the year when the program was actually introduced is not reported [1]. Of the 78 with an active BFHI program that completed the GNPR2 questionnaire, the majority of countries (N = 61; 78%) used the Global Criteria for the assessment of maternity facilities in BFH-designation process. Twenty-one percent (n = 16) used their own national criteria. **Table 2** presents some of the main statistics reported in the Report [4] with regard to the progress and current status of the BFHI countries globally 25 years after the launching of the Initiative.

**Table 3** reports the overall percentage of births that occurred in Baby-Friendlydesignated hospitals by each WHO region as well as the number of countries per


#### **Table 2.**

*Number of countries that reported implementation of the BFHI by year of introduction.*

<sup>1</sup> BFHI Coverage is the proportion of births that occur in Baby-Friendly-designated maternity facilities (as defined by the Global Nutrition Monitoring Framework).


*Source: WHO [1] National Implementation of the Baby-Friendly Hospital Initiative.*

#### **Table 3.**

*Percentage of births that occur in facilities BF-designated maternity facilities by WHO region and number of countries on the basis of the % BFHI coverage.*

region on the basis of BFHI coverage (e.g. None through to >50% of births occurring in BFH). Overall, BFHI coverage was estimated at about 10%, ranging from less than 5% in Africa and Southeast Asia to 36% in the European region [4]. However, significant between-country variability is observed, even within the European region. Only 12 (out of 47) countries in the WHO European region report that births in babyfriendly-designated hospitals exceed 50%, whereas as many as 16 countries report of no BF-designated facilities.

Among the participating countries, only 64 have reported that the "10 Steps for Successful Breastfeeding" have been incorporated into national policies or strategies. Only 39 countries (50%) reported having developed a reassessment process. Most of those (N = 21) reassessed the BF maternity facilities less frequently than 5 years and only 14 countries reported that they reassess facilities every 5 years [4].

In 2016, 23 countries reported that they had terminated the implementation of the BFHI. Among those, eight countries ceased its operation before 2005, seven countries stopped the use of the program during the period 2006–2010 and five stopped its implementation within the last 5 years [4]. The most frequently reported reason of BFHI program cessation was the termination of external funding (given by 12 countries), followed by the lack of human resources (given by seven countries), and lack of political interest (given by eight countries). Other reasons mentioned were the termination of governmental funding (given by five countries) and resistance from hospitals or healthcare system (given by five countries). The least common reasons included merging with other programs, lack of advocacy, lack of monitoring and non-adherence of the ICMBS [4].

#### **4. Evidence on the degree of implementation of the "10 steps" and association with breastfeeding**

While the original development of the 10 steps was based on clinical experience and good public health practice rather than research evidence in terms of their impact in influencing breastfeeding behavior and outcomes [1], there has been plenty of research evidence since to support the positive association (in observational studies)

and/or effectiveness (in intervention studies) of the adherence to BFHI's 10 Steps to Successful Breastfeeding on BF outcomes.

#### **4.1 Degree of implementation of the "10 steps"**

Generally, studies conducted to evaluate the impact of Baby-Friendly accredited hospitals demonstrated higher breastfeeding initiation and longer breastfeeding duration [5–7]. However, suboptimal implementation of the "10 Steps" has been reported in many countries worldwide [8–12].

Recording and assessment of the current situation in relation with the implementation of the "10 Steps" in maternity facilities is usually done at a unit level (by the answers provided from the heads/managers of the facilities) and less frequently from the perceived assessment of the facility personnel [13, 14]. The number of studies conducted to investigate the implementation of the Steps through the experiences of mothers seems to be relatively limited [14, 15].

The Maternity Experiences Survey in Canada [12] is one of the largest studies in the literature that assessed the implementation of the 10 steps based on the selfreported experience of a nationally representative sample of over 8000 women, who gave birth during 5–14 months prior to the study. The study reported that the implementation of the 10 steps was fragmented with highest degree of implementation for Step 3 (information about the benefits and management of breastfeeding) and Step 10 where as many as nine out of 10 mothers were given information about where to seek help and support after discharge from the hospital. On the other hand, only one in three mothers experienced skin-to-skin and 44.4% reported that their infant was given a pacifier or a soother within the first week after birth. In a Greek study with the participation of 312 mothers, the majority of the participants (90%) reported that their babies were fed with formula whereas only 3% initiated BF within 1 hour. About 66% of mothers reported rooming-in during their stay in the hospital, of whom all gave birth in a public hospital [9].

#### *4.1.1 Evidence from observational studies*

There have been numerous studies from several parts of the world during the last decades that have looked at the association of either the overall implementation (e.g. comparing BF-designated and non-BF-designated hospitals) or partial/select implementation of the 10 steps on BF initiation, duration and exclusivity. Overall, the findings of these studies have consistently demonstrated positive associations of the baby-friendly maternity practices on breastfeeding outcomes.

#### *4.1.2 BF rates in BF-designated and non-BF-designated maternity facilities*

This subsection provides evidence of the effect of the BF designation to maternity care facilities (overall effect of the 10 Steps to Successful BF) on BF outcomes. Studies commonly either compared BF and non-BF-designated maternity care facilities [6, 16] or compared changes in select breastfeeding indicators pre- and post-introduction of BF certification [17].

A study [17] that assessed EBF before and after the implementation of the BFHI in a University hospital in Turkey, found that there was a 1.5-fold increase in BF duration with a mean of 21.17 (SD: 0.42) months in the after BFHI group compared to 17.83 (SD: 0.6) months in the pre-BFHI group. Even though the authors found higher EBF

rates during the post-BFHI implementation period, the differences were not statistically significant.

In a survey conducted in all Scottish maternity clinics with the inclusion of 464,246 records of infants born during the period of 1995–2002, mothers who gave birth to a Baby-Friendly Hospital were about 28% more likely to initiate breastfeeding within the first week after birth after controlling for the potential effect of confounders [6]. Similar findings have been reported in other studies in terms of initiation [6, 18]. However, unlike breastfeeding initiation, evidence with regard to overall BF duration is conflicting. Whereas several studies have shown a positive effect on BF duration [7, 19], a number of studies did not identify a positive association with longer duration of breastfeeding [16]. For instance, in the Millennium Cohort study in UK with the participation of 17,359 mother-infant dyads from 248 maternity care facilities (of which 14 were BF-designated) higher breastfeeding initiation rates were reported in accredited BFHI hospitals. Nevertheless, this difference was no longer evident by the first month (adj RR: 0.96 95% CI: 0.84, 1.09).

In a different study from the US, with the participation of 29 of a total of 32 BF-designated hospitals, mean breastfeeding initiation rates were significantly higher in comparison to the overall US BF initiation rates (83.8% vs. 69.1%). In addition, mean EBF initiation rates were almost twice higher than the national EBF rates (78.4% vs. 46.3%). Interestingly, the study identified existing inaccuracies in EBF definitions as well as the lack of EBF data recording even in BF-designated hospitals. Only 16 BF hospitals (out of 29 that participated in the study) kept a record of EBF data, and of those only nine reported using the WHO definition for EBF (only breast milk). Six hospitals considered infants to be EBF, even they have also received sugar water for medical reasons and one hospital defined EBF on the basis of maternal perspective on supplementation i.e. infants fed with formula or sugar water for medical reasons were also considered as EBF. According to the hospitals' responses, Steps 3 (*Prenatal Information*), 6 (*only BM*) and 9 (*no use of pacifier or other teats*) were the most difficult to implement. Only a very small number of hospitals, specifically four out of 29, reported no problem on the implementation of the 10 Steps [20].

Implementation of the BFHI also appears to have a positive effect on BF rates in NICUs. Based on extracted data from medical records of infants born and admitted in the NICU of a BF-hospital designated in the USA, in [19]. BF outcomes were compared before the initiation of the procedure for the designation and after the hospital received the certification. The study reported that both BF and EBF initiation as well as duration during the first 6 weeks increased significantly.

#### *4.1.3 Association between the 10 steps and BF outcomes*

In a population-based study in the USA, in [21], the five practices that exhibited the strongest association with BF duration within the first 16 weeks independently of maternal socio-economic status, were: (1) initiation of BF within the first hour, (2) only breast milk (exclusive BF), (3) rooming-in, (4) no use of pacifier and (5) BF support after discharge. No association was found between the maternity practices that refer to Hospital staff providing support and information to mothers on breastfeeding (*information given on BF* (step 3); *Help given on how to BF* (Step 5); *BF on Demand* (Step 8); *No gifts or samples of BF substitutes* (ICBS)), suggesting that the type of information and support might not differ. On the contrary, BF duration was higher among mothers that experienced the following steps: *BF within the first hour after birth* (Step 4); *only BM while in the maternity clinic* (Step 6); *Rooming-in* (Step 7);

#### *Supporting and Promoting Breastfeeding: The 10 Steps to Successful Breastfeeding DOI: http://dx.doi.org/10.5772/intechopen.113317*

*No use of a pacifier* (Step 9) compared to those that they did not. When the effect of the implementation of the five maternity practices was investigated on the basis of their socio-economic status (defined as mothers whose incomes <= 185% of the poverty level and those whose incomes were > 185 the poverty level), low-income mothers reported higher BF rates between 1 and 14 weeks among those that experienced all five maternity clinics compared to those that did not (65% vs. 46%). For mothers above >185 the poverty level, BF rates among those that experience all maternity practices were significantly higher than those that did not between 9 and 12 weeks (at 12 weeks: 82% vs. 70%).

In a longitudinal study (Infant Feeding Practices Survey) conducted in the USA [22], five indicators were measured, thought to negatively affect breastfeeding outcomes to reflect the lack of implementation of good maternity care practices as described in the 10 steps, namely late BF initiation, introduction of supplementation, not rooming-in, not breastfeeding on demand, use of pacifiers. These were directly assessed by mothers who initiated breastfeeding during their stay in the maternity clinic and expressed the intention to BF for at least 2 months during pregnancy. The findings suggested a clear dose-response relationship between maternity practices and the risk of BF discontinuation before the first 6 weeks of birth. In fact, the fewer the number of "good practices" the mothers experienced during their stay, the higher the risk of BF discontinuation. Specifically, mothers who reported that they did no experience any of the maternity practices were nearly eight times more likely to discontinue BD prematurely by comparison to those who reported experienced all of the above five practices/steps (adjOR: 7.7; 95% CI: 2.3–25.8). When each "bad practice" was assessed separately, three of the five steps appeared to be more strongly associated with shorter BF duration; late BF initiation, supplementation and no BF on demand. After adjustment for other variables, late BF initiation and supplementation were identified as the stronger risk factors of early BF discontinuation. Mothers who experienced none of the maternity practices were about seven times more likely to discontinue BF within the first 6 weeks in comparison to those experienced all five practices. Among the factors that were found to be independently associated with discontinuation of BF before the sixth week were Initiation of breastfeeding (adj OR: 1.6; 95% CI: 1.1–2.3); formula supplementation (adj OR: 2.3; 95% CI: 1.5–3.3) and not BF on demand (adj OR: 1.2; 95% CI: 0.8–1.7). On the other hand, pacifier use (adj OR: 1.0; 95% CI: 0.7–1.4) and rooming-in (adj OR: 1.1; 95% CI: 0.8–1.7) were found not to be associated with BF discontinuation.

While there is clear evidence to suggest that the use of supplementation is one of the strongest independent risk factors of exclusivity as well as shorter BF duration in general, it has been suggested that even baby-friendly-designated hospitals fail to achieve its implementation. The Baby-Friendly requirement that the maternity clinics have to pay for the infant formulas, especially in countries that hospitals receive formulas from the companies for free, increases significantly the maternity clinics' expenses and becomes a barrier to the adherence of Step 6 (*Only BM*) [5].

A Swiss study [23] also confirmed the positive association between the implementation of BFHI and exclusivity as well as longer breastfeeding duration. While an improvement in BF and EBF rates was observed after accreditation of hospitals with the baby-friendly designation during 1994–2004, the authors observed significant variability in EBF rates as well as the degree of meeting the BFHI criteria, even among hospitals that acquired the designation. In the study, the authors reported that the strongest associations with shorter BF duration were observed in terms of formula supplementation in the maternity facility. Moreover, the introduction of other liquids

(not formula supplementation) was also associated with early cessation of BF. BF within the first hour after birth, full rooming-in, breastfeeding on demand and no use of pacifiers was shown to be associated with longer BF and EBF duration.

A survey in Brazil [24], as part of an immunization campaign, included 65,936 infants younger than 1 year of age and examined the association of the implementation of Baby-Friendly practices on breastfeeding outcomes. A higher proportion of mothers who delivered in a Baby-Friendly Hospital were more likely to experience the 10 steps. The experience of the 10 steps was shown to have a positive association with the duration of EBF up to the sixth month. Similar findings are confirmed by a series of studies from other countries [25, 26]. It has been suggested, however, that mothers who intend to BF longer or exclusively are more likely to choose to give birth in a Baby-Friendly hospital and are more willing to comply with the 10 Steps; hence, to some extent to which the observed differences represent a selection bias is not clear [26].

In any case, there is evidence to suggest that any effect is likely to be cumulative as the more "good practices" mothers experience the more likely they are to achieve EBF intentions [27]. Findings from the Infant Feeding study II in the USA suggest that experiencing all six practices investigated [*Initiate BF within 1 hour after birth* (Step 4); *only breast milk* (Step 6); *Rooming-In* (Step 7); *BF on Demand* (Step 8); *Use no Pacifier*/*Teats* (Step 9); *Provide information on how to seek support after discharge* (Step 10)] increases the odds of achieving the mother's intended duration of EBF by nearly three times in comparison to experiencing none or only one [27]. Furthermore, compared to mothers who experienced all six baby-friendly practices, mother that had not experienced any of the practices were at 13 times greater risk to discontinue any BF [8]. As additional baby-friendly practices were implemented, a stepwise decrease of the risk was observed, suggesting a dose–response relationship between the number of the Steps and breastfeeding. Using logistic regression analysis in order to implement mutual adjustment between the maternity practices [(*BF initiation within 1 hour* (Step 4); *only BM given* (Step 6), *Rooming-in* (Step 7), *BF on Demand* (Step 8); *No pacifiers given* (Step 9); *Provide information on BF* (Step 10) as well as to adjust for several socio-demographic factors (e.g. child gender, household income, marital status, parity, maternal education) and behavioral and attitudinal factors [e.g. number of friends and relatives who breastfed, maternal prenatal intentions to work after birth, prenatal attitudes toward BF (i.e. formula as good as BM)], the authors identified the three practices with the strongest positive association with BF outcomes in the first 6 weeks period after birth. These are: BF initiation within 1 hour, only breast milk given and no pacifiers or other soothers.

Another study [28] conducted in four Public hospitals in Hong Kong with a sample of 1242 mother-infant pairs investigated the effect of six maternity practices on breastfeeding duration up to the first month after birth. The maternity practices not investigated were: *Have a written BF policy* (Step 1), *Train health workers to implement the policy* (Step 2), *Inform all pregnant women about the benefits and management of BF* (Step 3) and *Support mothers on how to BF* (Step 5). Mothers who did not experience any of the good maternity care practices were about three times more likely to initiate weaning within the first 8 weeks (AdjOR: 3.13; 95% CI: 1.41–6.95). In order to identify the practices that are more strongly associated with successful breastfeeding outcomes, the authors performed a multivariable analysis. Only four of the six maternity practices investigated were associated with BF discontinuation at 8 weeks after adjustment for socio-demographic factors, mode of birth, return to work and other breastfeeding support factors. These are early BF initiation within 1 hour after birth (AdjOR: 0.65; 95% CI: 0.51–0.83), only breast milk (AdjOR: 0.47; 95% CI: 0.35–0.63),

#### *Supporting and Promoting Breastfeeding: The 10 Steps to Successful Breastfeeding DOI: http://dx.doi.org/10.5772/intechopen.113317*

no use of a pacifier (AdjOR: 0.66; 95% CI: 0.53–0.83), breastfeeding information and support (AdjOR: 0.67; 95% CI: 0.52–0.88). The study did not find any association between rooming-in (AdjOR: 1.13; 95% CI: 0.89–1.43) and breastfeeding on demand (AdjOR: 1.01; 95% CI: 0.78–1.31) and BF duration. When in the multivariate model, breastfeeding support variables (whether the mother BF as an infant, previous BF experience and paternal preference to BF) were also included, only EBF while in hospital stay (Step 6) was associated with BF duration.

It has to be noted that the majority of studies operationalize the extent to which the "10 steps" have been implemented based on self-report of the mothers. Furthermore, even though the set of good practices refers to 10 items, the first two items (i.e. written policy and education of maternity clinic staff) are almost always never included in the investigation since these are clinic-level rather than individuallevel variables and, unlike other steps (for example, breastfeeding within 1 hour of birth, rooming-in, breastfeeding on demand and so on) cannot be reported by the participating mothers in the form of self-reported experience.

A prospective study by Pincombe et al. [11] with a sample of 317 primiparous mothers in Australia followed for the first 6 months after birth found that the use of formula supplementation, the use of pacifier/dummy or nipple shield and, interestingly, breastfeeding on demand while in the hospital were associated with shorter duration of breastfeeding. After adjusting for different socio-demographic factors, "breastfeeding on demand" remained positively associated with early initiation of weaning (adjHR: 1.71; 95% CI: 1.03–2.86). The authors concluded that the surprising association between breastfeeding on demand and shorter duration of breastfeeding was confounded by other factors such as higher self-efficacy, smoking less, education level, type of birth delivery [11].

Even though studies have varied in terms of their study design (set of steps included in the investigation, breastfeeding outcomes, length of follow-up and so on), it appears that the most consistent, and perhaps non-surprising, association with early discontinuation of exclusive breastfeeding is the provision of other non-breast milk liquids while at the clinic [11, 27], especially formula supplementation [29–31].

A US national study [32] examined the effect of the implementation of the 10 Steps for mothers to achieve their intention for EBF duration in primiparas and multiparas separately. For primiparas, four maternity practices were associated with BF intention: only breast milk (not other supplement) (adjOR: 4.4; 95% CI: 2.1–9.3), providing information on community BF support resources (adjOR: 2.3; 95% CI: 1.1–4.9); health support for BF initiation (adjOR: 6.3; 95% CI: 1.8–21.6); no use of pacifier (adjOR: 2.3; 95% CI: 1.1–4.4). For multiparas, only breast milk (adjOR: 8.8; 95% CI: 4.4–17.6) and support of BF on demand (adjOR: 3.4; 95% CI: 1.7–6.8) were the only maternity services that were statistically significant with the fulfillment of the maternal intention of EBF duration.

#### **4.2 Evidence from intervention studies**

The majority of studies assessing the association between the implementation of the "10 steps" and breastfeeding outcomes in the published literature are observational. This was also the conclusion of a systematic review on the subject [33]. Of 58 reports identified in their review, nine were based on three randomized controlled trials. The rest of the studies were quasi-experimental designs (N = 19), prospective studies (N = 11) and cross-sectional or retrospective (N = 19). Even so, the authors concluded that adherence to the Ten Steps has a positive impact on

short-term, medium-term and long-term breastfeeding outcomes with a doseresponse relationship between the number of steps and the likelihood of improved BF outcomes. Interestingly, they also concluded that community support (step 10) appears to be essential for sustaining any impacts of the BFHI in the long term*.* The lack of intervention studies is not surprising due to the nature of the intervention and the pragmatic difficulty in randomizing units to BFHI. It is more likely that studies apply observational designs either in the form of descriptive comparative designs i.e. comparing maternity units that have implemented the BFHI to control facilities [34] or pre-post quasi-experimental designs [35, 36]. These studies have been discussed in the section above alongside the observational studies with a survey study design.

The first intervention study was the seminal and most well-cited to date PROBIT study in the Republic of Belarus [34]. This was a cluster randomized trial. The study investigated the effectiveness of BFHI by randomly assigning 31 hospitals to either the BFHI intervention or control arm. During the study period, as many as 17.046 mother-infant dyads were included in the data analysis. The prevalence of Breastfeeding and Exclusive Breastfeeding was measured at 3, 6, 9 and 12 months. The study found a higher prevalence of BF in the maternity clinics in the intervention arm compared to the control arm at the third (72.7% vs. 60%; adjOR: 0.52, 95% CI: 0.40, 0.69) and sixth month of follow-up (49.8% vs. 36.1%; adjOR: 0.52, 95% CI: 0.39, 0.71). Furthermore, the study showed differences between interventioncontrol arm at longer follow-up periods. The breastfeeding prevalence at 9 months among the group of women who delivered in a BFHI hospital (intervention arm) was 36.1% in comparison to 24.2% among mothers who gave birth in the control hospitals (adjOR: 0.51, 95% CI: 0.36, 0.73). At 12 months, the prevalence of BF was 19.7% in the intervention group compared to 11.4% in the control group (adjOR: 0.47, 95% CI: 0.32, 0.69).

The study demonstrated that the effectiveness of the implementation of the BFHI on improving breastfeeding was not short-lived since differences between intervention and control arms were observed both in the short term as well as the long term, and up to a period of 12 months after birth. Furthermore, the study found that the effect was not just restricted to a higher likelihood and longer duration of any breastfeeding, but also showed a significant effect of the intervention on exclusive breastfeeding. The proportion of mothers exclusively breastfeeding at 3 months was seven times higher in the experimental group than the control group (43.3% vs. 6.4%; p-value<0.001) and more than 12 times higher at 6 months after birth (7.9% vs. 0.6%; p-value = 0.01). Of course, it should be noted that even though there was a statistically significant effect of the intervention on the likelihood of breastfeeding at 6 months after birth (49.8% vs. 36.1% in the control group), as well as the likelihood that this is exclusive by comparison to the control group, the prevalence of mothers who exclusively breastfed at 6 months was quite low even in the intervention arm (7.9% vs. 0.6%). This finding is not surprising since recommendations for EBF are for 6 months.

The other two intervention studies identified by a review [33] were conducted in Brazil. However, the aim was not to assess the BFHI 10 steps as a pack, but certain aspects of it. In a study [37], following training of the maternity care staff in the 10 steps, mothers were randomized to receive 10 postnatal home visits (step 10). The authors found that strengthening step 10 had a significant positive impact of the intervention on the prevalence of exclusive and any breastfeeding. Taddei et al. [35] randomly assigned eight hospitals in Brazil to Ten Steps training or to continue the standard of care but did not find an impact of the training of the staff on breastfeeding duration.

#### *Supporting and Promoting Breastfeeding: The 10 Steps to Successful Breastfeeding DOI: http://dx.doi.org/10.5772/intechopen.113317*

A quasi-experimental study [36] was conducted in the USA with the participation of 13 hospitals that received BF accreditation before 1999 or became accredited during the period 1999–2009 (participants = 11,723) and 19 non-BF-designated matched hospitals (participants = 136,040). Matching was achieved by identifying the Baby-Friendly maternity facility's "nearest neighbors," determined by calculating the Euclidian distance between standardized values of pairs of observations. These were the number of births as a proxy for the size of birth facility, the proportion of white mothers and the proportion of mothers with high education. Even though the study did not find an overall difference between the BF and non-BF-designated hospitals, the study reported a differential effect of the intervention in terms of educational attainment. In fact, the study recorded an increase of 3.8% in Breastfeeding initiation rates in designated Baby-friendly hospitals (adj coef = 0.038; 95% CI: 0.00, 0.08) and of 4.5% in EBF for 4 months or more (adj coeff = 0.045; 95% CI: 0.01, 0.08) for only among mothers of lower educational attainment. This is due to the fact that mothers with higher maternal education are more likely to be aware of the BF accreditation and thereafter choose to give birth in Baby-friendly hospitals. On the contrary, BF accreditation might help to reduce the effect of socio-economic disparities and therefore reduce the gap of health inequalities. Similar were the findings by Sherburne-Hawkins et al. [38] with the participation of a smaller number of BFHI (n = 4, participants = 915) and non-BFHI hospitals (n = 6, participants = 1099) with an increase of 8.6% in Breastfeeding initiation rates in designated Baby-friendly hospitals (adj coeff: 0.086; 95% CI: 0.01–0.16) only among mothers of lower educational attainment. Also, for each additional BF maternity practice, there was an increase in BF initiation (adj coeff, 0.146 [95% CI, 0.13–0.16).

#### **5. Summary**

For over two decades, the "10 Steps" have been the cornerstone of national and international policies and strategies for the promotion, protection and support of BF. However, adherence to the "10 Steps" is suboptimal [10, 12, 22]. In fact, it seems that the maternity care practices which are more consistently associated with a positive impact on BF [22] appear to be the least implemented, such as the practice of early initiation of breastfeeding in skin-to-skin position and no use of a pacifier [12].

The literature that supports the beneficial effects of the adherence to the BFHI on BF outcomes, and specifically "good maternity care practices" in the model of the "10 Steps," is extensive. Observational and intervention studies have assessed the impact of implementation of the "10 Steps" on BF outcomes and have consistently shown positive effects on BF initiation, duration and exclusivity. The effect of the "10 Steps" is also apparent in the reduction of social inequalities in BF.

However, evidence of the individual effect of the "10 Steps" on BF outcomes is conflicting. While the implementation of specific maternity care practices has been consistently associated with BF outcomes, evidence is not as consistent or clear-cut for others. For example, immediate and longer skin-to-skin has been associated with higher BF initiation rates [39] as well as longer EBF and BF duration [40, 41]. Similarly, implementation of Step 9 (no pacifiers) has been acknowledged to be associated with longer BF [42–44] and EBF duration [45]. However, pacifier use might represent an outcome of a rather complex maternal behavior which is difficult to pinpoint. For instance, mothers who do not intent to breastfeed, encounter lactation problems or decide to discontinue BF are more likely to introduce a pacifier as a result. Thus, the direction of the association between pacifier use and breastfeeding is not clear. In relation to Step 3 (education in the prenatal period), evidence on the effect of breastfeeding initiation and duration is also not clear. While a number of studies suggest a beneficial effect of prenatal information on BF outcomes, others do not [21]. The type and nature of the interventions seem to influence the effectiveness of Step 3 on BF outcomes.

### **Author details**

Mary Economou and Nicos Middleton\* Cyprus University of Technology, Limassol, Cyprus

\*Address all correspondence to: nicos.middleton@cut.ac.cy

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Supporting and Promoting Breastfeeding: The 10 Steps to Successful Breastfeeding DOI: http://dx.doi.org/10.5772/intechopen.113317*

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*Midwifery – New Perspectives and Challenges*

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#### **Chapter 5**

## Description of a Relationship Focused Mother-Infant Group Program: Mother-Baby Nurture

*Sharon Cooke, Dawson Cooke and Sue Coleson*

#### **Abstract**

Mother-Baby Nurture is an innovative group program that focusses on strengthening the mother-infant relationship through enhancing reflective capacity within mothers and their infants. We describe the unique combination of the features that are central to this program and present comparisons with other early parenting interventions. Infancy is a unique period of acute developmental vulnerability and dependence on a caregiver. As the caregiver is the critical regulator between infant and their environment, disturbances in the caregiver-infant relationship have heightened potential to interfere in the infant's developmental trajectory and lifelong wellbeing. Mother-Baby Nurture is a 10-week targeted group program that is currently being implemented in Western Australia, for infants and their mothers experiencing relational or emotional distress. This program provides an emotionally containing space for a mother and her infant to explore mental states. We foster curiosity in the thoughts, feelings, and behaviour (of the baby, the mother, and others), as well as reflection on attachment relationships (past and present). This therapeutic approach shares common ground with parent-infant psychotherapy and mentalization-based treatment, and is informed by attachment theory and the neurobiological science of infant development.

**Keywords:** Mother-Baby Nurture, group, infant, mother, relationship, parenting, mentalization-based treatment

#### **1. Introduction**

Early infancy, more than any other time in the human lifecycle, is a time of unprecedented developmental capacity and vulnerability. During this time, experiences powerfully influence brain architecture and subsequently provide the foundation for all future learning [1, 2]. Adverse early experiences during the formative months of infancy, if not addressed, can have lifelong consequences for the developing person [3] and can be transmitted the next generation [4]. A critical experience during infancy is the relationship with caregivers, and for most infants the relationship with their mother is particularly influential.

In 1940, Winnicott declared "there is no such thing as an infant [on his or her own]", the infant exists "as a unit" in relationship with a caregiver [5]. Bowlby [6] described how ideally, the caregiver-infant relationship provides the infant with a secure base from which they can explore the world and return to have their needs met. A central means by which a parent influences the security of their relationship with their child is the capacity of mentalizing [7]; also referred to as reflective functioning [8]. Parental mentalizing helps the infant to make sense of their 'self' and their external world, as the caregiver provides a conduit for sharing, understanding, and regulating internal mental states including thoughts, feelings, longings, and desires. The capacity to mentalize and provide this secure base for the infant may be distorted or enabled by the caregiver's organisation of their own past childhood experiences of their caregivers, that informs their internal working model [9]. The transmission of secure infant-caregiver attachment across the generations provides the context for optimal psychological, social and emotional development of the infant, and is predictive of future social-emotional and cognitive functioning throughout the early years and into adulthood [10, 11]. This premise, that social, emotional and cognitive development during infancy occurs within the context of the infant-caregiver relationship, is an anchor point for the field of infant mental health [12], psychodynamic early intervention [13], and the central rationale behind Mother-Baby Nurture (MBN).

We provide a description of the MBN program and the nuanced role of the group facilitators. Following this is a discussion of the key distinguishing concepts at the heart of MBN: the importance of early relational experiences, infant as participant, the group as a containing space, and enhancing mentalizing [14]. The outcomes anticipated for the mother and for the infant are reflected upon. In this discussion paper, caregivers are described as 'she', and for ease of reading, infants will be described as 'he'.

#### **2. Description of Mother-Baby Nurture program**

Mother-Baby Nurture is a brief reflective group program for mothers and their infants (0–6 months of age) facilitated by two infant mental health clinicians over a 10-week duration in a community setting. Weekly 2-hour sessions take place with the facilitators and six mothers forming the outer circle, with babies held in mother's arms or within reach on baby rugs in the circle centre. It is an experiential group, where the pace is slow and spacious, and responsive to the felt needs of the babies and their mothers. Together, we agree on group guidelines to help create a safe space, where mothers and babies are invited to take time getting to know one another. There are predictable weekly rituals that invite curiosity, observation, and reflection. These include the mother-baby check-in, watch-with-wonder, infant observation time, nursery rhymes, and the use of imagery, metaphors, poetry, and music. The rituals are offered as gentle entry points for reflective discussion. Dedicated attachmentrelationship themes are introduced and explored in an effort to bring to mind past and present patterns of relating. Reflecting on mother-infant interaction helps to illuminate patterns of relating that may not have been previously noticed or thought about. Throughout the group, the infants' communications are welcomed, held in mind, and responded to, which significantly shapes the content and pace of the group process.

The primary intervention aim of MBN is to strengthen the mother-infant relationship. A central strategy to improve the relationship and infant outcomes is to

*Description of a Relationship Focused Mother-Infant Group Program: Mother-Baby Nurture DOI: http://dx.doi.org/10.5772/intechopen.110088*

foster and strengthen the mother's mentalizing capacity. A secondary strategy of the program is the reduction of symptoms of maternal postnatal depression and anxiety as well improving the mothers' parenting confidence and feelings of attachment with their infant [15].

We acknowledge that every family exists within the context of broader caregiving systems, with unique family, community and cultural expectations and structures [16]. Issues highlighted in the mother-infant relationship may also be relevant to father-infant relationships or other caregivers and family system level relationships [17, 18], although these dynamics are beyond the scope of this paper. In response to community demand, this program has been adapted for the unique needs of Aboriginal, culturally and linguistically diverse as well as adolescent mothers and their families. Presently, MBN is provided at ten locations across Western Australia, delivering 40 10-week groups per year, servicing approximately 240 vulnerable families every year.

#### **2.1 Role of the MBN facilitators**

Facilitators are recruited from different disciplines including psychology, social work, counselling, midwifery, and other relevant fields of allied health. Each facilitator has undertaken a three-day manualised MBN training process [14] and participates in ongoing monthly reflective supervision. Each group has a lead and co-facilitator, and over time through the process of mentoring, the co-facilitator may become the lead facilitator when the opportunity arises. Reflective supervision is a vital ingredient when working with young children and their caregivers in the shared exploration of the emotional content [19, 20]. Reflective supervision offers an emotionally containing relationship that mirrors the role of the facilitator with the mothers; this is vital to keep the thinking and feeling alive on behalf of the group. The main focus of this supervision is "the shared exploration of the emotional content of infant and family work as expressed in relationships between parents and infants, parents and practitioners, and supervisors and practitioners" [21, p. 63].

The role of the MBN facilitators is to create an emotionally containing environment for the mothers and infants while making mentalizing explicit through maintaining a stance of curiosity and reflection. The facilitator holds the baby in mind as a separate being whose experience and behaviours are meaningful while holding the mother's experience, even though these may seem intolerable or distorted at times [22]. To sufficiently hold the powerful projections and primitive processes in the mother-baby group, two facilitators are recommended [23].

The facilitators narrate their observations aloud in the group, at times making sense of differences of perspective, modelling not knowing the other's mind as well as sharing co-joint intent to work together to support group members [24, 25]. There may be minor misunderstandings and differences in the facilitator's perspectives, and these distinctions are talked about to model "good enough" parent relationship to the mothers. Facilitators may stop and rewind, slow the pace or seek clarification in an effort to reflect upon a shared moment when a member responds in a particular way. Emotional reactions are noted; sometimes explicitly identified and explored, perhaps acknowledged and explored at a later time, or simply noted for facilitators' shared reflection after the group. We acknowledge and celebrate moments of attunement and delight as well as offering a kind and curious presence in moments of distress and mis-attunement. As the facilitators work together in an unhurried pace, thinking aloud about the affects and processes encountered in the group, whilst holding each member

in mind, they attempt to embody the qualities found in a collaborative parenting model for the members to experience [23]. Facilitators work together to support one another to develop a reflective stance and to help provide a clearer lens to observe group processes and model mentalizing as a way of being together. In addition, co-facilitation can represent alternate perspectives, such as a father's experience or other siblings [23].

On becoming a mother, a woman's relationship with her own mother may be thrown into sharp relief, with mixed and often ambivalent feelings surfacing unexpectedly. In the MBN group setting, the facilitators may find the mothers relating to them in ways that echo these ambivalences. By maintaining consistent, thoughtful, compassionate, and accepting stance, facilitators offer a potentially new experience for mothers where these qualities may have been longed-for but not experienced in their relationship with their own caregivers. Once experienced, these mothers may become able to draw on an internal representations of a 'good grandmother' [26] facilitator to help contain and make sense of thoughts and feelings in a new and enriched way.

#### **3. Key distinguishing concepts of MBN**

There are four key concepts that we have identified as underpinning the Mother-Baby Nurture model: early relational experiences matter, infant as participant, the group as a containing space, and enhancing mentalizing.

#### **3.1 Early relational experiences matter**

The first six months post birth is a time of profound transition for both infant and mother. It is a highly sensitive period in the newborn infant's neurobiological development whereby exposure to early stressful experiences (such as an emotionally dysregulated mother) may alter the developing hypothalamic pituitary adrenal (HPA - stress response) system, sensitising the individual to future stressful life events and psychopathology [27]. It is also a vulnerable period of neuropsychological development where repeated relational experiences between mother and infant, over time accumulate to inform the infant's internal working model, shaping the patterns of attachment behaviour in response to the mother [2, 28]. The quality of these early attachments is understood to contribute significantly to a child's long term socioemotional development [29].

Described by Stern [26] as the "motherhood constellation", the presence of the infant typically activates the mother's attachment system, preoccupying the mother's mind and body with the survival and nurture of her baby. It can be an intense period of psychological reorganisation that may involve reshaping of the mother's perceived role, identity, internal working model and attachment patterns. These formative early months of motherhood can be a time of significant foment, evoking reflections on past and present attachment relationships precipitating surprising and strong affective responses to "ghosts" from the past [30] as well as more positive "angels" [31]. Being a new experience, the mother's thoughts and feelings towards her newborn baby and her new caring role are less established and likely to be more flexible. The mother's patterns of behaviour are still in formation and responses are not yet predictable and anticipated, allowing opportunity for flexibility and change. Consequently, the MBN program is offered within the first six months post birth to seize this opportunity of flexibility in the mother-infant dyad.

*Description of a Relationship Focused Mother-Infant Group Program: Mother-Baby Nurture DOI: http://dx.doi.org/10.5772/intechopen.110088*

#### **3.2 Infant as participant**

From birth, the infant has capacity for primary intersubjectivity; to be engaged as a person in their own right [32, 33]. More so, the infant's subjective sense of self is actually dependent on the quality of the interactions with those they relate to [33]. Engaging the mother in isolation misses an opportunity to directly contribute to the infant's development, the quality of the mother-infant interactions and the promotion of infant mental health [34]. Paradoxically due to neuroplasticity, the vulnerable infant is the most receptive and adaptive member in the dyad, making them a potent agent of change in the relationship. Stirred by the enlivened infant, the mother's attachment systems can be activated, creating opportunity for reorganisation of internal representations, role and emerging attachment patterns [26], as well as inhibiting disorganised attachment in infants [35].

During the MBN group, facilitators express curiosity and interest in the infant's experience, marking moments of brief exchange with curiosity and delight, which serve to legitimise the infant's experience. This sensitive and responsive exchange over time, supports the infant's developing sense of self and capacity to regulate emotions [36]. For example, while holding the infant's gaze and providing marked mirroring of the baby's expression the facilitator may say, "I wonder what you might be feeling as your mother shared that story? I think it makes your mummy feel sad; does it make you feel sad too?" The embodied act responding to the infant and holding him in mind as a thinking, feeling being is a central aspect of MBN. Such interventions support the mother's capacity for perspective-taking, beyond her own experience and adult concerns, to consider the perspective and experience of her infant [37].

As we (facilitator, mother, and group) practice holding a reflective stance, wondering aloud about the baby's efforts and shared moments of meeting, we consider how the infant's external behaviour is informed by his internal experiences. We acknowledge times when the infant and mother share joyful moments, as well as acknowledge (without judgement) shared moments of uncomfortable affect. The infant serves as the 'honest' member of the dyad, enacting feelings that are shared but not necessarily expressed by the mother [38, 39].

Infant-focused moments occur spontaneously, as well as formally through a weekly group practice derived from the Irish Gaelic definition of curiosity, ábhar le ionadh, which translates "to watch with wonder" [40]. Mothers quietly watch their baby, invited to wonder about what the infant may be experiencing, reflecting on their possible thoughts, feelings, urges and bodily sensations. The curious, 'not-knowing' stance is both an important marker of all mentalizing interventions and core component in the child-led psychotherapeutic program, Watch Wait and Wonder [41]. Exercising a state of presence and attention with the infant is especially powerful for mothers that may ordinarily withdraw (absorbed in their own internal world) or for the mother preoccupied with their infant's externalised behaviour (feeding, sleeping, or crying). It may also bring intrusive patterns of attachment behaviour to light, that are observed and held in mind by the facilitator. Reflecting on 'in-the-moment' experiences can illuminate past narratives and distortions that inform the mother's internal working model, shaping the way she responds to her infant [42]. It can offer a window into the mother's activated internal world that, if the infant were not present, may have taken longer or remained hidden from sight.

#### **3.3 The group as a containing space**

The MBN facilitators seek to provide a supportive relationship for the mother and the babies much like the role of a mother for an infant; described by Winnicott [5] as a necessary "holding" and Bion [43] as "containing". Scaffolded by agreed group guidelines and processes, the group can form a kind, non-judgemental space for the mother and infant to express distress, anxiety, and pain. Once expressed, these projections can be returned in a modified and palatable form [44]. The group provides a safe container from which its members (mothers and infants) can begin to trust in the observations and feedback made by other members and become more receptive to new learnings. The experience of authenticity and openness can support the mother to develop an experiential understanding of social environments and interactions, a process defined as epistemic trust [24]. The benefits of epistemic trust are expected to continue well after the facilitated group ends, leading to sustained supportive relationships between group members, which act as a steppingstone to wider social contexts.

The role of the MBN facilitators is to hold both the mother and the infant in mind as thinking, feeling beings whose experiences and behaviours are meaningful. The facilitators scaffold the dyads experience, noticing strengths in both infant and mother, creating opportunities for brief attuned interactions to be acknowledged and amplified. The role of the group then, is to offer the infant enlivening experiences that will support his engagement with others, in his exploration as well as providing an emotionally containing presence when the infant is seeking support to regulate emotions. The facilitators are also offered containment from their regular supervision, which completes a nested set of relationships much like a babushka doll, one contained within the next: supervisor, facilitators, mother and infant (A similar 'Containment Model' is presented in [45]).

The group process acts as a holding environment for the vulnerable mother [46] as facilitators carefully narrate changes and absences in the group, including preparation for the eventual group closure, as thoughts of separation can activate strong feelings [23]. When disruptions are repaired, it helps inform the members by providing suggested scripts on how minor family ruptures and repairs can be managed within trust relationships. When a member of the group shares an affective state, the containing experience of marked mirroring can be amplified and nuanced as the multiple members provide a "hall of mirrors" response that offers differing affective intensity and hues [47]. The group can also offer some distance when a member listens to another's experience, she can gain insight into aspects of her own internal world that may have been previously obscured. The process of identifying one's own experience within the story of another member is both validating as well as normalising, alleviating feelings of isolation and shame. Establishing the service within the community instead of hospital setting, also helps destigmatise their experience.

#### **3.4 Enhancing mentalizing**

Mentalizing is a concept that has origins in psychodynamic theory, attachment theory and cognitive psychology [5, 43, 48–50]. The concept of parental mentalizing provides a well-established theory and mode of relationship-focused intervention (Mentalization-Based Treatment) that is accessible across disciplines [51–54]. Evidence suggests that parental mentalizing is a central process in the intergenerational transmission of attachment patterns [55, 56], with poor parental mentalizing

#### *Description of a Relationship Focused Mother-Infant Group Program: Mother-Baby Nurture DOI: http://dx.doi.org/10.5772/intechopen.110088*

predictive of children's insecure [57] and disorganised attachment [58]. The way a mother cares for her infant is informed by her own experience of being parented, explicitly in behaviours, and implicitly through enacting her internal working model [30]. A recent study of these processes [59] found that mothers' poor mentalizing of their own early attachment relationships was predictive of negative parenting behaviours, which were strongly related to attachment insecurity and disorganisation. Interestingly, promoting maternal sensitivity behaviours alone (via psychoeducation) has not been found to mitigate the transmission of the caregiver's adult attachment patterns to the infant [60].

Time in each session is dedicated to supporting mother-infant play and experiencing or 'being-with' the emotions and mental states of the infant. Conversations are facilitated so mothers reflect on attachment relationships - both representations from her childhood and her current perceptions of her baby. Through facial expressions, gestures, talking or vocalising, and actions (including play), a mother can support her infant to recognise his own internal state and regulate his emotions. It is through experiencing a mother's mentalizing that a child can 'make sense' of his environment, supporting him to develop affect regulation, mitigating against stress arousal, and promoting the development of secure patterns of attachment and sense of personal agency [61, 62]. This engagement also contributes to the develop his sense of subjective self [63]. The MBN facilitator thinks about and relates to the mothers and babies as thinking, feeling beings. Through repetition, modelling curiosity about internal states is transmitted to the mothers, encouraging them to consider their own and their infants' internal states.

This curiosity and openness in thinking helps to develop the skill of metacognition, so rather than being 'in it' the mother is able to think 'on it' which enables her to examine her internal working model and how she views the intentions of her child and her own self [60]. Through practicing this type of perspective taking, the mother's mentalizing capacity is stretched and strengthened. This way of being, once nurtured in the group can continue to develop beyond the life of the group and is passed forward through the infant-parent relationship.

#### **4. Outcomes**

#### **4.1 Intended outcomes for the mother**

As the mother seeks to care for her infant, the facilitators may notice that the mother expresses strong emotions, ambivalent or negative feelings in what she says about her infant or in the way she responds or handles him. The facilitators emotionally contain the expressed state, allowing the mother to talk about her experiences, without fear of abandonment, intrusion, or criticism. A mother who is able to articulate her longing, or to mourn her loss or express her anger or despair within the context of a nurturing relationship may become clearer about her relational history and more emotionally available and sensitive to her infant [30, 64, 65]. In the safety of the supportive relationship, the mother may become more able to mentalize emotionally charged events and this lowers her epistemic vigilance [24]. This capacity will supports her to revisit the difficult experience in a more resourceful way, giving her opportunity to better understand and integrate the feelings that threaten the developing attachment relationship [24, 30]. Well-regulated affect between the dyad can be internalised into the child's developing internal working model and 'secure base' attachment relationship [66], reducing the risk of intergenerational

transmission [57, 67]. The mother learns how to provide contingent responses to the infant, so the infant can register his mental states as a coherent part of himself, rather than as random or alien [68]. This learning is possibly through the development of epistemic trust [24] and is then applied in everyday life. Based on these principles and understandings, the outcomes of MBN for the mother are summarised in **Figure 1**.

#### **4.2 Intended outcomes for the infant**

The infants developing sense of subjective self, as a separate entity from the caregiver, is a central organising process of psychological development [63, 69]. The group provides a transitional space for the infant [70], where he can observe those around him, noticing similarities and differences, and feel safe enough to explore new experiences of self. This can be a powerful learning opportunity especially for a socially isolated mother and baby, as it offers a space in which alternate expressions of thinking and feeling can be experienced and offered [37].

Ways of being together become imbedded in the infant's procedural memory, forming an internal representation of how others relate to him and how he relates to others. These repeated "serve and return" experiences between the infant and others, most especially their caregivers, form the infant's internal working model [66]. Although able to be revised and elaborated on, the internal working model is largely established early in infancy and acts to inform future ways of relating [71]. The emotionally containing and contingent interactions of the group support the infant to foster their developing subjective self, sense of agency, and capacity for emotional regulation and secure attachment (see **Figure 1**).

**Figure 1.** *Mother-Baby Nurture outcomes model.*

*Description of a Relationship Focused Mother-Infant Group Program: Mother-Baby Nurture DOI: http://dx.doi.org/10.5772/intechopen.110088*

#### **5. Conclusion**

We have outlined four key aspects of the Mother-Baby Nurture group program. Firstly, the early parent-infant relationship is understood as central in supporting better health and developmental outcomes for the developing child. Then we described how the infant is welcomed and included as a participant in the group, using moments of interaction as material for shared pleasure and reflective discussion. Within the safe environment of the group, the mothers are able to reflect on their relationships present and past, allowing distress and distortions to become seen and contained. Finally, the facilitators model a mentalizing stance of curiosity, supporting the mother to reflect on feelings and longings, as well as considering the experiences of her baby and other group participants.

This program offers a therapeutic experience for vulnerable families. Prioritising the infant-parent attachment relationship in tertiary services can prove difficult where treatment of acute maternal psychopathology can overshadow the experience of the infant. Mother-Baby Nurture delivers a unique targeted service for vulnerable families during a critical window in the infant's development while the tender caregiver relationship is in formation. This relationship-focused program can be delivered by infant mental health clinicians from all disciplines. It gives a family an experience that can foster a sense of trust, providing a stepping-stone to other protective support services, as well as engagement with the community at large.

#### **Acknowledgements**

The authors express gratitude to the infants and their mothers' who inform and inspire this program and who were willing to watch with wonder with us. Thank you to the Mother-Baby Nurture facilitators and supervisors whose reflections continue to shape the program and the brave pioneers that piloted the first group more than ten years ago.

#### **Author details**

Sharon Cooke1 , Dawson Cooke2 \* and Sue Coleson1

1 Playgroup WA, Perth, Australia

2 Curtin University, Perth, Australia

\*Address all correspondence to: dawson.cooke@curtin.edu.au

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### **Chapter 6**

## As New Challenges Emerge, Africa is Still Faced with Sociocultural and Health System Challenges Leading to Maternal Mortality

*Thendo Gertie Makhado, Lufuno Makhado, Mutshinyalo Lizzy Netshikeweta and Azwidihwi Rose Tshililo*

#### **Abstract**

Globally, the most crucial element of development strategies is a decrease in maternal mortality. Every 2 minutes, a pregnant woman dies from complications related to pregnancy or childbirth. According to studies, the majority of pregnancy and delivery difficulties are mostly influenced by sociocultural and health system factors. PUBMED, Google Scholar, National EDT, EBSCOHost, and Science Direct databases were used to find relevant articles. The process for choosing relevant and qualified articles was based on a PRISMA flowchart. The standard of the accepted articles was evaluated using the Critical Appraisal Skill Program (CASP) checklists. This study employed a thematic analysis, and in the articles on sociocultural and healthcare system factors influencing maternal mortality, six themes and 23 subthemes were found. It was determined that most women choose to consult traditional experts during pregnancy or childbirth rather than health facilities, and that there is little interaction between societal expectations and the healthcare system, which further contributes to problems and maternal mortality. This study found that social, cultural, and health system factors may directly and indirectly contribute to maternal mortality. It is also recommended that cultural norms and health system norms collaborate together to reduce maternal mortality.

**Keywords:** maternal mortality, sociocultural factors, health system factors, pregnancy, childbirth

#### **1. Introduction**

A worldwide crisis has been identified: maternal mortality. Despite all the efforts put in place, maternal mortality has been reported by the World Health Organization (WHO) [1] to be high in African countries. Despite various methods and estimates, it is a fact that Nigeria has the highest maternal mortality rate in Africa. The rate is considerably higher than the global average of 290 maternal deaths per 100,000

live births [2–4]. Sub-Saharan Africa continues to have the highest rates of maternal mortality in the entire world. Up to half of all maternal deaths worldwide caused by pregnancy-related complications occur in sub-Saharan Africa [5–7]. According to the literature, sub-Saharan Africa has the highest maternal death rate in the world [8]. Moreover, Mozambique is one of the sub-Saharan African nations with a high death rate of 500 per 100,000 live births [8–11]. Maternal mortality is more prevalent in poor households than in rich households in sub-Saharan countries, according to studies comparing maternal mortality between rich and poor households [12–15]. This is mainly because poor households lack the resources to pay for quality prenatal and postpartum care. Although maternal mortality in South Africa has decreased compared to other African nations, it is still above the objective. The WHO [1] underlined this objective, noting that it aimed to "reduce the global maternal mortality rate (MMR) to fewer than 70 per 100,000 births, with no nation having a maternal mortality rate that is more than twice the global average." Maternal mortality has decreased in South Africa, according to Moodley et al. [16]. The number of deaths resulting from specific conditions that increase maternal mortality is still stubbornly high. Much research has been carried out to determine the causes of maternal mortality in several African nations, including South Africa [2, 16–18]. However, maternal mortality is still increasing [1, 19]. Cardiovascular problems, obstetric hemorrhage, eclampsia, and ectopic pregnancy are factors in maternal mortality that have been extensively studied [20, 21]. According to a study conducted in Africa, traditional practices and health system factors may cause pregnant women to wait longer before seeking medical attention, which increases the risk of maternal mortality [22–24]. This indicates that there are some cultural beliefs and health system factors that may increase the risk of maternal mortality.

This systematic review seeks to present a clear or comprehensive picture of sociocultural practices/contributors and aspects of the health system that have been identified as factors influencing maternal mortality, specifically in scholarly papers of studies conducted in Africa. It appears that no systematic review of the expanding body of knowledge on this subject, specifically in Africa, has been published. Consequently, the researcher conducted a methodical examination of the available data on sociocultural practices and healthcare system factors that play a role in maternal mortality in Africa, and pinpointed the elements that were referenced in the studies mentioned earlier. The review question was, "What are the sociocultural and health systems factors contributing to maternal mortality in Africa?"

#### **2. Methods and materials**

The aim of this systematic review was to identify the sociocultural and health system factors influencing maternal mortality in Africa. The review utilized specific search strategies, inclusion criteria, study selection, data abstraction, and article evaluation methods. The search was conducted using various databases including PUBMED, Google Scholar, National EDT, EBSCOHost, and Science Direct, and the search terms used were "sociocultural factors," "health system factors," "traditional practices," "contribut\*," "maternal mortality," and "Africa." The inclusion criteria involved articles published in English, between 2012 and 2022, conducted on humans, using both qualitative and quantitative methods, and focusing on sociocultural and health system factors contributing to maternal mortality in Africa. Participants included pregnant women or those who had given birth within 42 days. The PRISMA

#### *As New Challenges Emerge, Africa is Still Faced with Sociocultural and Health System… DOI: http://dx.doi.org/10.5772/intechopen.110791*

flow diagram [25] was used to select relevant studies and eliminate duplicates. All articles were initially screened using their titles and abstracts; they included PubMed (n = 24), EBSCOHOST (n = 227), National EDT (n = 129), ScienceDirect (n = 1922), and Google Scholar (n = 18,401), for a total of 20,703. Additionally, 2666 duplicates were eliminated from the list, leaving a total of 180,367. Following a review of the themes and abstracts of the studies, 7633 studies were eliminated. Of the 10,404 studies that met the inclusion criteria—which included being published in English and being located on the African continent and having a publication year between 2012 and 2022—2110,383 studies were excluded (see PRISMA Flowchart in **Figure 1**). After screening and eliminating articles that did not meet the inclusion criteria, eight articles matched the criteria. Permission was not required since all articles were publicly available.

The researcher conducted a comparison of collected data and extracted information. They gathered information on all research articles and literature reviews that met the inclusion criteria, including the study's author, publication year, location, aims, population, outcomes, and limitations. More details on the study's characteristics that were examined during the review are available in **Table 1**. (Refer to **Table 1** for further information.)

Quality assessment only applied to the entire texts of the papers that were selected and met the criteria for inclusion (see **Table 2**). Utilizing Critical Appraisal Skill Program (CASP), all the researches included in the review were methodically and

**Figure 1.** *Study selection procedure (PRISMA flowchart).*



*As New Challenges Emerge, Africa is Still Faced with Sociocultural and Health System… DOI: http://dx.doi.org/10.5772/intechopen.110791*


**Table 1.** *Characteristics of the selected studies.* *As New Challenges Emerge, Africa is Still Faced with Sociocultural and Health System… DOI: http://dx.doi.org/10.5772/intechopen.110791*


#### **Table 2.**

*Appraisal of studies using CASP.*

meticulously assessed to determine their value, applicability, and credibility. The included studies' overall quality ranged from 60 to 90%, with an average of 75% exhibiting moderate to high quality.

A thematic analysis was performed to identify similar patterns among the articles reviewed. The similar patterns were grouped together, forming themes, and the following were the themes that emerged from the review: community members' opinions about the state of maternal health (n = 8), culture-related factors (n = 7), ppregnant-women-related factors (n = 4), healthcare system factors (n = 4), choice of care (n = 5), and Traditional birth attendant (TBA)-related factors (n = 2).

#### **3. Results**

According to the studies examined in this review, the majority of women prefer TBAs over medical visits, despite the fact that doing so carries a significant risk of complications that could result in maternal mortality. This showed that women's decisions about their healthcare are influenced by a variety of other factors. Six themes and 23 subthemes emerged regarding sociocultural and health system factors/practices contributing to maternal mortality from the included articles (see **Table 3**). The themes that emerged included culture-related factors, pregnantwomen-related factors, health system factors, choice of care, and traditional-birthattendant-related factors.

#### **3.1 Community members' opinions about the state of maternal health**

The reviewed studies have shown that a variety of factors, including ignorance (n = 7, 100%), traditional birth attendance experience (n = 3, 43%), prior childbirth experience (n = 3, 43%), perceptions of risk (n = 1, 14%), and facility-based experiences (n = 2, 29%), affect people's perceptions of maternal health [26–32]. Lack of knowledge was revealed to be the main factor influencing how community members perceive maternal mortality. According to Meh et al. [4], Batist [5], Yemane & Tiruneh [6], Ahinkorah et al. [7], Central Intelligence Agency [8], Buor & Bream [9], and Adde et al. [10], the lack of awareness about risk factors and problems may

contribute to maternal mortality, which may result in most women delaying booking for antenatal care (ANC) and opting to deliver their babies in hospitals rather than at home. Lack of information has been identified as the primary barrier to receiving maternal health services in a study by Kea et al. [26], and the majority of women who have delivered at home say they would not do so if they were aware of the advantages of receiving maternal health services in health facilities.

Through the reviewed studies, most women's perceptions regarding maternal health have been reported to be affected by their previous experiences during pregnancy, their perceptions regarding the risks associated with maternal mortality, and their earlier experiences with the healthcare facilities' services during childbirth [26, 27, 31]. According to Kea et al. [26], some women who experienced issues during delivery at the healthcare facilities and were passionately assisted may not think twice about going to the facilities during their pregnancy, childbirth, and recovery time. However, other women had unpleasant experiences with prior deliveries in medical facilities due to issues in the healthcare system, such as the unfavorable attitudes of medical staff, the facilities' remote locations, and a lack of privacy, which led them to choose home birth to medical facilities. Culture-influenced lack of decision-making on the part of women regarding their past pregnancies is another element influencing how people view maternal health. According to research by Kea et al. [26] and Marchie [32], women are never given the opportunity to make decisions throughout pregnancy, childbirth, or following delivery. Yet, the family's elders, who are the custodians of culture, decide based on their customs and culture. Several behaviors have been shown to prevent women from accessing prenatal care in a way that reduces their risk of maternal death [26].

#### **3.2 Culture-related factors**

Early marriage, genital mutilation, limited women's power in decision-making, cultural beliefs, and harmful traditional practices were identified to be the factors influencing maternal mortality under cultural factors [26, 30, 31]. The problems that cause maternal mortality have been shown to be influenced by customs or culturally relevant elements. In this context, women who participated in the research that are included stated that it is extremely difficult for them to decide to visit the healthcare facilities owing to culture because they are not permitted to make decisions [26, 28, 32]. The main factor in this theme was limited women's power in decision-making (n = 3, 43%), which means that elders are responsible for making decisions for pregnant women according to culture [26, 29]. Therefore, older women hold power over the outcomes of ANC attendance.

#### **3.3 Pregnant-women-related factors**

In this theme, the subthemes that were identified were: late ANC booking, frequency of ANC attendance, unwanted pregnancy, and lack of knowledge [26, 30, 31]. The studies revealed that married women attended ANC earlier than unmarried women. Moreover, employed women attended ANC most frequently compared to unemployed women. Moreover, it was found that most women visiting ANC had planned pregnancies rather than unintended pregnancies [30].

The review found that several pregnant women in the studies did not show up for ANC on time. Hence, insufficient ANC attendance or late reservations may prevent women from receiving a diagnosis for diseases that could arise early in


*As New Challenges Emerge, Africa is Still Faced with Sociocultural and Health System… DOI: http://dx.doi.org/10.5772/intechopen.110791*

**Table 3.**

*Themes and subthemes.*

pregnancy and result in complications that could result in maternal mortality [26, 30, 31]. Lack of awareness of the significance of attending antenatal clinics, unintended pregnancy, and unprofessional behavior of healthcare professionals all contributed to late booking.

#### **3.4 Healthcare system factors**

The healthcare system factors, such as distance from the healthcare facilities, a lack of resources, including human resources, the provision of services only during the designated hours, and a lack of privacy in the healthcare facilities, were also found to be contributing factors to maternal mortality [26, 30, 32, 33]. Lack of privacy discouraged pregnant women from going to the hospital; they claimed it was preferable to give birth in front of their husbands and family members than in front of medical personnel. Due to poor mobility, pregnant women who live in those areas are not frequently visited or attended by healthcare facilities [30, 32]. According to the literature, women are prevented from visiting medical facilities because; when they

go for an ANC appointment, there is occasionally no medical personnel available to help them or, more frequently, there is no medical equipment available to offer them the necessary care [26, 30].

#### **3.5 Choice of care**

Pregnant women in this situation typically rely on TBAs for assistance rather than contact medical institutions [26, 29–33]. The included studies indicated that past delivery experiences and the attitudes of healthcare professionals in healthcare facilities are two factors that influence the choice of women. Past birth experiences in medical facilities accounted for most of the theme's variance (n = 6, 71%) [26, 29–33]. The ladies in the included studies stated that they were persuaded to avoid using healthcare facilities while pregnant by their unpleasant experiences there.

#### **3.6 Traditional-birth-attendant-related factors**

Poor referral procedures for maternal problems and strained relationships with the local medical staff were factors that were identified under this theme [27]. Because there is a dearth of referrals when there is an obstetric difficulty, there are no partnerships between healthcare facilities and traditional birth attendants, which exacerbates the issues that could cause maternal mortality. Traditional birth attendants have stated that traditional substances can be utilized to handle difficulties such as protracted labor, obstructed labor, retained placenta, and maternal bleeding instead of sending the women to a medical center [27]. The absence of referrals when issues develop has also been linked to a bad interaction between the TBAs and the neighborhood healthcare institutions [27].

The themes were conceptualized hereunder into a framework that provides the interrelationship triad between pregnant women, healthcare facilities, and traditional birth attendants. The review provided that both directions of the relationship triad have contributory factors at different levels (see **Figure 2**).

#### **4. Discussion**

In this systematic review, five major factors that influence maternal mortality in Africa emerged. These were identified as past birth delivery, late booking, lack of transportation to the facility, attitude of healthcare professionals, and traditional practices. According to the included studies, traditional practices are the major factor leading to complications causing maternal mortality. It has been revealed that TBAs do not refer pregnant women to healthcare facilities for further management. However, they report to the traditional authorities about the complications [27]. Poor referral systems between TBA and healthcare professionals are a serious concern as the two sectors should approach maternal care collaboratively, involving a positive combined effort to eradicate avoidable maternal mortality.

Although maternal mortality declines in developed countries, it remains unexpectedly high in rural communities. Various factors have been found to contribute to maternal mortality. The elements mentioned above had a significant role in this systematic study regarding problems resulting in maternal death. However, all the factors that affect maternal mortality are grouped under cultural norms and practices. The included research showed that culture has a big impact on expecting mothers.

*As New Challenges Emerge, Africa is Still Faced with Sociocultural and Health System… DOI: http://dx.doi.org/10.5772/intechopen.110791*

#### **Figure 2.**

*Conceptual map of the systematic review results.*

To avoid witchcraft and keep the baby from dying, some women, for example, choose not to enroll in ANC since the culture forbids them from being seen while pregnant. Many customs prevent women from seeking out healthcare facilities at this time. It has been noted that multifaceted factors heavily impact the goal of reducing maternal mortality. Thus, sociocultural factors have been reported to take the lead and warrant the collaborative approach from the health system and traditional or community-based stakeholders. Similar issues have been raised in Pakistan, and the most challenging struggle to reduce maternal mortality is firmly rooted in tackling sociocultural practices that build hindrances to maternal care-seeking [34, 35].

It is indeed difficult for African women to find themselves cornered between sociocultural practices that they have been taught from their initiation through rites of passage and the teachings from the healthcare professional in primary healthcare facilities. A need for a socioculturally congruent approach to creating awareness of the sociocultural maternal health practices' impact on their health has the potential to reduce maternal mortality. Community outreach programs are critical through community gatherings, door-to-door family-based visits, social media, and the use of community health workers can be implemented and maintained sustainably to help reduce maternal mortality. Some sociocultural factors are imposed based on the family history, knowledge, and beliefs, which becomes an internalized body of knowledge that requires combined effort to correct. There is also a need to eradicate the onesize-fits-all approach from TBAs, elderly family members, and traditional healthcare

practitioners. This is important given that most women will still go through the cultural practice regardless of the previous encounter that may not have ended well.

Besides the sociocultural factors, the attitudes of healthcare professionals, mainly midwives, are reported to be a considerable challenge that also, in a way, influences women rather to follow cultural practices and continue to use TBA. There is a need for healthcare professionals to be capacitated in terms of positive values grounded by the Ubuntu philosophy. Thus, the ability to attend to pregnant women with respect, courtesy and all positive morals and within the positive boundaries of ethics. The latter is imperative and crucial as women need to rely on both systems for the greater good of the maternal care outcome.

#### **5. Identified gaps**

The reviewed research studies showed that culture is important, particularly for pregnant women, and that older persons are mostly in charge of maintaining it. Early booking is one of the strategies to reduce problems that can result in maternal death, according to the WHO [1]. But according to the research included, some women are forbidden from leaving the house when they are expecting to avoid witchcraft. Hence, sociocultural traditions and the health system's needs must be in harmony.

#### **6. Conclusion**

Globally, maternal mortality is a crucial issue. The millennium development goal (MDG) of 38 deaths per 10,000 live births was not achieved in 2015 due to several issues. This comprehensive review identifies the causes of maternal mortality in Africa. The interventions being developed are intended to lessen this issue and are also based on patient-reported barriers to attending ANC or maternity check-ups at healthcare facilities to avoid problems that could result in maternal mortality. Due to many traditional circumstances, there still appears to be a gap in the required compliance in other regions, particularly in rural areas. It is anticipated that relevant interventions that are collaborative can be created using the data from this review, which will assist in preventing the problems that cause maternal death and achieving SDG 3 target 1.

#### **Acknowledgements**

The authors acknowledge the University of Venda librarian for assistance in the literature search.

The authors also acknowledge SAMRC for funding this study.

#### **Conflict of interest**

The authors declare no conflict of interest.

*As New Challenges Emerge, Africa is Still Faced with Sociocultural and Health System… DOI: http://dx.doi.org/10.5772/intechopen.110791*

#### **Author details**

Thendo Gertie Makhado1 \*, Lufuno Makhado2 , Mutshinyalo Lizzy Netshikeweta1 and Azwidihwi Rose Tshililo1

1 Department of Advanced Nursing Sciences, University of Venda, South Africa

2 Office of the Executive Dean, University of Venda, South Africa

\*Address all correspondence to: gertie.makhado@univen.ac.za

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[7] Ahinkorah BO, Ameyaw EK, Seidu AA, Odusina EK, Keetile M, Yaya S. Examining barriers to healthcare access and utilization of antenatal care services: Evidence from demographic health surveys in sub-Saharan Africa. BMC Health Services Research. 2021;**21**(1):1-6

[8] Cia U. Central Intelligence Agency-the World Factbook. New Zealand: Central Intelligence Agency; 2016

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[10] Adde KS, Dickson KS, Amu H. Prevalence and determinants of the place of delivery among reproductive age women in sub–Saharan Africa. PLoS One. 2020;**15**(12):e0244875

[11] Lancaster L, Barnes RF, Correia M, Luis E, Boaventura I, Silva P, et al. Maternal death and postpartum hemorrhage in sub-Saharan Africa–a pilot study in metropolitan Mozambique. Research and Practice in Thrombosis and Haemostasis. 2020;**4**(3):402-412

[12] Van Malderen C, Amouzou A, Barros AJ, Masquelier B, Van Oyen H, Speybroeck N. Socioeconomic factors contributing to under-five mortality in sub-Saharan Africa: A decomposition analysis. BMC Public Health. 2019;**19**(1):1-9

[13] Mumtaz S, Bahk J, Khang YH. Current status and determinants of maternal healthcare utilization in Afghanistan: Analysis from Afghanistan demographic and health survey 2015. PLoS One. 2019;**14**(6):e0217827

[14] Tuyisenge G, Hategeka C, Kasine Y, Luginaah I, Cechetto D, Rulisa S. Mothers' perceptions and experiences of using maternal healthcare services in Rwanda. Women & Health. 2019;**59**(1):68-84

[15] Jolivet RR, Moran AC, O'Connor M, Chou D, Bhardwaj N, Newby H, et al. Ending preventable maternal mortality: Phase II of a multi-step process to develop a monitoring framework, 2016- 2030. BMC Pregnancy and Childbirth. 2018;**18**(1):1-3

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[16] Moodley J, Fawcus S, Pattinson R. Improvements in maternal mortality in South Africa. South African Medical Journal. 2018;**108**(3):4-8

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[19] Rahman MA, Halder HR, Islam SM. Effects of COVID-19 on maternal institutional delivery: Fear of a rise in maternal mortality. Journal of Global Health. 2021:**11**

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## Different Approach to Family Planning

#### **Chapter 7**

## Male Involvement in Family Planning Services

*Mesfin Abebe, Tsion Mulat Tebeje, Wondwosen Molla and Getnet Melaku*

#### **Abstract**

Family planning is the ability of individuals and couples to anticipate and obtain their preferred number of children, spacing, and timing of births. It is accomplished through the use of contraceptive methods and the treatment of involuntary infertility. Family planning is important for the well-being of women and their families, and it can help a country reduce poverty and achieve the SDGs faster. When family planning methods are used effectively, they assist couples in having the number of children they desire, improve maternal and child health, which may assist women in avoiding unintended pregnancies, and lower risk factors for maternal and child mortality. Increasing the use of condoms and vasectomies among men is only one aspect of male involvement in family planning. It also includes the number of men who support and encourage their partners and peers to use family planning, as well as the number of men who influence policy to make it more favorable to promoting male-related programs. Men's participation is critical to women's health and program completion, as it promotes shared responsibility for birth control, contraceptive reputation, and thus the women are more likely to adopt and continue using beginning prevention if their partner's active assistance.

**Keywords:** male involvement, family planning, magnitude, associated factors, Ethiopia

#### **1. Introduction**

Family planning is the process by which individuals and couples predict and achieve the number, spacing, and timing of children they desire. By using contraceptive methods and treating unintentional infertility, it is achieved [1, 2]. It encompasses the services, policies, information, attitudes, practices, and commodities, such as contraception, that enable women, men, couples, and adolescents to avoid unintended pregnancy and make decisions about whether and/or when to have a child [3]. Programs for family planning (FP) have mainly focused on women. However, there is a shift to involve men in supporting and using FP services as a result of the focus on gender equity for best health. The World Health Organization (WHO) and the Ministry of Health in the majority of countries have recommended and approved the use of FP methods as an effective intervention, and men, as the decision-makers in most African families, have a crucial role to play in this process [4].

Family planning has been a major concern in programs to reduce the population as well as those that promote and improve reproductive health [5]. Family planning is critical for the health of women and families, and it can accelerate a country's progress toward eradicating poverty and achieving the Sustainable Development Goals. Effective family planning techniques enable couples to have as many children as they want, improve maternal and child health, which may assist women in avoiding unintended pregnancies, and reduce risk factors for maternal and infant mortality [6].

The use of contraception has been linked to decreased fertility, better maternal and child health due to birth spacing and fewer pregnancies, and increased women's empowerment by enabling them to complete their education and enter the workforce [7] . The two types of contraceptive methods. This are modern and traditional methods of contraceptive. Male and female sterilization, IUDs, implants, injectable contraceptives, pills, male and female condoms, emergency contraception, and the lactational amenorrhea method are all modern methods. (LAM), While traditional methods consist of rhythm (calendar), withdrawal, and folk methods [8, 9].

Contraception has a number of advantages, including ensuring couples have the number of children they want and lowering infant, perinatal, and maternal mortality. Additionally, it lowers the chance of HIV transmission, STI acquisition, and unintended pregnancy. Furthermore, it reduces pregnancy and birth-related complications by giving a mother enough time to recover from previous pregnancy complications [8]. Globally, women have played a significant role in household management and decision-making regarding their own health care and life through family planning. There has been a significant improvement in family planning utilization and birth rates. However, male involvement in family planning remains minimal, with men playing a secondary role [10].

Male involvement in family planning (FP) refers to all organizational actions aimed at increasing the acceptability and uptake of FP among both sexes. It includes men participating in decision making, approving it, or encouraging their spouse's use of family planning [11]. Through increased spousal communication, male involvement can lead to contraceptive use [12–14]. It encompasses more than just an increase in the proportion of men who use condoms and get vasectomies. It also includes the proportion of men who support and encourage their partners and their peers to use FP and who influence public policy to make male-related programs more widely promoted. In this context, "male involvement" refers to activities aimed at men as a distinct group with the goal of raising couples' acceptance and use of family planning, more so than male contraception [15].

In African nations, men are frequently the main decision-makers, and this has a big impact on their spouse's health and access to healthcare, including decisions about family planning (FP) [16]. Family planning is critical for slowing unsustainable population growth and its negative effects on the economy, environment, and national and regional development efforts [9]. Men are also blamed for a large proportion of their female partners' poor reproductive health. Furthermore, male involvement aids not only in the acceptance of a contraceptive but also in its effective use and continuation [9].

Family planning is crucial for achieving the goals and the post-2015 development agenda. The five SDG themes of People, Planet, Prosperity, Peace, and Partnership can all advance more quickly as a result. In the time frame of the SDGs, there is a chance for the world to achieve significant convergence between the developed and developing worlds, ending avoidable child and maternal deaths and achieving relative parity in addressing the family planning requirements of women, men, couples, and

#### *Male Involvement in Family Planning Services DOI: http://dx.doi.org/10.5772/intechopen.111949*

teenagers who want to space or limit childbearing [3]. Target 3.7 of the Sustainable Development Goals (SDGs) calls for universal access to sexual and reproductive health care services, including birth control, information, and education, by the end of 2030, and thus the integration of reproductive health into national strategy and programs [1, 17, 18]. Men's involvement in reproductive health issues is essential for achieving the SDGs. Furthermore, increasing economic development requires regulating fertility to the level of substitution. Family planning can reduce maternal and child mortality by 32% and 10%, respectively [19]. Male participation includes not only male contraception but also all other national program activities aimed at increasing male awareness, acceptability, and prevalence of family planning methods. The primary goal of family planning is to allow women and men to plan their families and space their children using modern contraceptives [20]. Sub-Saharan Africa has the highest fertility rate (more than 5 children per woman) as well as the fastest growth rate (on average 2.5 percent per year) [21].

According to UN projections, the population of Sub-Saharan Africa will reach 2.12 billion by 2050 [22]. The second-most populous country in Africa is Ethiopia. It has the highest rate of annual growth (2.6%), infant mortality (43/1000 live births), and maternal mortality (412 per 100,000 live births) [23, 24]. Over the previous ten years, the Ethiopian population increased, rising from 55.18 million in 1994 to 112 million in 2019 and probably over 114 million in 2020 [22]. The United Nations reported that in 2019 Africa had a contraceptive prevalence rate (CPR) of 29.4%, sub-Saharan Africa had a CPR of 28.5%, Ethiopia had a CPR of 26.5%, and there was a 22% unmet need for FP in Africa [1]. According to the EDHS 2019 report, usage of modern contraceptives among married women has increased since 2000, 2005, 2011, 2016, and 2019 by 6%, 14%, 27%, 35%, and 41%, respectively, while usage of traditional methods has remained stable for the years of 2005, 2011, 2016, and 2019 at about 1%. Injectable usage among modern methods of contraception, which increased steadily from 3% in 2000 to 27% in 2019, and primarily to blame for the rise in the use of modern methods than others [24].

Studies have shown that the involvement of men significantly changed the way family planning is used in many developing nations. Their participation in using family planning services is still minimal. Several studies on male involvement in family planning use and reproductive health have been carried out in Ethiopia in various regions of the nation. The husband plays a significant role in this country in approving or disapproving the use of family planning services by their wives based on a number of barriers between these religions and cultures that are said to have a negative impact on them. This is due to the fact that in many developing nations, such as Ethiopia, men frequently have the deciding influence over major family decisions, such as their wives' use of contraceptives [25].

Traditionally, men have been excluded from receiving or providing information about sexuality, reproductive health, and birth spacing. They have also been ignored or excluded in some way from participating in many family planning programs, owing to the perception that family planning is a woman's domain [14, 26]. To reduce contraceptive discontinuation rates, male participation is required [27]. In Ethiopia the extent of male involvement in family planning service utilization 68% from a previous study [28]. Few pieces of research suggest that male involvement can increase uptake and continuation of family planning methods by improving spousal communication through pathways of increased knowledge or decreased male opposition [12, 13] . Husbands have a significant impact on women's access to family planning services and other forms of healthcare [29].

#### **2. Factors affecting male involvement in family planning**

Studies done in African contexts have found that men's lack of knowledge about contraceptive methods, as well as gender norms regarding men's roles, may be important factors in men's negative perceptions of and disengagement from family planning. Some studies also suggest that spousal communication is low even in situations where men approve of contraceptive methods [30, 31]. The West African Demographic and Health Survey found that about 75% of men and women had not discussed family planning with their partners in the year before the survey [32]. In Tanzania, 45% of married women said they were unaware of their husbands' thoughts on family planning or thought they were opposed to it, even though in fact many of the husbands were in favor [33]. Several socioeconomic factors, including religion and tradition, the role of women in decision-making in society, cultural values, and others, have a significant impact on family planning services in Ethiopia. Women's access to family planning services may be impacted by their status in the family, the economy, and public life [34].

In a study conducted in Kenya, it was discovered that male involvement in family planning was significantly associated with demographic factors such as age, the number of children, educational attainment, and social factors such as social group membership and religion of the respondent. Knowing a place that provides family planning services, having a general understanding of family planning, and being aware of particular family planning techniques accessible to both men and women were all significantly associated. However, only the ease of access to family planning services for men was found to be strongly associated with male participation [26].

Another Nigerian study found that the level of education, the number of living children, and approval of family planning are all indicators of male involvement in reproductive health care [35]. According to a Bangladesh study, the level of male involvement was associated to schooling experience, type of residency, and exposure to electronic media [36]. Men who participate in family planning, in addition to using contraception, support and encourage their partners' contraceptive needs and decisions, encourage their peers to use contraception, and influence public policy to improve male-related programs [37]. One of the essential health care services that can promote and ensure reproductive health is family planning. According to studies, males' intentions to discuss family planning are influenced by their attitudes, norms, and self-efficacy. Males' perceptions of family planning as a female responsibility also influence family planning [20].

In many sub-Saharan African nations, men were also key decision-makers in the household and typically opposed their partners' use of contraceptives. The male predominance in decision-making among couples and its impact on women's decisionmaking power in the use of contraceptives are both caused by women's young age at marriage, the age gap between husband and wife, polygamous family structures, and culture. Decisions about limiting fertility are made by the husband or his parents in societies where gender stratification is common [38, 39].

Recently, the husband's involvement in the decision-making process for family planning has come to light as an important factor influencing the use of contraceptives. Men who participate in family planning make decisions about using contraception [12], but study indicates that male involvement is lower in less developed nations [40, 41].

Research from the past suggested that men should even participate in family planning programs [41], but until now, the majority of countries worldwide have only

#### *Male Involvement in Family Planning Services DOI: http://dx.doi.org/10.5772/intechopen.111949*

targeted women in these programs [42, 43]. According to some studies, men as well as women must be involved in order for targeted family planning coverage to be successfully achieved [44]. According to study done in Malawi, targeting men for family planning interventions may greatly increase the uptake of contraceptives [45]. Others suggested that targeting both spouses with family planning education rather than focusing solely on one gender might be more effective [46]. t has also been demonstrated how important it is to involve husbands in family planning initiatives in order to increase the use of modern contraceptives rather than traditional methods [47].

Men typically serve as the health care system's gatekeepers in developing countries. They are the ones who make the majority of decisions that have a direct impact on the health of their spouse and their children. Their choices have an impact on resource utilization, access to health care services, contraceptive use, birth spacing, the availability of nutritious food, and the workload of women [48].

However, research on couples' contraceptive use has primarily focused on the knowledge, attitudes, discussion, and intentions regarding family planning rather than examining the specific effects of programs on the use of contraceptives and family planning services [49]. In order to achieve higher levels of contraceptive prevalence, efforts must be made to promote spousal cooperation and communication as well as to encourage men's involvement in family planning [44].

According to a qualitative study conducted in Nepal, men's education and attitude, knowledge and awareness, sociocultural factors, psychological factors, aspects of the health system, and policies all have a significant impact on male involvement in reproductive health [48]. Another study done in Ethiopia found that lack of knowledge, myths, misconceptions, access issues, the desire to have more children, fear of social rejection, concerns about side effects, the husband's opposition and religious prohibition, negative attitudes, the husband and partner's educational status, the number of living children, the male approach to family planning, male family planning awareness, and conversation with the wife about family planning have all contributed to the lack of access to family planning services [21, 27, 50–52].

#### **3. Conclusion**

Men's involvement in family planning could increase the prevalence of contraception in a number of ways, including by giving couples who are dissatisfied with their current method options, increasing male contraceptive use, encouraging more conversation between sexual partners, and altering male attitudes toward contraception. According to a study conducted in Ethiopia, husband participation in home visits during discussions increased the likelihood that couples would start using contraceptives and keep using them [34].

*Midwifery – New Perspectives and Challenges*

### **Author details**

Mesfin Abebe1 \*, Tsion Mulat Tebeje2 , Wondwosen Molla1 and Getnet Melaku1

1 Department of Midwifery, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia

2 School of Public Health, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia

\*Address all correspondence to: mesfiaau@gmail.com; mesfin.abebe@du.edu.et

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### *Edited by Vasfiye Bayram Değer*

Discover fresh insights and confront emerging challenges in the world of midwifery with *Midwifery - New Perspectives and Challenges*. This edited volume delves into the evolving landscape of midwifery, offering a comprehensive exploration of contemporary issues, practices, and perspectives shaping this vital field. From the latest advancements in maternal care to the evolving role of midwives in today's healthcare system, this book brings together a diverse range of voices and expertise to illuminate the transformative potential of midwifery. Whether you are a seasoned practitioner or a newcomer to the field, this collection provides a thought-provoking journey into the heart of modern midwifery.

Published in London, UK © 2023 IntechOpen © Tatomm / iStock

Midwifery - New Perspectives and Challenges

Midwifery

New Perspectives and Challenges

*Edited by Vasfiye Bayram Değer*