Facilitators, barriers, and key influencers of breastfeeding among low birthweight infants: a qualitative study in India, Malawi, and Tanzania
Authors: Vesel Linda , Benotti Emily , Somji Sarah , Bellad Roopa M , Charantimath Umesh , Dhaded Sangappa M , Goudar Shivaprasad S , Karadiguddi Chandrashekhar , Mungarwadi Geetanjali , Vernekar Sunil S , Kisenge Rodrick , Manji Karim , Salim Nahya , Samma Abraham , Sudfeld Christopher R , Hoffman Irving F , Mvalo Tisungane , Phiri Melda , Saidi Friday , Tseka Jennifer , Tsidya Mercy , Caruso Bethany A , Duggan Christopher P , Israel-Ballard Kiersten , Lee Anne CC , Mansen Kimberly L , Martin Stephanie L , North Krysten , Young Melissa F , Fishman Eliza , Fleming Katelyn , Semrau Katherine EA , Spigel Lauren , Tuller Danielle E , Henrich Natalie 
Published: November 2023

Abstract
Background
Low birthweight (LBW) infants are at increased risk of morbidity and mortality. Exclusive breastfeeding up to six months is recommended to help them thrive through infection prevention, growth improvements, and enhancements in neurodevelopment. However, limited data exist on the feeding experiences of LBW infants, their caregivers and key community influencers. The qualitative component of the Low Birthweight Infant Feeding Exploration (LIFE) study aimed to understand practices, facilitators, and barriers to optimal feeding options in the first six months for LBW infants in low-resource settings.

Methods
This study was conducted in four sites in India, Malawi, and Tanzania from July 2019 to August 2020. We conducted 37 focus group discussions with mothers and family members of LBW infants and community leaders and 142 in-depth interviews with healthcare providers, government officials, and supply chain and donor human milk (DHM) experts. Data were analyzed using a framework approach.

Results
All participants believed that mother’s own milk was best for LBW infants. Direct breastfeeding was predominant and feeding expressed breast milk and infant formula were rare. DHM was a new concept for most. Adequate maternal nutrition, lactation support, and privacy in the facility aided breastfeeding and expression, but perceived insufficient milk, limited feeding counseling, and infant immaturity were common barriers. Most believed that DHM uptake could be enabled through community awareness by overcoming misconceptions, safety concerns, and perceived family resistance.

Conclusion
This study fills an evidence gap in LBW infant feeding practices and their facilitators and barriers in resource-limited settings. LBW infants face unique feeding challenges such as poor latching and tiring at the breast. Similarly, their mothers are faced with numerous difficulties, including attainment of adequate milk supply, breast pain and emotional stress. Lactation support and feeding counseling could address obstacles faced by mothers and infants by providing psychosocial, verbal and physical support to empower mothers with skills, knowledge and confidence and facilitate earlier, more and better breast milk feeding. Findings on DHM are critical to the future development of human milk banks and highlight the need to solicit partnership from stakeholders in the community and health system.