Exclusive Breastfeeding Practices and Challenges in Nigeria, Sub-saharan Africa: An Integrative Review

Exclusive Breastfeeding Practices and Challenges in Nigeria, Sub-saharan Africa: An Integrative Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Exclusive Breastfeeding Practices and Challenges in Nigeria, Sub-saharan Africa: An Integrative Review Ugochi Felicitas Oputa-Uzoukwu, Helen Nichols, Friday Ilop Joseph This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7255627/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Feb, 2026 Read the published version in International Breastfeeding Journal → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Exclusive breastfeeding (EBF) remains a key public health strategy for improving infant and maternal outcomes. In Nigeria, despite policy commitments, EBF practice rates remain inconsistent and highly context-dependent. Objectives: This integrative review assesses the prevalence and patterns of EBF in Nigeria, examines the socio-demographic and systemic factors influencing practice, identifies barriers and enablers, and evaluates existing interventions to promote EBF. Methods: Nineteen peer-reviewed primary studies, published between 2013 and 2024, were systematically identified across six geopolitical zones. Data extraction and synthesis followed a deductive coding framework, drawing on qualitative and quantitative findings, and guided by socio-ecological and capability-oriented perspectives. Results: EBF prevalence varied significantly across regions and contexts (12.5%–73.8%). Key themes emerged around socio-demographic variability, contextual factors, cultural practices, and structural barriers. Despite high knowledge levels, systemic and relational constraints limited the sustained implementation of EBF practice. The review also identified gaps in research, including the limited inclusion of fathers, informal caregivers, and mothers in displaced or rural communities. Conclusion: This review advances the literature by offering a context-sensitive, multi-dimensional interpretation of EBF practices in Nigeria. It highlights the need for equity-focused policies and interventions that move beyond individual awareness to address structural enablers of maternal capabilities. Exclusive breastfeeding integrative review cultural barriers children Nigeria Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Every infant and child has the right to good nutrition, as stated in the “Convention on the Rights of the Child” [1]. In 2022, WHO estimated that 149 million children were too short for their age, 45 million were too thin for their height, and 37 million were overweight or obese. Poor child nutrition is linked to approximately 50% of child mortality. Improving nutrition could save over 820,000 lives annually among children under five if all children aged 0-23 months received optimal breastfeeding [2]. Exclusive breastfeeding is one of the most cost-effective ways to promote child health and survival. Breastmilk provides all the energy and nutrients the infant needs in the first months of life, and it continues to supply up to half or more of a child’s nutritional requirements during the second half of the first year, and up to one-third during the second year. Breastfed children tend to score higher on intelligence tests, are less likely to become overweight or obese, and have a lower risk of developing diabetes later in life. Furthermore, women who breastfeed face a decreased risk of breast and ovarian cancers [2,3]. WHO recommendations on breastfeeding include early initiation within one hour of birth, exclusive breastfeeding until six months of age, and continued breastfeeding until 24 months of age. However, contrary to the WHO set target of 50% of infants being exclusively breastfed for the first 6 months of life by 2025, only 38% of infants worldwide are exclusively breastfed within the first six months of life. There is a strong connection between optimal breastfeeding and the reduction of diarrhoea and pneumonia, which are the leading causes of death among children under five in developing countries [4,5]. Exclusive breastfeeding can reduce the rate of pneumonia among young infants by 15 to 23%. Globally, in 2021, the number of childhood deaths due to diarrhoeal diseases linked to suboptimal and non-exclusive breastfeeding was 63,133 and 54,770, respectively[3]. Western Sub-Saharan Africa, South Asia, and Eastern Sub-Saharan Africa ranked as the top three regions concerning suboptimal/non-exclusive attributed deaths [6]. Globally, the promotion of optimal breastfeeding faces numerous socio-cultural barriers, along with poor policy design and weak program implementation. Evidence suggests that many women lack access to a supportive environment for breastfeeding, partly due to a lack of social support, inadequate funding, poor enforcement and monitoring of laws, and limited institutional capacity to promote and safeguard optimal breastfeeding practices [7]. In Nigeria, infant mortality rates are alarmingly high, with one in 25 infants dying within their first month and one in 16 not surviving their first year [8]. This highlights the urgent importance of adequate nutrition and care during the critical first 1000 days of life. The 2024 Nigeria Demographic and Health Survey (NDHS) notes that only 36% of newborns are breastfed within the first hour, and 29% of children under six months are exclusively breastfed. In 2016, Nigeria recorded 22,371 deaths from diarrhoea among children under five, largely linked to poor breastfeeding practices. These practices accounted for about 56.5% of diarrhoea deaths in the late neonatal period, 39.0% during post-neonatal and infancy stages, and 22.8% in children under five. Additionally, the estimated Disability-Adjusted Life Years (DALYs) due to diarrhoea from suboptimal breastfeeding amounted to 1.9 million among children under five [6]. Nigeria ranks first in deaths among children under five due to suboptimal and non-exclusive breastfeeding, followed by India and Chad [3]. Given the critical role optimal breastfeeding hold for the survival of under five children in Nigeria, this integrative review aims to examine the prevalence, characteristics, and various influences—such as individual, cultural, socio-economic, and healthcare factors—on exclusive breastfeeding (EBF), with the goal of developing effective strategies and policies to increase EBF rates and enhance public health outcomes. The main objectives are to address the following questions: “What is the prevalence of exclusive breastfeeding (EBF) and its socio-demographic characteristics in Nigeria?" “What factors influence the decision to initiate and continue exclusive breastfeeding as recommended by WHO?" and “What interventions are available in Nigeria to promote exclusive breastfeeding?". Methods This study employed an integrative literature review (ILR) to critically synthesis existing research on exclusive breastfeeding (EBF) in Nigeria, acknowledging the topic’s evolving nature. Rather than attempting to include all publications exhaustively, the ILR facilitates the critical evaluation and creative integration of diverse perspectives to generate new theoretical understandings [9,10]. This approach aligns with the view that for broad, interdisciplinary topics, a strict systematic review may be impractical, making a more flexible, narrative method preferable [10]. By incorporating both quantitative data, such as prevalence rates, and qualitative insights into participants’ experiences, the review presents a comprehensive and multifaceted view of the factors influencing EBF practices in the region, thereby informing the development of tailored policies and interventions. Through this synthesis, the study not only addresses specific research questions but also reconceptualises the topic, considering emerging patterns and challenges [9,11]. The data are from three databases: PubMed, ScienceDirect, and the University of Hull library, using search terms such as “exclusive breastfeeding practices and challenges in Nigeria” and “breastfeeding practices in Nigeria and Sub-Saharan Africa.” The searched databases, as illustrated in [ Figure 1 ] (PRISMA flow diagram), identified 1,233 results; 204 duplicates were removed, and 1,029 studies were screened based on titles and abstracts. Forty-one studies were assessed for eligibility, and only 19 studies met eligibility criteria for review. PRISMA flow diagram for Identified studies The study systematically sourced data from research conducted and published between January 2013 to December 2024, aligning search criteria with research objectives and considering research period, publication date, methodology, and geographic scope. The screening process scrutinised abstracts for relevance to ensure they met the inclusion and exclusion criteria. The inclusion criteria were studies that used primary data involving women of childbearing age, mothers, healthcare workers, and family members engaged in childcare, while exclusion criteria targeted studies of secondary data review and analysis, non-English studies, those predating 2013, and studies focusing on health issues unrelated to exclusive breastfeeding. It is worth noting that this article is adapted from an MSc dissertation at the University of Hull, which initially reviewed twenty-two studies identified between 13 June and 4 August 2023. However, the author refined the search terms to exclude five studies: one review study, three studies not directly aligned with EBF practices, and one study conducted in December 2012. The reviewer conducted further research and screening between 12 December 2024 and 6 January 2025, yielding a final set of nineteen studies that aligned with the predefined inclusion criteria. For quality appraisal, this review adopted the approach of an “own-assessment checklist” [12], arguing that critical appraisal methods may not reveal the validity of a study because several checklist limitations may affect research conduct and reporting in a journal. The primary focus here is to assess whether the reviewed studies provide accounts of the study objectives, design, participants’ selection, method of data collection, analysis, and ethical considerations. Studies reveal that the structured appraisal methods employed by reviewers are insufficient criteria for excluding a paper based on quality [13]; hence, including all research helps minimize a possible source of bias rather than excluding it based only on quality [14]. The Study date and the adopted quality appraisal questions are listed in [Table 1] , and the detailed responses are included in [Table 2] below. Table 1 : Adopted Quality Appraisal Checklist for Reporting Reviewed Studies Question Definition and assessment: Yes / No / Unclear The study design and approach reasons Yes (If the choice of study design was given and explained) if it states, eg. “a case study approach was used because . . .”, “interviews were used because . . .” No if paper does not specify question and study design The selection of participants Yes, if paper describes selection explicitly as eg. purposive, convenience, theoretical etc. No if just details of participants are given Methods of data collection Yes, if details of data collection method are given eg. piloting; topic guides for interviews; number of items in a survey; use of open or closed items; validation; etc. No if just states “focus group”, “interview” or “questionnaire” Methods of analysis Yes, if details of analysis are given, eg. transcription, form of analysis (with reference), etc. No if just states “content analysis” or data were “analysed” The quality appraisal checklist used in this study was adapted from [12] and refined to align with the research objectives and context. Table 2 : Responses to the adopted quality appraisal questions Study Literature Study Date/Year The study design and approach (Yes, No) The selection of participants (Yes, No) Methods of data collection (Yes, No) Methods of data analysis (Yes, No) 1 Adamu et al. (2022) Jan 01 to Sept 30, 2016 Yes (Reasons not stated) Yes Yes Yes 2 Akadri & Odelola (2020) No data Yes Yes Yes Yes 3 Aliyu et al. (2019) October 2017 and December 2017 Yes (Reasons not stated) Yes Yes Yes 4 Amat Camacho et al. (2023) March, 2022 Yes Yes Yes Yes 5 Anaba et al. (2022) September 2019 to October 2019 Yes Yes Yes Yes 6 Anazonwu et al. (2018) No data Yes Yes Yes Yes 7 Anyanwu et al. (2014) No data Yes Yes Yes Yes 8 Atimati & Adam (2020) May 2016 and January 2017 Yes Yes Yes Yes 9 Balogun et al. (2017) No data Yes Yes Yes Yes 10 Bisi-Onyemaechi et al. (2017) No data Yes Yes Yes Yes 11 Elegbua et al. (2023) No data Yes Yes Yes Yes 12 Joseph & Earland (2019) June and July 2016 Yes Yes Yes Yes 13 Mohammed & Aliyu (2021) No data Yes No Yes Yes 14 Odu et al. (2016) No data Yes Yes Yes Yes 15 Ogundairo et al. (2024) June 2020 to December 2021 Yes No Yes Yes 16 Okoroiwu et al. (2021) No data Yes Yes Yes Yes 17 Olasinde et al. (2021) 20th May 2020 and 25th June 2020 Yes Yes Yes Yes 18 Ugboaja et al. (2013) No data Yes Yes Yes Yes 19 Yakubu et al. (2023) No data Yes Yes Yes Yes Given the high rate of published papers on breastfeeding practices in Nigeria, the primary purpose of this review is to draw insights from both what is known and what is unknown about the topic and to provide direction on prominent, underexplored areas for further research. The study adheres to ethical research practices and utilises publicly accessible databases, thereby placing a significant emphasis on research integrity, transparency, confidentiality, and proper citation of sources. It is essential to note that informed consent is not applicable in this case, as the data used are secondary, publicly available, and accessible. Therefore, in accordance with the University of Hull's ethical standards, approval was granted by the Faculty Research Ethics Committee. Description of extracted Data and analysis Data is structured on 19 reviewed studies conducted across the 36 states and the capital of Nigeria, made up of six geo-political zones, namely the North Central (NC), North-West (NW), North-East (NE), South-East (SE), South-West (SW), and South-South regions (SS). The summary of the studies is found in Supplementary Table 1, listed in alphabetical order, comprising geo-political zones, study area, setting, study methodology, socio-demographic characteristics of respondents, and study findings including EBF practice rate, Early initiation, skin-to-skin contact after birth, and continued breastfeeding up to 2 years. The study locations are as follows: NW - Sokoto (2) Kebbi (2), Zamfara, Katsina, Kano, Kaduna; NE - Borno; NC - Abuja (FCT); SW - Ogun, Lagos, Osun, Oyo (2); SE - Enugu (2), Ebonyi, Anambra; and SS – Edo and Rivers state. The study areas were Urban = 8, Urban & Rural = 3, Semi-Urban = 4, Rural = 2, Non-specific wards = 1, Humanitarian = 1. Participants were recruited in various study settings, including THF = 7, THF & SHF = 1, PHCs = 3, Community and markets = 5, LGAs = 1, non-specific wards = 1, and MSN project Centres = 1. Fourteen papers adopted a quantitative study method: Cross-sectional Descriptive = 12 [15,16,25,26,17–24] and Comparative cross sectional = 2 [27,28], Qualitative study methods were two [29,30], Mixed method were two ([31,32] and one Quasi-experimental study [33] which was a Longitudinal cohort study of two groups carried out mid pregnancy to 6 months post-partum. Across the 19 studies, a total of 7,573 participants, including mothers and infant caregivers, were included. The six studies were conducted and published between 2013 and 2018, while the 13 studies were conducted between 2019 and 2024. Data from these studies were manually reviewed and extracted into an evidence table, coded using a deductive approach, analysed and synthesised with the aid of a MS Word pre‐defined codebook and Excel spreadsheet. Drawing on Saldaña’s coding framework [34], my analysis integrated prevalence rates, statistical findings, and qualitative data to interpret recurring patterns and connections in exclusive breastfeeding (EBF) practices across Nigeria. Theoretical Framework The research is guided by Urie Bronfenbrenner’s Socio-Ecological Model (SEM), which was developed in the 1970s and later expanded in the 1980s, and the Health Belief Model (HBM), established by Hochbaum and Rosenstock in the 1950s. These theoretical frameworks provide insights into the influence of individual, interpersonal, community, and societal factors on health behaviors, offering a comprehensive understanding of the complexities of attitudes and behaviors for effective public health interventions [35–37] . Drawing from the SEM and HBM theories, the research evaluates how various factors at different levels influence exclusive breastfeeding behaviors among mothers in Nigeria. Through the analysis of thematic content, three primary themes emerged: regional diversity, maternal influences, and societal factors. These themes are further delineated into fourteen categories and four sub-themes, enhancing the understanding of the study and its implications for breastfeeding practices in Nigeria. This study further proposes a causal conceptual framework building on the foundational theories of the Socio-Ecological Model (SEM) and the Health Belief Model (HBM), to explore the range of factors that influence exclusive breastfeeding (EBF) practices. These theories highlight how individual beliefs, social influences, and broader systemic conditions interact to shape maternal health behaviour. Informed by these perspectives, the framework groups the potential determinants of EBF into three main categories: Immediate, Underlying, and Basic determinants (see Figure 2 ). This structure reflects the complex realities mothers face in Nigerian communities and helps to organise the social, cultural, and structural influences that support or hinder EBF. Results An analysis of 19 studies highlights the actual prevalence rates of key breastfeeding practices for infants aged 0–6 months. Exclusive breastfeeding rates vary from 12.5–73.8%, with an overall average of 46.4%. Results from 9 studies on early initiation and skin-to-skin contact for infants in the same age group range from 38.8–99.3%, with a mean of 57.3% (see Fig. 3 and Supplementary Table 1). Joseph and Earland [ 30 ] described the prevalence of EBF and early initiation as ‘low’ without providing specific figures; however, Table 3 details all data for these variables. Using thematic content analysis, the results identified two primary themes: Socio-Contextual factors and Maternal factors. These themes were developed from five sub-themes and sixteen categories. The sub-themes are: (1) Socio-demography and economic Factors; (2) Socio-cultural influences and beliefs; (3) Healthcare access and support systems; (4) Maternal knowledge and perceptions about practice; and (5) Maternal confidence, cognitions, and barriers to EBF practice. These themes are summarised in Fig. 4, showing the Barriers and Enabling factors for EBF practice in Nigeria. Table 3 Summary of Prevalence Rate of EBF, EI and STSC Practices (%) Study EBF Early initiation STSC Odu et al. (2016)[ 22 ] 73.8 75 - Aliyu et al . (2019)[ 16 ] 70.1 - - Yakubu et al. (2023)[ 18 ] 70 - - Mohammed & Aliyu, (2021)[ 21 ] 68.5 - - Elegbua et al . (2023)[ 28 ] 60.3 58.4 - Akadri & Odelola, (2020)[ 25 ] 58.8 38.8 - Okoroiwu et al. (2021)[ 23 ] 54.4 99.3 - Balogun et al. (2017)[ 27 ] 52.4 59.6 - Olasinde et al. (2023)[ 26 ] 46.1 40.6 - Anazonwu et al. (2018)[ 31 ] 39.9 - - Anaba et al . (2022)[ 17 ] 37.5 42.1 29.8 Atimati & Adam, (2020)[ 19 ] 36.6 44.5 - Ugboaja et al. (2013)[ 32 ] 35.9 - - Adamu et al. (2022)[ 15 ] 34.2 - - Ogundairo et al . (2024)[ 33 ] 33.1 - - Bisi-Onyemaechi et al. (2017)[ 24 ] 26 - - Anyanwu et al. (2014)[ 20 ] 25 - - Amat Camacho et al. (2023)[ 29 ] 12.5 - - Joseph & Earland (2019)[ 30 ] Low EBF Low EI - SOCIO-CONTEXTUAL FACTOR Socio-Demography and Economic Factors: Prevalence and Patterns This theme includes factors that positively or negatively affect EBF practices. Essential elements consist of maternal age, education, occupation and income, parity, and marital status. Maternal Age There is a significant link between breastfeeding self-efficacy and maternal age[ 19 , 24 , 26 , 32 , 33 ]. Higher exclusive breastfeeding (EBF) rates were observed among older mothers (aged 31 and above) compared to those aged 30 and below [ 19 , 24 ]. Additionally, delayed breastfeeding initiation was more common in mothers aged 20 years and below. However, a few studies have noted a decline in EBF practice with increasing maternal age in the 20–29 age group [ 26 , 32 ]. Maternal Education Levels Maternal level of education showed a strong link with exclusive breastfeeding (EBF) practice among mothers with higher education levels. Mothers with tertiary education had significantly better knowledge, practice, and acceptance of EBF, and likely to practice EBF [ 19 , 21 ]. Other studies indicate that mothers with more formal education are more likely to practice EBF [ 15 , 32 , 33 ], with one study reporting a significant effect (p = 0.003)[ 26 ]. However, one study found that while EBF was more common among younger women (under 35) and those with more than primary education, maternal age and education level were not significant determinants of EBF practice [ 20 ]. Maternal Occupation, Employment and Income Status Maternal occupation, employment and income status were identified in 11 of the 19 reviewed studies as influencing exclusive breastfeeding practices. Several studies highlighted maternal occupation as a key factor, with the type of job impacting both the start and continuation of breastfeeding. Jobs in the formal sector, such as health workers, teachers, and business owners, were more positively linked to EBF [ 21 , 26 ]. Similarly, maternal occupation predicted breastfeeding self-efficacy and initiation [ 33 ]. Conversely, Civil servants faced high work-related pressure, with 19.9% and 61.8% of mothers respectively citing job demands as reasons for stopping EBF [ 18 , 31 ]. Employment-related issues, especially short maternity leave and early return to work, were often identified as obstacles to exclusive breastfeeding (EBF). Multiple studies indicated that mothers returning to work soon after childbirth faced significant challenges in maintaining EBF. In one study, 17.7% of employed mothers stopped EBF due to limited maternity leave [ 15 ]. Another study, reported that 88.5% of mothers who did not return to work early successfully practiced EBF, whereas only 11.5% did not [ 20 ]. Therefore, early re-entry into the workforce was a common barrier [ 16 , 24 , 27 ]. Income level and employment status influence EBF behaviours. The review showed that many mothers who were artisans or traders earned less than the $ 20 monthly minimum wage and had lower breastfeeding self-efficacy [ 33 ]. Conversely, employment isn't always a negative factor as employed mothers, including those in low-income households and on-site jobs, showed higher rates of early breastfeeding initiation [ 17 ]. Additionally, some evidence indicates that unemployment can support EBF. One study noted that unemployed mothers practiced EBF more often than civil servants, with a significant difference (p = 0.007) [ 15 ]. Marital factors Marital dynamics like polygyny, early marriage, and domestic violence as barriers to EBF, noting that spouses often influence decisions to start or continue breastfeeding [ 29 ]. Meanwhile, one study observed that marital status positively affects EBF practice [ 33 ]. These opposing findings emphasize the complexity of marital roles and suggest a need for further investigation. Parity This variable is important, especially since the reviewed studies include both primiparous and multiparous mothers, offering different views on childbearing and infant nutrition challenges. Notably, only one study reported that parity influenced early breastfeeding initiation, with some first-time mothers delaying initiation due to traditional practices [ 30 ]. Meanwhile, a mother's ability to breastfeed may change over time, often declining with age and the number of births, as they could breastfeed their first children but faced difficulties with subsequent ones[ 29 ]. Across 11 studies reporting participants' parity, only three studies documented an EBF practice rate of over 40% [ 21 , 24 , 25 ]. This suggests that parity might have a complex, context-dependent impact on exclusive breastfeeding, warranting further research. Socio-Cultural Influences and Beliefs This theme emphasizes the influences of community, family, friends, and beliefs on infant feeding, including personal anxiety, cultural, traditional, and religious practices, which determine infant feeding behaviours. Family and Social support Mothers’ exclusive breastfeeding (EBF) practices are strongly influenced by both internal and external family members, as well as broader social networks. Several studies have identified family support as a positive factor; encouragement from family and friends significantly predicts successful EBF [ 20 , 26 , 29 ]. Similarly, one study emphasized the critical role of spousal support in promoting breastfeeding [ 22 ]. Conversely, some research highlights family dynamics as barriers; family approval can support EBF, and the lack of family or social support can hinder it [ 31 ]. One study observed that larger families (more than four members) often motivated EBF due to resource constraints, yet mothers also faced pressure from relatives to choose other feeding options [ 24 ]. Other studies mentioned direct barriers such as spousal disapproval [ 17 ], grandmother’s refusal [ 32 ], and the absence of supportive family structures [ 18 ]. Additionally, another study pointed out that family members' decisions and partners’ knowledge of breastfeeding benefits are crucial, with insufficient support ultimately limiting EBF adherence [ 30 ]. Beliefs on infant feeding Several studies reveal a common perception that breastmilk alone isn't enough; many believe infants need water or other liquids for hydration or nutrition. Mothers worry about babies appearing weak, losing weight, or feeling thirsty, leading them to introduce water or herbal mixtures early [ 15 , 26 , 27 , 29 ]. While some mothers feared conditions like sunken fontanels or illness, which they thought breastmilk couldn't prevent [ 33 ]. Socio-cultural beliefs, traditional practices, and gender norms significantly influence infant feeding behaviours. Beliefs that infants, especially boys, need more breastfeeding and extra liquids; breastmilk perceived as inadequate or unnecessary, prompting early use of complementary feeds [ 17 , 31 ]. One study identified delays in breastfeeding related to infant uvulectomy and the infant’s gender—three days for boys and four for girls. Postpartum practices included herbal treatments applied to the breast for two days and a 40-day period of maternal bathing, which, while culturally important, often delayed early breastfeeding [ 30 ]. Although breastfeeding was viewed as a cultural obligation, community norms often disrupted exclusive breastfeeding by delaying initiation for three to four days and giving other liquids, especially during maternal or infant health issues. Traditional healers sometimes advised mothers to stop breastfeeding under conditions like HIV, mastitis, or multiple births, further discouraging or preventing EBF[ 29 ]. Additionally, another study reported that fears of infants rejecting other foods later discouraged some mothers from practicing EBF [ 20 ]. While culture and illiteracy were linked to adverse EBF outcomes, religion and literacy positively influenced breastfeeding practices [ 23 ]. HEALTHCARE ACCESS AND SUPPORT SYSTEMS This theme explores how access to healthcare services affects mothers' health-seeking behaviours related to exclusive breastfeeding (EBF). It covers aspects such as lactation support, the use of health facilities for Antenatal and Postnatal Care (ANC/PNC), and childbirth practices. Breastfeeding support Supportive interactions with healthcare providers positively affect exclusive breastfeeding (EBF) practices among mothers[ 17 ]. Similarly, several studies emphasized the importance of healthcare support through prenatal and postnatal follow-ups [ 33 ]. Their intervention study revealed that ongoing healthcare engagement notably extended EBF duration, with 43.2% of mothers in the intervention group maintaining EBF at six months postpartum, compared to 22.9% in the control group, highlighting the benefits of continuous breastfeeding support. However, the success of professional breastfeeding support varies by setting. In a cross-sectional study, mothers visited by lactation experts had a lower exclusive breastfeeding rate (6.4%) than those with no contact with such experts (29%)[ 20 ]. Antenatal and postnatal care (ANC/PNC) engagement Of the 19 studies examined, 11 focused on maternal involvement in antenatal and postnatal care (ANC/PNC). Most studies addressed ANC attendance, while two looked at PNC use, and two reported minimal or no engagement with either service. High ANC (97.2%) and PNC (91.7%) attendance positively influenced exclusive breastfeeding (EBF) practices [ 19 , 32 ]. Similarly, the ANC attendance rate of 98.8%, which significantly impacted EBF outcomes (p = 0.0001), mainly through prenatal and postnatal infant feeding education [ 15 ]. Mothers' proximity to health facilities was linked to higher EBF rates, whereas limited access to functional healthcare facilities hindered effective EBF, emphasizing the need for accessible health infrastructure [ 21 , 25 , 29 ]. One study reported that mothers attending ANC four or more times were more likely to initiate breastfeeding early and maintain EBF [ 17 ]. Similarly, one study reported that 78.3% of mothers received EBF guidance from health workers during ANC and PNC visits, highlighting the importance of health personnel in providing consistent breastfeeding education through routine ANC and PNC [ 26 , 32 ]. Though mothers who received ANC from traditional birth attendants (TBAs) also showed early initiation, this subgroup was small and warrants cautious interpretation. Conversely, one study documented limited ANC engagement, but counselling from healthcare workers and TBAs still promoted early initiation and EBF, despite overall low EBF rates. A few mothers also recalled receiving advice on colostrum's benefits during their ANC visits [ 30 ]. Place and mode of birthing or delivery Hospital-based delivery and vaginal birth consistently correlate with better exclusive breastfeeding (EBF) outcomes across multiple studies. The facility type for ANC and delivery showed a significant link to EBF at six months ( p = 0.001 for ANC; p = 0.004 for delivery). Likewise, hospital birth (P = 0.004) positively impacted EBF through access to prenatal and postnatal feeding advice [ 15 , 25 ]. Hospital delivery was also significantly associated with greater breastfeeding knowledge (P < 0.05), supporting informed EBF practices [ 27 ]. Mothers who delivered in hospitals were more likely to start breastfeeding earlier than those delivering at home [ 30 ]. Regarding delivery methods, vaginal delivery is a predictor of breastfeeding self-efficacy, including both initiation and continuation of EBF [ 27 , 30 , 33 ]. One study found that 67.5% of mothers had vaginal deliveries, and 61.3% delivered in hospitals [ 24 ]. Both factors were positively linked to EBF practices. MATERNAL KNOWLEDGE AND PERCEPTION OF PRACTICE This theme highlights how maternal knowledge, awareness, and perceptions impact exclusive breastfeeding (EBF) practices. It also shows how understanding breastfeeding guidelines, beliefs about the benefits of colostrum and breastmilk, and sources of health information influence maternal choices. Breastfeeding Awareness Across the reviewed studies, sufficient knowledge and positive perceptions of exclusive breastfeeding (EBF) consistently correlated with better practices. Mothers who understood breastfeeding benefits and accurately knew the guidelines were more likely to start breastfeeding early and maintain EBF [ 17 , 21 – 23 , 28 ]. Despite widespread awareness, some studies revealed gaps; one study found that 72.2% of mothers knew about EBF, but only 27.8% practiced it, often due to limited understanding of its importance [ 15 ]. Another study reported similar issues among female medical practitioners: while 95.1% had general awareness, only 52.1% could define EBF correctly [ 16 ]. Also, noted that knowledge gaps among female healthcare workers constrained consistent practice [ 18 ]. Colostrum and Breastmilk Perception Perceptions of colostrum and breastmilk shape behaviour. Some mothers and caregivers viewed colostrum as harmful or dirty, leading to its rejection, especially among first-time mothers or those who experienced infant loss. In these cases, breastmilk was often discarded, replaced with herbal mixtures, or breastfeeding was delayed until older relatives or traditional attendants gave their approval [ 17 , 29 , 30 ]. [One study highlighted that “the perceptions of colostrum as bad were a major influence on practice,” noting that, “among mothers who had previously experienced neonatal or infant mortality, the child’s death was often attributed to ‘poisonous’ breastmilk. As a result, many of these mothers either refused or were pressured to stop breastfeeding subsequent children”. [ 29 ] ] [Similarly, another study reported that “among first-time mothers, colostrum was perceived as ‘dirty,’ with concerns that a baby can contract diseases from it. A few took herbs to make the perceived bad milk good for the baby, while a new mother’s breast milk must be ‘checked’ by a grandmother or a Traditional Birth Attendant before breastfeeding. In subsequent birthing, colostrum was not discarded.” [ 30 ] ] In contrast, mothers who understood the nutritional benefits of colostrum were more likely to start exclusive breastfeeding (EBF) early and maintain it. Additionally, women with greater awareness of EBF and its benefits were more inclined to initiate breastfeeding promptly and continue the practice [ 17 , 23 ]. Health information source Among the studies reviewed, health workers were the most frequently cited source of breastfeeding information. An impressive 92.7% of respondents reported learning about exclusive breastfeeding (EBF) from health professionals [ 22 ]. A study found that women who obtained EBF information from mass media were significantly more likely to practice EBF for six months than those who relied on other sources. The study also emphasized the combined role of health workers and mass media in promoting EBF[ 25 ]. There is a wider array of information sources, including media, health facilities, NGOs, and community channels [ 29 ]. Conversely, in areas where institutional delivery was less common, such as among women delivering at home, breastfeeding guidance mainly came from traditional birth attendants or elder family members like grandmothers. MATERNAL CONFIDENCE, COGNITIONS, AND BARRIERS TO EBF PRACTICE. This theme reflects the mother’s personal beliefs, motivations, and ability to practice exclusive breastfeeding (EBF). It encompasses exposure to specific interventions, self-confidence, maternal intentions, health status, worries about body image, breastfeeding requirements, lactation challenges, and infant feeding problems. Maternal Motivations and Intentions Several studies have shown that targeted interventions effectively promote exclusive breastfeeding (EBF). Community efforts supported by non-governmental organisations like Médecins Sans Frontières (MSF) have positively influenced EBF rates. [ 29 ]. Studies emphasise the importance of ongoing Social and Behaviour Change (SBC) programs in encouraging exclusive breastfeeding (EBF). Visual cues, like pictures of healthy EBF infants, further boost mothers’ motivation to sustain the practice. Additionally, a two-week drama-based intervention before childbirth, combined with postpartum follow-ups, proved effective in supporting continued EBF [ 17 , 33 ]. Mother's self-efficacy is vital for maintaining exclusive breastfeeding (EBF). In IDP settings, the lack of trained lactation support staff hampers mothers’ ability to practice EBF effectively, emphasising the importance of MSF Breastfeeding support in enhancing maternal confidence. [ 29 ]. Self-motivation plays a crucial role in EBF; mothers with greater confidence tend to engage more actively EBF[ 17 , 26 ]. A mother’s intention to breastfeed exclusively is a strong predictor of her actual breastfeeding behavior and positively impacts her chances of success. [ 17 , 20 , 29 ]. Maternal Cognitions Numerous studies have highlighted concerns about body image and physical changes associated with breastfeeding. Some mothers are concerned about breast sagging, and anxieties about body shape often discourage them from initiating or maintaining exclusive breastfeeding (EBF). Fear of bodily changes acts as a common mental barrier to EBF. Additionally, social and emotional factors contribute to these concerns [ 15 , 26 , 28 , 31 ]. Some mothers discontinued exclusive breastfeeding after becoming pregnant again or avoided breastfeeding in public because of shame or stigma. [ 18 ]. Infant-related issues include reluctance to breastfeed and delayed lactation. [ 19 ], early or natural discontinuation [ 18 ], and frequent crying [ 20 ], causing distress and uncertainty, lowering mothers’ confidence in continuing EBF. Mothers’ personal opposition to EBF discouraged its practice, describing it as physically demanding and stressful [ 15 , 17 , 18 , 32 ]. Mothers associate the perceived difficulty and time-consuming nature of EBF, along with sleepless nights, with early discontinuation, which discourages continued EBF practice [ 26 – 28 , 33 ]. Breastfeeding barriers Various physical health factors, such as maternal illness [ 24 ] and postnatal complications, directly impede exclusive breastfeeding (EBF) by affecting a mother’s capacity to initiate or sustain breastfeeding. In more severe cases, these health issues led to early cessation of EBF or necessitated alternative feeding options, like using wet nurses—particularly in instances of maternal death [ 29 ]. Breastfeeding challenges like lactation issues, low milk supply, and feeding difficulties greatly affected exclusive breastfeeding (EBF). A crucial predictor of successful EBF was the 'absence of lactation problems.' Nipple pain is a common obstacle that can discourage some mothers from continuing EBF [ 25 , 33 ]. Poor knowledge of proper breastfeeding technique (positioning and attachment) contributed to lactation issues, affecting mothers' decisions to start or continue EBF[ 29 ]. Actual low milk supply, rather than perceived insufficiency, was identified as a common challenge that hindered mothers from maintaining EBF [ 26 , 27 , 33 ]. Mothers’ worries about infant illness or malnutrition often originated from their personal experiences of inadequate milk supply. [ 29 ]. Discussion This integrative review aimed to determine the prevalence of exclusive breastfeeding (EBF) in Nigeria and examine the socio-demographic, cultural, and systemic factors influencing maternal feeding decisions. Drawing on nineteen studies across all six geopolitical zones, two primary themes — socio-contextual factors and Maternal factors — framed the review. The discussion follows thematic categories, allowing for a deeper contextual interpretation. Patterns in EBF prevalence and Socio-demographic determinants EBF rates across the reviewed studies ranged from 12.5% in humanitarian or rural contexts [ 29 ] to 73.8% in urban, facility-based studies [ 22 ], with an overall mean of 46.4%. This reflects some progress toward the WHO 2025 target (50%) but still falls short of the SDG 2030 goal (60%) and the global average of 48% [ 39 ]. These variations point not only to methodological diversity but to underlying structural inequities in health infrastructure, socioeconomic conditions, and maternal support systems in Nigeria. Broader literature has also cautioned that definitional inconsistencies, such as what qualifies as "exclusive" and “early initiation," can misrepresent breastfeeding levels, reinforcing the need for context-specific interpretations of prevalence data [ 40 ]. Maternal age emerged as a recurrent, though inconsistent, predictor. Older mothers (≥ 30 years) were more likely to maintain EBF, probably due to experience and confidence [ 19 , 24 ], while younger mothers (20–30 years) also showed favourable practices when supported [ 26 , 33 ]. However, other studies suggest that age alone cannot determine practice variation, as it often intersects with counselling exposure, work demands, and family roles [ 15 , 19 , 24 , 32 , 33 ]. Additionally, sampling bias, such as the overrepresentation of specific age groups in some studies, may have influenced the observed associations. Educational qualification also demonstrated mixed influence. While several studies reported that tertiary education correlated with improved EBF knowledge and practice [ 15 , 21 , 26 , 32 ], others reported no apparent effect [ 20 ], and in a similar study conducted in Cameroon, higher education was associated with earlier cessation [ 41 ]. These contradictions suggest that knowledge alone is insufficient unless an enabling environment supports it. Education may empower, but it can also expose mothers to competing pressures such as career demands or social acceptance of formula feeding. Occupational status and employment structure played a nuanced yet influential role in shaping EBF. While formal employment, particularly in education and health sectors, was associated with higher breastfeeding knowledge and uptake [ 21 ], rigid schedules and limited maternity leave in formal roles often constrained sustained practice [ 15 , 27 ]. These constraints were particularly evident among civil servants and professionals who returned to work shortly after childbirth. By contrast, mothers earning low incomes in informal or site-based roles sometimes maintained better EBF continuity, likely due to greater job flexibility [ 17 ]. This suggests that a flexible, supportive work environment is more crucial to a mother’s decision to practice EBF than income alone. It also implies that employment structures such as maternity leave policies and work flexibility have a significant impact on overall breastfeeding behaviour. Marital status and parity showed similarly nuanced effects. While marriage often offered support [ 33 ], some dynamics, including early marriage, polygyny, and male-dominated decision-making, hindered mothers from making informed breastfeeding decisions [ 29 ]. Parity, too, presented inconsistencies: first-time mothers delayed breastfeeding due to traditional constraints [ 30 ], while multiparous women cited fatigue and shifting priorities [ 29 ]. These findings suggest that both marital status and parity operate through layered social and relational mechanisms. Overall, socio-demographic variables such as age, education, employment, and marital status should not be misreported or misinterpreted as fixed indicators of breastfeeding behaviour. Instead, they often reflect bigger systems of support or barriers affecting mothers differently depending on issues like healthcare access, family roles, culture, and gender expectations. Methodological differences across studies, particularly on how participants were selected, also influenced observed prevalence patterns, showcasing the need for a subtle analysis based on context. To improve EBF outcomes in Nigeria, future interventions must move beyond demographic profiling and engage with the deeper structural realities shaping maternal choices. Socio-Cultural Beliefs and Practices Exclusive breastfeeding (EBF) decisions are rarely made by mothers alone. Instead, they are negotiated within a broader socio-cultural ecosystem involving spouses, elders, extended family members, and wider community expectations. Family support was positively linked to EBF practice [ 20 , 22 , 26 , 29 ], while disapproval from partners [ 17 ], grandmothers [ 32 ], or the absence of supportive networks [ 18 ] often undermined maternal intent, revealing the ambivalent nature of social influence. In many settings, elderly women assume authority during postpartum care and infant feeding, highlighting the need to consider influential community actors in maternal health efforts. Cultural interpretations of infant well-being further shaped feeding behaviours. Perceptions that breastmilk alone is insufficient and infants require water or other feeds [ 15 , 17 , 26 , 29 , 31 ] are usually due to fears of dehydration, weakness, or sunken fontanels [ 33 ], prompting early introduction of fluids or traditional remedies. These beliefs, while medically inaccurate, come from a genuine maternal concern often reflected in context-specific logics in hot climates where infant distress is readily attributed to thirst or hunger. Furthermore, there is a widespread notion that all living things require water to grow, reinforcing the perception that EBF is a modern or “Western” practice [ 42 ], despite traditional breastfeeding customs often aligning with WHO guidelines in practice. This highlights a knowledge gap among mothers regarding the broader biomedical evidence in the literature, indicating that breastmilk comprises 87–88% water and supplies complete nutrition [ 43 ]. Additionally, definitional inconsistencies, such as whether giving plain water disqualifies EBF, complicate cross-cultural comparisons of EBF data [ 40 ]. In many households, traditional knowledge systems retain stronger credibility than biomedical advice. Traditional healers also shape practices by advising cessation of breastfeeding in cases such as maternal illness, HIV, or multiple births [ 29 ]. Additionally, rituals such as infant uvulectomy or postpartum seclusion periods delay initiation and disrupt early feeding [ 30 ]. These findings suggest that beliefs surrounding EBF are not merely “barriers” but part of dynamic care systems, in which authority, tradition, and local logics shape maternal choices. A recurring issue across the literature is that most interventions target mothers directly through health facilities, often overlooking the wider social actors who significantly shape infant feeding decisions. This narrow focus reveals a critical gap: without engaging those who hold decision-making power within caregiving networks, improving maternal knowledge alone may not lead to sustained behavioural change. Healthcare Access and Support Systems Evidence from multiple studies suggests that the use of health facilities and the support and interactions of health workers positively influence EBF practice [ 17 ], highlighting the importance of consistent breastfeeding support over time [ 33 ]. In contrast, visits from lactation experts yielded lower practice rates [ 20 ], suggesting that outcomes may vary depending on the study context and other behavioural factors, as well as culturally appropriate counselling. Proximity to health facilities was associated with higher EBF rates[ 21 ], while limited access to functional healthcare facilities was a barrier [ 29 ], pointing to the need for adequate and accessible health services, especially for mothers in under-represented areas. Similarly, studies revealed that attendance or engagement with antenatal care (ANC), either in a hospital setting [ 15 , 17 , 19 ] or with traditional birth attendants [ 30 ], had a significant influence on the timely and early initiation of breastfeeding. This suggests that experiences within the health system shape maternal health behaviours and practices. This is corroborated by more extensive data from Rwanda [ 44 ], which demonstrated that mothers who gave birth in a hospital had a higher chance of receiving immediate obstetric and postnatal care, as well as breastfeeding education on topics such as benefits, proper positioning, attachment, and breast care. This improved their ability to initiate and sustain EBF. This review also found that the place and mode of birthing, mostly hospital-based and via vaginal delivery, contributed to improved EBF practices and outcomes [ 15 , 24 , 27 , 30 , 33 ]. This may be linked to the prenatal and postnatal feeding advice that mothers received while at health facilities. On the other hand, mothers’ perception that pain or complications from caesarean delivery limited skin-to-skin contact and early breastfeeding initiation could lead to delayed lactation and the early introduction of other liquids, ultimately discouraging sustained EBF practices. In addition, several studies highlighted the role of health workers during antenatal and postnatal care [ 22 , 26 , 32 ] and mass media [ 25 , 29 ] as significant sources of breastfeeding information. These findings suggest the combined influence of both the Socio-Ecological Model (SEM) and the Health Belief Model (HBM) in shaping health behaviours at the individual and community levels. Maternal Knowledge and Perception to Practice Maternal knowledge, awareness level, and perception regarding EBF, its nutritional benefits, and the value of colostrum are strong determinants of early initiation and sustained practice [ 16 , 22 , 28 , 33 ]. However, these findings also reveal that awareness alone does not guarantee adherence. High awareness levels of EBF did not necessarily translate into practice[ 15 ]. This gap appears to stem from superficial understanding: knowing the term "exclusive breastfeeding" without grasping its full definition or implications[ 16 , 18 ]. Misconceptions surrounding colostrum further demonstrate how cultural beliefs mediate maternal knowledge. Several studies have found that colostrum is often perceived as “bad milk” and discarded, particularly among first-time mothers and in lower-income settings [ 17 , 29 , 30 ]. These perceptions undermine optimal EBF practices, indicating that awareness campaigns must not only convey facts but also address deeply rooted beliefs. This implies that actionable advice is still lacking even when informational awareness is highlighted. These results highlight the urgent need for comprehensive, culturally aware breastfeeding instruction that gives mothers confidence and valuable skills in addition to educating them. More than just knowledge is needed to close the knowledge-practice gap; women must be empowered to overcome perceived and actual barriers, and misunderstandings must be dispelled. Maternal Confidence and Cognitions to EBF Practice. Out of the 19 reviewed studies, three provided evidence that targeted interventions such as community and health facility-based support from Médecins Sans Frontières (MSF) in a humanitarian context [ 29 ], Social and Behaviour Change (SBC) programmes [ 17 ], and drama viewing combined with prenatal and postnatal follow-up [ 33 ] are effective motivators for improved EBF outcomes. In other studies, not part of the initial review, the Baby-Friendly Hospital Initiative (BFHI), a notable global intervention, has shown slow progression since being adopted by tertiary health facilities in Nigeria [ 45 , 46 ]. However, when introduced, the findings show higher rates of exclusive breastfeeding at 49% and any breastfeeding at 66% within the ten recommended steps of breastfeeding support. Despite these examples, a notable gap remains in the scholarship on evaluating breastfeeding interventions and their direct effects on exclusive breastfeeding outcomes in Nigerian studies. While a mother’s positive intention often predicts actual practice [ 20 , 29 ], her motivation and confidence to practice are sustained by feelings of self-efficacy [ 17 , 26 ]. This supports a broader idea in the Health Belief Model (HBM) framework, which posits that EBF practice, like other health behaviours, is essentially a personal choice [ 17 ]. Beyond the reviewed studies, a case study in Australia [ 47 ] suggests that most mothers are not only knowledgeable and intentional about EBF but are also driven by self-determination, which fosters optimism and confidence in initiating and sustaining EBF for up to six months. In internally displaced persons (IDP) settings, the limited availability of health workers to support EBF [ 29 ] indicates a contextual environmental influence. Within such contexts, the Socio-Ecological Model (SEM) offers further insight into how multiple levels of influence shape health behaviours. To date, these observations suggest the need for additional research on intervention-based EBF practices among mothers in Nigeria. However, studies also indicate that specific barriers and concerns undermine maternal confidence. For instance, postnatal illness was reported as a challenge to EBF [ 24 , 29 ], alongside worries over body shape [ 26 , 28 , 31 ] and breast sagging [ 15 ]. These findings suggest the need for improved maternal care and mental health support to sustain breastfeeding efforts. Other studies reported that mothers stopped EBF while avoiding breastfeeding in public due to being ashamed [ 18 ], reflecting the barriers to practice caused by societal pressures and stigma. These further details show how most public infrastructures and organisations in Nigeria do not have designated facilities or private structures to support nursing mothers to breastfeed their babies while in public. Other studies, not part of the initial review, provide additional insight into this barrier; however, they also highlight the cognitive response of ‘not flashing’ as well as respecting other spaces by always covering up with a blanket and being discreet while breastfeeding in public [ 47 ]. This further suggests that maternal intentions and adaptability usually supersede pressures when it comes to perceived need for infants’ health. Some mothers ceased EBF upon becoming pregnant again[ 18 ]. Aside from this, societal stigma is sometimes associated with the myth that breastfeeding during pregnancy negatively affects the nursing child’s development, such as delayed walking or speech or even other social interactions. This highlights a critical knowledge gap within communities and points to the need for clearer public education on infant and child feeding practices within specific social and cultural contexts. Mothers also reported discontinuing EBF due to discomfort or shame associated with breastfeeding in public [ 18 ], reflecting how societal pressures and stigma function as barriers. This illustrates a broader infrastructural issue, where most public spaces and organisations in Nigeria lack designated facilities or private areas for nursing mothers. Additional literature, although not part of the initial review, provides further insight into this challenge, highlighting coping mechanisms such as discreet breastfeeding and covering with a blanket to avoid “flashing” or violating social norms [ 47 ]. These responses indicate that maternal intentions and adaptability can, at times, override public pressures, particularly when guided by the perceived health needs of the infant. Moreover, the reviews identified the intensity of the practice itself as a deterrent. Several studies reported EBF to be stressful[ 18 , 32 , 33 ], intensive [ 26 – 28 ], and physically demanding [ 15 ], all of which contribute to discontinuation among some mothers. These findings suggest the need for continuous health education and support, as well as policies that promote and facilitate the practice of EBF for mothers. Additionally, breastfeeding challenges such as perceived low milk supply [ 26 , 27 , 33 ], nipple pain [ 33 ] s , and delayed milk onset [ 19 ] were commonly reported barriers to sustained EBF. In contrast, the absence of such lactation difficulties was significantly associated with higher rates of EBF [ 25 ], indicating that these challenges are not solely physiological; they often reflect a broader gap in maternal support and practical breastfeeding guidance. For example, inadequate instruction on proper positioning and latching contributed to feeding difficulties[ 29 ]. Evidence from studies in India and Denmark [ 48 , 49 ] reinforces that breastfeeding technique training is essential in preventing early cessation. Similarly, other Nigerian studies [ 50 , 51 ] emphasise the role of technique in sustaining EBF, yet such support was rarely addressed in the reviewed interventions. Strengths and Limitations To the best of our knowledge, this review is the first of its kind to integrate quantitative, qualitative, and mixed studies, as well as studies in developed and less developed areas (rural and humanitarian settings), making it unique in providing an exhaustive insight into the state of EBF in Nigeria. This provides opportunities for general recommendations on intervention and further research to inform policy, practice, and impact. On the other hand, the review also has some weaknesses. First, it has been conducted by a lone reviewer, which creates the risk for potential researcher bias in the selection of studies and data interpretation. This limitation was mitigated by adopting a self-assessment approach for quality appraisal, which provided a grounded summary and critique of the relevant literature in response to the research questions. Additionally, the 19 studies reviewed present reports on the six geopolitical zones of Nigeria, which comprise 36 states and the Federal Capital Territory; however, the evidence primarily reflects 15 states and the FCT, with limited data or literature available on the other states. Although all the zones are duly represented, this may affect the generalisability of facts since evidence from other states was not represented. Other limitations were from the reviewed studies which are listed in the table, and include a lack of in-depth insight based on study designs, issues with generalisability due to study setting, and inconsistent presentation of variables and interpretation for missing or excluded responses in the result tables [ 16 ] within the socio-demography and health facility use, for instance, marital status, parity, mode and place of birthing, and ANC and PNC attendance, which are likely to indicate barriers for mothers to practice EBF. Another limitation is that studies had limited data on key EBF practices such as skin-to-skin and early initiation and exclusion of data regarding any EBF health outcomes for both mother and infant and interventions, which reduces the ability to generalise on prevalence rates and factors influencing the mother’s decision to initiate and continue EBF practice. Recommendations for Policy and Practice To strengthen exclusive breastfeeding (EBF) in Nigeria, policymakers should expand and improve antenatal and postnatal care (ANC/PNC) and community‑based breastfeeding support, particularly in underserved areas such as rural communities and IDP camps. Additionally, National surveys and health information systems should adopt a single, standardised definition of EBF and early initiation to ensure consistent monitoring and evaluation against WHO and SDG targets. Furthermore, interventions should be designed to reflect community realities by involving key stakeholders, such as spouses, elders, and traditional leaders, and integrating breastfeeding support into broader family and community systems. Health facilities can complement this by publicising peer‑mentor schemes, creating private lactation spaces, and training staff in culturally sensitive counselling. Workplace policies must also evolve to support lactating mothers through extended maternity leave, flexible schedules, and breastfeeding-friendly environments. Finally, the ministries of health and their related partners should invest in robust monitoring and evaluation systems that link EBF practices to maternal-child health outcomes, ensuring that programmes are continually refined based on real-world evidence. Future Research To address the methodological gaps in the EBF literature in Nigeria, future studies should employ qualitative, mixed-method, and intersectional designs to capture mothers’ in-depth experiences beyond the constraints of Likert-scale surveys, which often fail to capture the complexity of maternal behaviours and challenges. There is a need for further research to consistently collect and report on key variables like skin‑to‑skin contact, early initiation, parity, delivery mode and place, and both antenatal and postnatal care attendance, alongside socio‑demographic and economic indicators such as age, education, occupation, income, religion, ethnicity, and marital status. These approaches will provide a richer understanding of the socio-contextual realities that influence maternal decisions. Clear operational definitions of “exclusive breastfeeding” and transparent data‑handling procedures (including justifications for exclusions and methods for addressing missing values) are essential to improve comparability and credibility across studies. Longitudinal and intervention-based studies should be urgently adopted to assess both short- and long-term outcomes of EBF on maternal and child health in Nigeria. Evaluating the effectiveness and scalability of culturally tailored interventions will provide actionable insights for programme design. Priority must be given to under‑represented contexts (rural, humanitarian settings, IDP camps) to ensure findings reflect the full diversity of Nigerian mothers. Finally, building national research capacity through training, standardised methodologies, and institutional support will strengthen the quality and policy relevance of future EBF research. Conclusion This review enhances the existing literature by providing a context-sensitive, multi-dimensional analysis of EBF practices in Nigeria. It shows a notable increase in EBF adoption and practice in both urban and rural areas. Despite high awareness levels, systemic and relational barriers hinder the sustained practice of EBF. The decision to start and continue EBF varies, influenced by socio-cultural and maternal factors. The review also points out research gaps, such as limited involvement of fathers, informal caregivers, and mothers in displaced or rural settings. It emphasizes the importance of equity-focused policies and interventions that go beyond individual awareness to address structural factors enabling maternal health and breastfeeding. Abbreviations ANC Ante-natal care BF Breastfeeding BFHI Baby-Friendly Hospital Initiative CBF Continued Breastfeeding (up to two years old) CGs Caregivers EI Early initiation immediately or few hours after birth EBF Exclusive breastfeeding FCT Federal Capital Territory HCWs Health care workers HF Health Facility HV Hospital visits HWs Health Workers LGA Local Government Area NEBF Not exclusively breastfed NDHS Nigerian Demographic and Health Survey PNC Postnatal care PHCs Primary Health Centres (operate at the LGAs and Community level) SHCs Secondary Health Centres (both public and private at the state level) STSC Skin-to-skin contact TBA Traditional Birth Attendant THF Tertiary Health Facility (at the Federal level, e.g. Teaching hospitals) UNICEF United Nations Children’s Fund WHO World Health Organisation Declarations Acknowledgements: My sincere gratitude to the University of Hull library for the permission and support to extract publications from their database for the review. Authors’ contributions: UFO conceived the study, collected the data, analysed, interpreted and wrote the initial manuscript. HN and FIJ provided critical input to the manuscript. All authors read and approved the final manuscript. Funding: This study was a dissertation submitted for the award of an MSc in Social Research from the University of Hull, United Kingdom. No organization funded this review. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate: Not applicable. However, the University of Hull's Research Ethics Committee approved to conduct the review. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests. 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Use of drama for improving breastfeeding initiation, exclusive breastfeeding and breastfeeding self-efficacy among rural pregnant women from selected communities in two Local Government Areas (LGAs) in Ibadan, Nigeria. Olu-Abiodun OO, editor. PLoS One [Internet]. 2024;19:e0290130. Available from: https://dx.plos.org/10.1371/journal.pone.0290130 Saldana J. The coding manual for qualitative researchers. 3rd ed. Sage Publications Ltd; 2015. Kilanowski JF. Breadth of the socio-ecological model. J Agromedicine [Internet]. 2017;1059924X.2017.1358971. Available from: https://www.tandfonline.com/doi/full/10.1080/1059924X.2017.1358971 Ghorbani-Dehbalaei M, Loripoor M, Nasirzadeh M. The role of health beliefs and health literacy in women’s health promoting behaviours based on the health belief model: a descriptive study. BMC Womens Health [Internet]. 2021;21:421. Available from: https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-021-01564-2 Glanz K, Rimer B, Viswanath K. Health behavior: theory, research, and practice. 5th ed. New York: Wiley; 2015. Joseph FI, Earland J, Ahmed MA. Experience of Conducting Sensitive Qualitative Research as a Cultural Outsider: Formulation of a Guide for Reflexivity. Int J Qual Methods [Internet]. 2021;20:160940692110586. Available from: http://journals.sagepub.com/doi/10.1177/16094069211058616 UNICEF. Improving child nutrition: The achievable imperative for global progress. Div. Commun. UNICEF. 2013. Chabé-Ferret B. Measuring breastfeeding prevalence using demographic and health surveys. BMC Public Health [Internet]. 2024;24:2366. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-024-19821-y Ndum Okwen GA, Karimuribo ED, Ngowi HA, Fombang EN. Exclusive Breastfeeding and Its Determinants in Yaoundé, Cameroon: A Retrospective Survival Analysis. Ozgu-Erdinc AS, editor. J Pregnancy [Internet]. 2022;2022:1–8. Available from: https://www.hindawi.com/journals/jp/2022/8396586/ Ibekwe AM, Obeagu EI, Ibekwe CE, Onyekwuo C, Ibekwe CV, Okoro AD, et al. Challenges of Exclusive Breastfeeding among Working Class Women in a Teaching Hospital South East, Nigeria. J Pharm Res Int [Internet]. 2022;1–10. Available from: https://journaljpri.com/index.php/JPRI/article/view/6487 Kim SY, Yi DY. Components of human breast milk: from macronutrient to microbiome and microRNA. Clin Exp Pediatr [Internet]. 2020;63:301–9. Available from: http://e-cep.org/journal/view.php?doi=10.3345/cep.2020.00059 Bahemuka G, Munyanshongore C, Birungi F. Knowledge, attitudes, and practices of exclusive breast-feeding of infants aged 0-6 months by urban refugee women in Kigali. Rwanda Med J [Internet]. 2013;70:7–10. Available from: https://www.bioline.org.br/pdf?rw13002 Ogunba B, Omotuase O, Idemudia S. KnowledKnowledge and Practices of Baby Friendly Hospital Initiative Among Mothers in Southwestern Nigeria. Int J Fam Consum Sci [Internet]. 2020;9. Available from: https://ijfacs.org/index.php/ijfacs/article/view/26/23 Abdul RA, Agbede CO, Adekoya AO, Abolurin OO, Obadina OO. Assessment of the Baby‐Friendly Hospital Initiative showed suboptimal knowledge and a low exclusive breastfeeding rate in Ogun State, Nigeria. Acta Paediatr [Internet]. 2024;113:753–60. Available from: https://onlinelibrary.wiley.com/doi/10.1111/apa.17051 Charlick SJ, Fielder A, Pincombe J, McKellar L. ‘Determined to breastfeed’: A case study of exclusive breastfeeding using interpretative phenomenological analysis. Women and Birth [Internet]. 2017;30:325–31. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1871519217300045 Dongre A, Deshmukh P, Rawool A, Garg B. Where and how breastfeeding promotion initiatives should focus its attention? A study from rural Wardha. Indian J Community Med [Internet]. 2010;35:226. Available from: https://journals.lww.com/10.4103/0970-0218.66865 Kronborg H, Væth M. How Are Effective Breastfeeding Technique and Pacifier Use Related to Breastfeeding Problems and Breastfeeding Duration? Birth [Internet]. 2009;36:34–42. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1523-536X.2008.00293.x Nduagubam OC, Ndu IK, Bisi-Onyemaechi A, Onukwuli VO, Amadi OF, Okeke IB, et al. Assessment of Breastfeeding Techniques in Enugu, South-East Nigeria. Ann Afr Med [Internet]. 2021;20:98–104. Available from: https://journals.lww.com/10.4103/aam.aam_22_20 Mbada CE, Olowookere AE, Faronbi JO, Oyinlola-Aromolaran FC, Faremi FA, Ogundele AO, et al. Knowledge, attitude and techniques of breastfeeding among Nigerian mothers from a semi-urban community. BMC Res Notes [Internet]. 2013;6:552. Available from: https://bmcresnotes.biomedcentral.com/articles/10.1186/1756-0500-6-552 Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1SummaryofReviewedStudiesEvidenceTable.xlsx Cite Share Download PDF Status: Published Journal Publication published 03 Feb, 2026 Read the published version in International Breastfeeding Journal → Version 1 posted Editorial decision: Revision requested 24 Nov, 2025 Reviews received at journal 05 Nov, 2025 Reviews received at journal 29 Oct, 2025 Reviewers agreed at journal 11 Sep, 2025 Reviewers agreed at journal 08 Sep, 2025 Reviewers invited by journal 15 Aug, 2025 Editor assigned by journal 31 Jul, 2025 Submission checks completed at journal 31 Jul, 2025 First submitted to journal 30 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7255627","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":494006008,"identity":"f346e24f-fab1-4358-b268-e6bb80e1c590","order_by":0,"name":"Ugochi Felicitas Oputa-Uzoukwu","email":"data:image/png;base64,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","orcid":"","institution":"University of Hull","correspondingAuthor":true,"prefix":"","firstName":"Ugochi","middleName":"Felicitas","lastName":"Oputa-Uzoukwu","suffix":""},{"id":494006009,"identity":"667fdc6d-634a-438f-a1a4-dbc1e42abd90","order_by":1,"name":"Helen Nichols","email":"","orcid":"","institution":"University of 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1","display":"","copyAsset":false,"role":"figure","size":48126,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA flow diagram for Identified studies\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7255627/v1/9e7c97fdeaf001c2c790a8d9.png"},{"id":88421592,"identity":"42a011a0-02ca-4e01-b281-84596721a3f5","added_by":"auto","created_at":"2025-08-06 09:30:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":37193,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCausal Conceptual Framework for Determinants of Exclusive Breastfeeding\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7255627/v1/0d7a9450e26801e53fa85704.png"},{"id":88422947,"identity":"2c20751a-6a90-48be-95be-107c3c0fc9f7","added_by":"auto","created_at":"2025-08-06 09:38:35","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":40241,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eActual prevalence of key breastfeeding practices (EBF, EI, STSC) across 19 studies\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7255627/v1/963802717baaa1f5eab2e2ce.png"},{"id":88421599,"identity":"6aee2a26-ad16-430a-99ab-fcac044010ff","added_by":"auto","created_at":"2025-08-06 09:30:35","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":141908,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThematic Summary of findings showing Barriers and enablers of EBF in Nigeria\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7255627/v1/41b3bf32a54d93bad716b66f.png"},{"id":102234160,"identity":"14f1f0d6-096b-41a2-80d3-08fa882b893c","added_by":"auto","created_at":"2026-02-09 16:06:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1433386,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7255627/v1/28f49fbc-19d8-45ca-918d-135a0346ef00.pdf"},{"id":88421598,"identity":"c89bdfec-3b99-4cd6-bb83-c3ba781e168d","added_by":"auto","created_at":"2025-08-06 09:30:35","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21454,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1SummaryofReviewedStudiesEvidenceTable.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7255627/v1/951e75ea856e9daf100c7f2f.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eExclusive Breastfeeding Practices and Challenges in Nigeria, Sub-saharan Africa: An Integrative Review\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eEvery infant and child has the right to good nutrition, as stated in the “Convention on the Rights of the Child” [1]. In 2022, WHO estimated that 149 million children were too short for their age, 45 million were too thin for their height, and 37 million were overweight or obese. Poor child nutrition is linked to approximately 50% of child mortality. Improving nutrition could save over 820,000 lives annually among children under five if all children aged 0-23 months received optimal breastfeeding [2].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExclusive breastfeeding is one of the most cost-effective ways to promote child health and survival. Breastmilk provides all the energy and nutrients the infant needs in the first months of life, and it continues to supply up to half or more of a child’s nutritional requirements during the second half of the first year, and up to one-third during the second year. Breastfed children tend to score higher on intelligence tests, are less likely to become overweight or obese, and have a lower risk of developing diabetes later in life. Furthermore, women who breastfeed face a decreased risk of breast and ovarian cancers [2,3]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO recommendations on breastfeeding include early initiation within one hour of birth, exclusive breastfeeding until six months of age, and continued breastfeeding until 24 months of age. However, contrary to the WHO set target of 50% of infants being exclusively breastfed for the first 6 months of life by 2025, only 38% of infants worldwide are exclusively breastfed within the first six months of life. There is a strong connection between optimal breastfeeding and the reduction of diarrhoea and pneumonia, which are the leading causes of death among children under five in developing countries [4,5]. Exclusive breastfeeding can reduce the rate of pneumonia among young infants by 15 to 23%. \u0026nbsp;Globally, in 2021, the number of childhood deaths due to diarrhoeal diseases linked to suboptimal and non-exclusive breastfeeding was 63,133 and 54,770, respectively[3]. Western Sub-Saharan Africa, South Asia, and Eastern Sub-Saharan Africa ranked as the top three regions concerning suboptimal/non-exclusive attributed deaths [6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGlobally, the promotion of optimal breastfeeding faces numerous socio-cultural barriers, along with poor policy design and weak program implementation. Evidence suggests that many women lack access to a supportive environment for breastfeeding, partly due to a lack of social support, inadequate funding, poor enforcement and monitoring of laws, and limited institutional capacity to promote and safeguard optimal breastfeeding practices [7].\u003c/p\u003e\n\u003cp\u003eIn Nigeria, infant mortality rates are alarmingly high, with one in 25 infants dying within their first month and one in 16 not surviving their first year [8]. This highlights the urgent importance of adequate nutrition and care during the critical first 1000 days of life. The 2024 Nigeria Demographic and Health Survey (NDHS) notes that only 36% of newborns are breastfed within the first hour, and 29% of children under six months are exclusively breastfed. In 2016, Nigeria recorded 22,371 deaths from diarrhoea among children under five, largely linked to poor breastfeeding practices. These practices accounted for about 56.5% of diarrhoea deaths in the late neonatal period, 39.0% during post-neonatal and infancy stages, and 22.8% in children under five. Additionally, the estimated Disability-Adjusted Life Years (DALYs) due to diarrhoea from suboptimal breastfeeding amounted to 1.9 million among children under five [6].\u003c/p\u003e\n\u003cp\u003eNigeria ranks first in deaths among children under five due to suboptimal and non-exclusive breastfeeding, followed by India and Chad [3]. Given the critical role optimal breastfeeding hold for the survival of under five children in Nigeria, this integrative review aims to examine the prevalence, characteristics, and various influences—such as individual, cultural, socio-economic, and healthcare factors—on exclusive breastfeeding (EBF), with the goal of developing effective strategies and policies to increase EBF rates and enhance public health outcomes. The main objectives are to address the following questions: “What is the prevalence of exclusive breastfeeding (EBF) and its socio-demographic characteristics in Nigeria?\" “What factors influence the decision to initiate and continue exclusive breastfeeding as recommended by WHO?\" and “What interventions are available in Nigeria to promote exclusive breastfeeding?\".\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employed an integrative literature review (ILR) to critically synthesis existing research on exclusive breastfeeding (EBF) in Nigeria, acknowledging the topic\u0026rsquo;s evolving nature. Rather than attempting to include all publications exhaustively, the ILR facilitates the critical evaluation and creative integration of diverse perspectives to generate new theoretical understandings [9,10]. This approach aligns with the view that for broad, interdisciplinary topics, a strict systematic review may be impractical, making a more flexible, narrative method preferable [10]. By incorporating both quantitative data, such as prevalence rates, and qualitative insights into participants\u0026rsquo; experiences, the review presents a comprehensive and multifaceted view of the factors influencing EBF practices in the region, thereby informing the development of tailored policies and interventions. Through this synthesis, the study not only addresses specific research questions but also reconceptualises the topic, considering emerging patterns and challenges [9,11].\u003c/p\u003e\n\u003cp\u003eThe data are from three databases: PubMed, ScienceDirect, and the University of Hull library, using search terms such as \u0026ldquo;exclusive breastfeeding practices and challenges in Nigeria\u0026rdquo; and \u0026ldquo;breastfeeding practices in Nigeria and Sub-Saharan Africa.\u0026rdquo; The searched databases, as illustrated in\u0026nbsp;[\u003cstrong\u003eFigure 1\u003c/strong\u003e] (PRISMA flow diagram), identified 1,233 results; 204 duplicates were removed, and 1,029 studies were screened based on titles and abstracts. Forty-one studies were assessed for eligibility, and only 19 studies met eligibility criteria for review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePRISMA flow diagram for Identified studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study systematically sourced data from research conducted and published between January 2013 to December 2024, aligning search criteria with research objectives and considering research period, publication date, methodology, and geographic scope. The screening process scrutinised abstracts for relevance to ensure they met the inclusion and exclusion criteria. The inclusion criteria were studies that used primary data involving women of childbearing age, mothers, healthcare workers, and family members engaged in childcare, while exclusion criteria targeted studies of secondary data review and analysis, non-English studies, those predating 2013, and studies focusing on health issues unrelated to exclusive breastfeeding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is worth noting that this article is adapted from an MSc dissertation at the University of Hull, which initially reviewed twenty-two studies identified between 13 June and 4 August 2023. However, the author refined the search terms to exclude five studies: one review study, three studies not directly aligned with EBF practices, and one study conducted in December 2012. The reviewer conducted further research and screening between 12\u0026nbsp;December\u0026nbsp;2024 and 6\u0026nbsp;January\u0026nbsp;2025, yielding a final set of nineteen studies that aligned with the predefined inclusion criteria.\u003c/p\u003e\n\u003cp\u003eFor quality appraisal, this review adopted the approach of an \u0026ldquo;own-assessment checklist\u0026rdquo; [12], arguing that critical appraisal methods may not reveal the validity of a study because several checklist limitations may affect research conduct and reporting in a journal. The primary focus here is to assess whether the reviewed studies provide accounts of the study objectives, design, participants\u0026rsquo; selection, method of data collection, analysis, and ethical considerations. Studies reveal that the structured appraisal methods employed by reviewers are insufficient criteria for excluding a paper based on quality [13]; hence, including all research helps minimize a possible source of bias rather than excluding it based only on quality [14]. The Study date and the adopted quality appraisal questions are listed in\u0026nbsp;\u003cstrong\u003e[Table 1]\u003c/strong\u003e, and the detailed responses are included in\u0026nbsp;\u003cstrong\u003e[Table 2]\u003c/strong\u003e below.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e: Adopted Quality Appraisal Checklist for Reporting Reviewed Studies\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eQuestion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 392px;\"\u003e\n \u003cp\u003eDefinition and assessment: Yes / No / Unclear\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eThe study design and approach reasons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 392px;\"\u003e\n \u003cp\u003eYes (If the choice of study design was given and explained) if it states, eg. \u0026ldquo;a case study approach was used because . . .\u0026rdquo;, \u0026ldquo;interviews were used because . . .\u0026rdquo;\u003c/p\u003e\n \u003cp\u003eNo if paper does not specify question and study design\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eThe selection of participants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 392px;\"\u003e\n \u003cp\u003eYes, if paper describes selection explicitly as eg. purposive, convenience, theoretical etc.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo if just details of participants are given\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eMethods of data collection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 392px;\"\u003e\n \u003cp\u003eYes, if details of data collection method are given eg. piloting; topic guides for interviews; number of items in a survey; use of open or closed items; validation; etc.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo if just states \u0026ldquo;focus group\u0026rdquo;, \u0026ldquo;interview\u0026rdquo; or \u0026ldquo;questionnaire\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eMethods of analysis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 392px;\"\u003e\n \u003cp\u003eYes, if details of analysis are given, eg. transcription, form of analysis (with reference), etc.\u003c/p\u003e\n \u003cp\u003eNo if just states \u0026ldquo;content analysis\u0026rdquo; or data were \u0026ldquo;analysed\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe quality appraisal checklist used in this study was adapted from \u003cstrong\u003e[12]\u003c/strong\u003e and refined to align with the research objectives and context.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e: Responses to the adopted quality appraisal questions\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"584\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eStudy Literature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eStudy Date/Year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eThe study design and approach (Yes, No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eThe selection of participants (Yes, No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eMethods of data collection (Yes, No)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eMethods of data analysis (Yes, No)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eAdamu et al. (2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eJan 01 to Sept 30, 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes (Reasons not stated)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eAkadri \u0026amp; Odelola (2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eAliyu et al. (2019)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eOctober 2017 and December 2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes (Reasons not stated)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eAmat Camacho et al. (2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eMarch, 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eAnaba et al. (2022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eSeptember 2019 to October 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eAnazonwu et al. (2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eAnyanwu et al. (2014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eAtimati \u0026amp; Adam (2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eMay 2016 and January 2017\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eBalogun et al. (2017)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eBisi-Onyemaechi et al. (2017)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eElegbua et al. (2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eJoseph \u0026amp; Earland (2019)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eJune and July 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eMohammed \u0026amp; Aliyu (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eOdu et al. (2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eOgundairo et al. (2024)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eJune 2020 to December 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eOkoroiwu et al. (2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eOlasinde et al. (2021)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e20th May 2020 and 25th June 2020\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eUgboaja et al. (2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003eYakubu et al. (2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003eNo data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 97px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 79px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 76px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eGiven the high rate of published papers on breastfeeding practices in Nigeria, the primary purpose of this review is to draw insights from both what is known and what is unknown about the topic and to provide direction on prominent, underexplored areas for further research.\u003c/p\u003e\n\u003cp\u003eThe study adheres to ethical research practices and utilises publicly accessible databases, thereby placing a significant emphasis on research integrity, transparency, confidentiality, and proper citation of sources. It is essential to note that informed consent is not applicable in this case, as the data used are secondary, publicly available, and accessible. Therefore, in accordance with the University of Hull\u0026apos;s ethical standards, approval was granted by the Faculty Research Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription of extracted Data and analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is structured on 19 reviewed studies conducted across the 36 states and the capital of Nigeria, made up of six geo-political zones, namely the North Central (NC), North-West (NW), North-East (NE), South-East (SE), South-West (SW), and South-South regions (SS). The summary of the studies is found in Supplementary Table 1, listed in alphabetical order, comprising geo-political zones, study area, setting, study methodology, socio-demographic characteristics of respondents, and study findings including EBF practice rate, Early initiation, skin-to-skin contact after birth, and continued breastfeeding up to 2 years. The study locations are as follows: NW - Sokoto (2) Kebbi (2), Zamfara, Katsina, Kano, Kaduna; NE - Borno; NC - Abuja (FCT); SW - Ogun, Lagos, Osun, Oyo (2); SE - Enugu (2), Ebonyi, Anambra;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eand SS \u0026ndash; Edo and Rivers state. The study areas were Urban = 8, Urban \u0026amp; Rural = 3, Semi-Urban = 4, Rural = 2, Non-specific wards = 1, Humanitarian = 1. Participants were recruited in various study settings, including THF = 7, THF \u0026amp; SHF = 1, PHCs = 3, Community and markets = 5, LGAs = 1, non-specific wards = 1, and MSN project Centres = 1. Fourteen papers adopted a quantitative study method: Cross-sectional Descriptive = 12 [15,16,25,26,17\u0026ndash;24] and Comparative cross sectional = 2 [27,28], Qualitative study methods were two [29,30], Mixed method were two ([31,32] and one Quasi-experimental study [33] which was a Longitudinal cohort study of two groups carried out mid pregnancy to 6 months post-partum. Across the 19 studies, a total of 7,573 participants, including mothers and infant caregivers, were included. The six studies were conducted and published between 2013 and 2018, while the 13 studies were conducted between 2019 and 2024.\u003c/p\u003e\n\u003cp\u003eData from these studies were manually reviewed and extracted into an evidence table, coded using a deductive approach, analysed and synthesised with the aid of a MS Word pre‐defined codebook and Excel spreadsheet. Drawing on Salda\u0026ntilde;a\u0026rsquo;s\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ecoding framework\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e[34], my analysis integrated prevalence rates, statistical findings, and qualitative data to interpret recurring patterns and connections in exclusive breastfeeding (EBF) practices across Nigeria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheoretical Framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research is guided by Urie Bronfenbrenner\u0026rsquo;s Socio-Ecological Model (SEM), which was developed in the 1970s and later expanded in the 1980s, and the Health Belief Model (HBM), established by Hochbaum and Rosenstock in the 1950s. These theoretical frameworks provide insights into the influence of individual, interpersonal, community, and societal factors on health behaviors, offering a comprehensive understanding of the complexities of attitudes and behaviors for effective public health interventions [35\u0026ndash;37]\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDrawing from the SEM and HBM theories, the research evaluates how various factors at different levels influence exclusive breastfeeding behaviors among mothers in Nigeria. Through the analysis of thematic content, three primary themes emerged: regional diversity, maternal influences, and societal factors. These themes are further delineated into fourteen categories and four sub-themes, enhancing the understanding of the study and its implications for breastfeeding practices in Nigeria.\u003c/p\u003e\n\u003cp\u003eThis study further proposes a causal conceptual framework building on the foundational theories of the Socio-Ecological Model (SEM) and the Health Belief Model (HBM), to explore the range of factors that influence exclusive breastfeeding (EBF) practices. These theories highlight how individual beliefs, social influences, and broader systemic conditions interact to shape maternal health behaviour. Informed by these perspectives, the framework groups the potential determinants of EBF into three main categories: Immediate, Underlying, and Basic determinants (see\u0026nbsp;\u003cstrong\u003eFigure 2\u003c/strong\u003e). This structure reflects the complex realities mothers face in Nigerian communities and helps to organise the social, cultural, and structural influences that support or hinder EBF.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAn analysis of 19 studies highlights the actual prevalence rates of key breastfeeding practices for infants aged 0\u0026ndash;6 months. Exclusive breastfeeding rates vary from 12.5\u0026ndash;73.8%, with an overall average of 46.4%. Results from 9 studies on early initiation and skin-to-skin contact for infants in the same age group range from 38.8\u0026ndash;99.3%, with a mean of 57.3% (see Fig.\u0026nbsp;3 and Supplementary Table\u0026nbsp;1). Joseph and Earland [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e] described the prevalence of EBF and early initiation as \u0026lsquo;low\u0026rsquo; without providing specific figures; however, Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e details all data for these variables.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u003c/div\u003e\n\u003cp\u003eUsing thematic content analysis, the results identified two primary themes: Socio-Contextual factors and Maternal factors. These themes were developed from five sub-themes and sixteen categories. The sub-themes are: (1) Socio-demography and economic Factors; (2) Socio-cultural influences and beliefs; (3) Healthcare access and support systems; (4) Maternal knowledge and perceptions about practice; and (5) Maternal confidence, cognitions, and barriers to EBF practice. These themes are summarised in Fig. 4, showing the Barriers and Enabling factors for EBF practice in Nigeria.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSummary of Prevalence Rate of EBF, EI and STSC Practices (%)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEBF\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEarly initiation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSTSC\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOdu \u003cem\u003eet al.\u003c/em\u003e (2016)[\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAliyu \u003cem\u003eet al\u003c/em\u003e. (2019)[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYakubu \u003cem\u003eet al.\u003c/em\u003e (2023)[\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMohammed \u0026amp; Aliyu, (2021)[\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eElegbua \u003cem\u003eet al\u003c/em\u003e. (2023)[\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAkadri \u0026amp; Odelola, (2020)[\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOkoroiwu \u003cem\u003eet al.\u003c/em\u003e (2021)[\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBalogun \u003cem\u003eet al.\u003c/em\u003e (2017)[\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOlasinde \u003cem\u003eet al.\u003c/em\u003e (2023)[\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnazonwu \u003cem\u003eet al.\u003c/em\u003e (2018)[\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnaba \u003cem\u003eet al\u003c/em\u003e. (2022)[\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAtimati \u0026amp; Adam, (2020)[\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUgboaja \u003cem\u003eet al.\u003c/em\u003e (2013)[\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdamu \u003cem\u003eet al.\u003c/em\u003e (2022)[\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOgundairo \u003cem\u003eet al\u003c/em\u003e. (2024)[\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBisi-Onyemaechi \u003cem\u003eet al.\u003c/em\u003e (2017)[\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnyanwu \u003cem\u003eet al.\u003c/em\u003e (2014)[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmat Camacho \u003cem\u003eet al.\u003c/em\u003e (2023)[\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJoseph \u0026amp; Earland (2019)[\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow EBF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLow EI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eSOCIO-CONTEXTUAL FACTOR\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocio-Demography and Economic Factors: Prevalence and Patterns\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme includes factors that positively or negatively affect EBF practices. Essential elements consist of maternal age, education, occupation and income, parity, and marital status.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMaternal Age\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere is a significant link between breastfeeding self-efficacy and maternal age[\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. Higher exclusive breastfeeding (EBF) rates were observed among older mothers (aged 31 and above) compared to those aged 30 and below [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, delayed breastfeeding initiation was more common in mothers aged 20 years and below. However, a few studies have noted a decline in EBF practice with increasing maternal age in the 20\u0026ndash;29 age group [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMaternal Education Levels\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMaternal level of education showed a strong link with exclusive breastfeeding (EBF) practice among mothers with higher education levels. Mothers with tertiary education had significantly better knowledge, practice, and acceptance of EBF, and likely to practice EBF [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Other studies indicate that mothers with more formal education are more likely to practice EBF [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e], with one study reporting a significant effect (p\u0026thinsp;=\u0026thinsp;0.003)[\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, one study found that while EBF was more common among younger women (under 35) and those with more than primary education, maternal age and education level were not significant determinants of EBF practice [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMaternal Occupation, Employment and Income Status\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMaternal occupation, employment and income status were identified in 11 of the 19 reviewed studies as influencing exclusive breastfeeding practices. Several studies highlighted maternal occupation as a key factor, with the type of job impacting both the start and continuation of breastfeeding. Jobs in the formal sector, such as health workers, teachers, and business owners, were more positively linked to EBF [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. Similarly, maternal occupation predicted breastfeeding self-efficacy and initiation [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. Conversely, Civil servants faced high work-related pressure, with 19.9% and 61.8% of mothers respectively citing job demands as reasons for stopping EBF [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Employment-related issues, especially short maternity leave and early return to work, were often identified as obstacles to exclusive breastfeeding (EBF). Multiple studies indicated that mothers returning to work soon after childbirth faced significant challenges in maintaining EBF. In one study, 17.7% of employed mothers stopped EBF due to limited maternity leave [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. Another study, reported that 88.5% of mothers who did not return to work early successfully practiced EBF, whereas only 11.5% did not [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore, early re-entry into the workforce was a common barrier [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. Income level and employment status influence EBF behaviours. The review showed that many mothers who were artisans or traders earned less than the \u003cspan\u003e$\u003c/span\u003e20 monthly minimum wage and had lower breastfeeding self-efficacy [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. Conversely, employment isn\u0026apos;t always a negative factor as employed mothers, including those in low-income households and on-site jobs, showed higher rates of early breastfeeding initiation [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. Additionally, some evidence indicates that unemployment can support EBF. One study noted that unemployed mothers practiced EBF more often than civil servants, with a significant difference (p\u0026thinsp;=\u0026thinsp;0.007) [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMarital factors\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMarital dynamics like polygyny, early marriage, and domestic violence as barriers to EBF, noting that spouses often influence decisions to start or continue breastfeeding [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Meanwhile, one study observed that marital status positively affects EBF practice [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. These opposing findings emphasize the complexity of marital roles and suggest a need for further investigation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParity\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis variable is important, especially since the reviewed studies include both primiparous and multiparous mothers, offering different views on childbearing and infant nutrition challenges. Notably, only one study reported that parity influenced early breastfeeding initiation, with some first-time mothers delaying initiation due to traditional practices [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. Meanwhile, a mother\u0026apos;s ability to breastfeed may change over time, often declining with age and the number of births, as they could breastfeed their first children but faced difficulties with subsequent ones[\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Across 11 studies reporting participants\u0026apos; parity, only three studies documented an EBF practice rate of over 40% [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. This suggests that parity might have a complex, context-dependent impact on exclusive breastfeeding, warranting further research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocio-Cultural Influences and Beliefs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme emphasizes the influences of community, family, friends, and beliefs on infant feeding, including personal anxiety, cultural, traditional, and religious practices, which determine infant feeding behaviours.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFamily and Social support\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMothers\u0026rsquo; exclusive breastfeeding (EBF) practices are strongly influenced by both internal and external family members, as well as broader social networks. Several studies have identified family support as a positive factor; encouragement from family and friends significantly predicts successful EBF [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Similarly, one study emphasized the critical role of spousal support in promoting breastfeeding [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Conversely, some research highlights family dynamics as barriers; family approval can support EBF, and the lack of family or social support can hinder it [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. One study observed that larger families (more than four members) often motivated EBF due to resource constraints, yet mothers also faced pressure from relatives to choose other feeding options [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Other studies mentioned direct barriers such as spousal disapproval [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e], grandmother\u0026rsquo;s refusal [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e], and the absence of supportive family structures [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Additionally, another study pointed out that family members\u0026apos; decisions and partners\u0026rsquo; knowledge of breastfeeding benefits are crucial, with insufficient support ultimately limiting EBF adherence [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBeliefs on infant feeding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral studies reveal a common perception that breastmilk alone isn\u0026apos;t enough; many believe infants need water or other liquids for hydration or nutrition. Mothers worry about babies appearing weak, losing weight, or feeling thirsty, leading them to introduce water or herbal mixtures early [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. While some mothers feared conditions like sunken fontanels or illness, which they thought breastmilk couldn\u0026apos;t prevent [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. Socio-cultural beliefs, traditional practices, and gender norms significantly influence infant feeding behaviours. Beliefs that infants, especially boys, need more breastfeeding and extra liquids; breastmilk perceived as inadequate or unnecessary, prompting early use of complementary feeds [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. One study identified delays in breastfeeding related to infant uvulectomy and the infant\u0026rsquo;s gender\u0026mdash;three days for boys and four for girls. Postpartum practices included herbal treatments applied to the breast for two days and a 40-day period of maternal bathing, which, while culturally important, often delayed early breastfeeding [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. Although breastfeeding was viewed as a cultural obligation, community norms often disrupted exclusive breastfeeding by delaying initiation for three to four days and giving other liquids, especially during maternal or infant health issues. Traditional healers sometimes advised mothers to stop breastfeeding under conditions like HIV, mastitis, or multiple births, further discouraging or preventing EBF[\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Additionally, another study reported that fears of infants rejecting other foods later discouraged some mothers from practicing EBF [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. While culture and illiteracy were linked to adverse EBF outcomes, religion and literacy positively influenced breastfeeding practices [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHEALTHCARE ACCESS AND SUPPORT SYSTEMS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme explores how access to healthcare services affects mothers\u0026apos; health-seeking behaviours related to exclusive breastfeeding (EBF). It covers aspects such as lactation support, the use of health facilities for Antenatal and Postnatal Care (ANC/PNC), and childbirth practices.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBreastfeeding support\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSupportive interactions with healthcare providers positively affect exclusive breastfeeding (EBF) practices among mothers[\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, several studies emphasized the importance of healthcare support through prenatal and postnatal follow-ups [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. Their intervention study revealed that ongoing healthcare engagement notably extended EBF duration, with 43.2% of mothers in the intervention group maintaining EBF at six months postpartum, compared to 22.9% in the control group, highlighting the benefits of continuous breastfeeding support. However, the success of professional breastfeeding support varies by setting. In a cross-sectional study, mothers visited by lactation experts had a lower exclusive breastfeeding rate (6.4%) than those with no contact with such experts (29%)[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAntenatal and postnatal care (ANC/PNC) engagement\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOf the 19 studies examined, 11 focused on maternal involvement in antenatal and postnatal care (ANC/PNC). Most studies addressed ANC attendance, while two looked at PNC use, and two reported minimal or no engagement with either service. High ANC (97.2%) and PNC (91.7%) attendance positively influenced exclusive breastfeeding (EBF) practices [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. Similarly, the ANC attendance rate of 98.8%, which significantly impacted EBF outcomes (p\u0026thinsp;=\u0026thinsp;0.0001), mainly through prenatal and postnatal infant feeding education [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. Mothers\u0026apos; proximity to health facilities was linked to higher EBF rates, whereas limited access to functional healthcare facilities hindered effective EBF, emphasizing the need for accessible health infrastructure [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. One study reported that mothers attending ANC four or more times were more likely to initiate breastfeeding early and maintain EBF [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, one study reported that 78.3% of mothers received EBF guidance from health workers during ANC and PNC visits, highlighting the importance of health personnel in providing consistent breastfeeding education through routine ANC and PNC [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. Though mothers who received ANC from traditional birth attendants (TBAs) also showed early initiation, this subgroup was small and warrants cautious interpretation. Conversely, one study documented limited ANC engagement, but counselling from healthcare workers and TBAs still promoted early initiation and EBF, despite overall low EBF rates. A few mothers also recalled receiving advice on colostrum\u0026apos;s benefits during their ANC visits [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePlace and mode of birthing or delivery\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHospital-based delivery and vaginal birth consistently correlate with better exclusive breastfeeding (EBF) outcomes across multiple studies. The facility type for ANC and delivery showed a significant link to EBF at six months (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001 for ANC; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004 for delivery). Likewise, hospital birth (P\u0026thinsp;=\u0026thinsp;0.004) positively impacted EBF through access to prenatal and postnatal feeding advice [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. Hospital delivery was also significantly associated with greater breastfeeding knowledge (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), supporting informed EBF practices [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. Mothers who delivered in hospitals were more likely to start breastfeeding earlier than those delivering at home [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. Regarding delivery methods, vaginal delivery is a predictor of breastfeeding self-efficacy, including both initiation and continuation of EBF [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. One study found that 67.5% of mothers had vaginal deliveries, and 61.3% delivered in hospitals [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Both factors were positively linked to EBF practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMATERNAL KNOWLEDGE AND PERCEPTION OF PRACTICE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme highlights how maternal knowledge, awareness, and perceptions impact exclusive breastfeeding (EBF) practices. It also shows how understanding breastfeeding guidelines, beliefs about the benefits of colostrum and breastmilk, and sources of health information influence maternal choices.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBreastfeeding Awareness\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAcross the reviewed studies, sufficient knowledge and positive perceptions of exclusive breastfeeding (EBF) consistently correlated with better practices. Mothers who understood breastfeeding benefits and accurately knew the guidelines were more likely to start breastfeeding early and maintain EBF [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. Despite widespread awareness, some studies revealed gaps; one study found that 72.2% of mothers knew about EBF, but only 27.8% practiced it, often due to limited understanding of its importance [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. Another study reported similar issues among female medical practitioners: while 95.1% had general awareness, only 52.1% could define EBF correctly [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Also, noted that knowledge gaps among female healthcare workers constrained consistent practice [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eColostrum and Breastmilk Perception\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePerceptions of colostrum and breastmilk shape behaviour. Some mothers and caregivers viewed colostrum as harmful or dirty, leading to its rejection, especially among first-time mothers or those who experienced infant loss. In these cases, breastmilk was often discarded, replaced with herbal mixtures, or breastfeeding was delayed until older relatives or traditional attendants gave their approval [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e[One study highlighted that \u003cem\u003e\u0026ldquo;the perceptions of colostrum as bad were a major influence on practice,\u0026rdquo; noting that, \u0026ldquo;among mothers who had previously experienced neonatal or infant mortality, the child\u0026rsquo;s death was often attributed to \u0026lsquo;poisonous\u0026rsquo; breastmilk. As a result, many of these mothers either refused or were pressured to stop breastfeeding subsequent children\u0026rdquo;.\u003c/em\u003e[\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e] \u003cem\u003e]\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[Similarly, another study reported that \u0026ldquo;among first-time mothers, colostrum was perceived as \u0026lsquo;dirty,\u0026rsquo; with concerns that a baby can contract diseases from it. A few took herbs to make the perceived bad milk good for the baby, while a new mother\u0026rsquo;s breast milk must be \u0026lsquo;checked\u0026rsquo; by a grandmother or a Traditional Birth Attendant before breastfeeding. In subsequent birthing, colostrum was not discarded.\u0026rdquo;\u003c/em\u003e [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003cem\u003e]\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast, mothers who understood the nutritional benefits of colostrum were more likely to start exclusive breastfeeding (EBF) early and maintain it. Additionally, women with greater awareness of EBF and its benefits were more inclined to initiate breastfeeding promptly and continue the practice [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHealth information source\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong the studies reviewed, health workers were the most frequently cited source of breastfeeding information. An impressive 92.7% of respondents reported learning about exclusive breastfeeding (EBF) from health professionals [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. A study found that women who obtained EBF information from mass media were significantly more likely to practice EBF for six months than those who relied on other sources. The study also emphasized the combined role of health workers and mass media in promoting EBF[\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. There is a wider array of information sources, including media, health facilities, NGOs, and community channels [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Conversely, in areas where institutional delivery was less common, such as among women delivering at home, breastfeeding guidance mainly came from traditional birth attendants or elder family members like grandmothers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMATERNAL CONFIDENCE, COGNITIONS, AND BARRIERS TO EBF PRACTICE.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme reflects the mother\u0026rsquo;s personal beliefs, motivations, and ability to practice exclusive breastfeeding (EBF). It encompasses exposure to specific interventions, self-confidence, maternal intentions, health status, worries about body image, breastfeeding requirements, lactation challenges, and infant feeding problems.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMaternal Motivations and Intentions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral studies have shown that targeted interventions effectively promote exclusive breastfeeding (EBF). Community efforts supported by non-governmental organisations like M\u0026eacute;decins Sans Fronti\u0026egrave;res (MSF) have positively influenced EBF rates. [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Studies emphasise the importance of ongoing Social and Behaviour Change (SBC) programs in encouraging exclusive breastfeeding (EBF). Visual cues, like pictures of healthy EBF infants, further boost mothers\u0026rsquo; motivation to sustain the practice. Additionally, a two-week drama-based intervention before childbirth, combined with postpartum follow-ups, proved effective in supporting continued EBF [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eMother\u0026apos;s self-efficacy is vital for maintaining exclusive breastfeeding (EBF). In IDP settings, the lack of trained lactation support staff hampers mothers\u0026rsquo; ability to practice EBF effectively, emphasising the importance of MSF Breastfeeding support in enhancing maternal confidence. [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Self-motivation plays a crucial role in EBF; mothers with greater confidence tend to engage more actively EBF[\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. A mother\u0026rsquo;s intention to breastfeed exclusively is a strong predictor of her actual breastfeeding behavior and positively impacts her chances of success. [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMaternal Cognitions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNumerous studies have highlighted concerns about body image and physical changes associated with breastfeeding. Some mothers are concerned about breast sagging, and anxieties about body shape often discourage them from initiating or maintaining exclusive breastfeeding (EBF). Fear of bodily changes acts as a common mental barrier to EBF. Additionally, social and emotional factors contribute to these concerns [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Some mothers discontinued exclusive breastfeeding after becoming pregnant again or avoided breastfeeding in public because of shame or stigma. [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Infant-related issues include reluctance to breastfeed and delayed lactation. [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e], early or natural discontinuation [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e], and frequent crying [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e], causing distress and uncertainty, lowering mothers\u0026rsquo; confidence in continuing EBF. Mothers\u0026rsquo; personal opposition to EBF discouraged its practice, describing it as physically demanding and stressful [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. Mothers associate the perceived difficulty and time-consuming nature of EBF, along with sleepless nights, with early discontinuation, which discourages continued EBF practice [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBreastfeeding barriers\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eVarious physical health factors, such as maternal illness [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e] and postnatal complications, directly impede exclusive breastfeeding (EBF) by affecting a mother\u0026rsquo;s capacity to initiate or sustain breastfeeding. In more severe cases, these health issues led to early cessation of EBF or necessitated alternative feeding options, like using wet nurses\u0026mdash;particularly in instances of maternal death [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Breastfeeding challenges like lactation issues, low milk supply, and feeding difficulties greatly affected exclusive breastfeeding (EBF). A crucial predictor of successful EBF was the \u0026apos;absence of lactation problems.\u0026apos; Nipple pain is a common obstacle that can discourage some mothers from continuing EBF [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. Poor knowledge of proper breastfeeding technique (positioning and attachment) contributed to lactation issues, affecting mothers\u0026apos; decisions to start or continue EBF[\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Actual low milk supply, rather than perceived insufficiency, was identified as a common challenge that hindered mothers from maintaining EBF [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. Mothers\u0026rsquo; worries about infant illness or malnutrition often originated from their personal experiences of inadequate milk supply. [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis integrative review aimed to determine the prevalence of exclusive breastfeeding (EBF) in Nigeria and examine the socio-demographic, cultural, and systemic factors influencing maternal feeding decisions. Drawing on nineteen studies across all six geopolitical zones, two primary themes \u0026mdash; socio-contextual factors and Maternal factors \u0026mdash; framed the review. The discussion follows thematic categories, allowing for a deeper contextual interpretation.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatterns in EBF prevalence and Socio-demographic determinants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEBF rates across the reviewed studies ranged from 12.5% in humanitarian or rural contexts [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] to 73.8% in urban, facility-based studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], with an overall mean of 46.4%. This reflects some progress toward the WHO 2025 target (50%) but still falls short of the SDG 2030 goal (60%) and the global average of 48% [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. These variations point not only to methodological diversity but to underlying structural inequities in health infrastructure, socioeconomic conditions, and maternal support systems in Nigeria. Broader literature has also cautioned that definitional inconsistencies, such as what qualifies as \"exclusive\" and \u0026ldquo;early initiation,\" can misrepresent breastfeeding levels, reinforcing the need for context-specific interpretations of prevalence data [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMaternal age emerged as a recurrent, though inconsistent, predictor. Older mothers (\u0026ge;\u0026thinsp;30 years) were more likely to maintain EBF, probably due to experience and confidence [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], while younger mothers (20\u0026ndash;30 years) also showed favourable practices when supported [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, other studies suggest that age alone cannot determine practice variation, as it often intersects with counselling exposure, work demands, and family roles [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Additionally, sampling bias, such as the overrepresentation of specific age groups in some studies, may have influenced the observed associations.\u003c/p\u003e\u003cp\u003eEducational qualification also demonstrated mixed influence. While several studies reported that tertiary education correlated with improved EBF knowledge and practice [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], others reported no apparent effect [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and in a similar study conducted in Cameroon, higher education was associated with earlier cessation [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. These contradictions suggest that knowledge alone is insufficient unless an enabling environment supports it. Education may empower, but it can also expose mothers to competing pressures such as career demands or social acceptance of formula feeding.\u003c/p\u003e\u003cp\u003eOccupational status and employment structure played a nuanced yet influential role in shaping EBF. While formal employment, particularly in education and health sectors, was associated with higher breastfeeding knowledge and uptake [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], rigid schedules and limited maternity leave in formal roles often constrained sustained practice [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These constraints were particularly evident among civil servants and professionals who returned to work shortly after childbirth. By contrast, mothers earning low incomes in informal or site-based roles sometimes maintained better EBF continuity, likely due to greater job flexibility [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This suggests that a flexible, supportive work environment is more crucial to a mother\u0026rsquo;s decision to practice EBF than income alone. It also implies that employment structures such as maternity leave policies and work flexibility have a significant impact on overall breastfeeding behaviour.\u003c/p\u003e\u003cp\u003eMarital status and parity showed similarly nuanced effects. While marriage often offered support [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], some dynamics, including early marriage, polygyny, and male-dominated decision-making, hindered mothers from making informed breastfeeding decisions [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Parity, too, presented inconsistencies: first-time mothers delayed breastfeeding due to traditional constraints [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], while multiparous women cited fatigue and shifting priorities [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These findings suggest that both marital status and parity operate through layered social and relational mechanisms.\u003c/p\u003e\u003cp\u003eOverall, socio-demographic variables such as age, education, employment, and marital status should not be misreported or misinterpreted as fixed indicators of breastfeeding behaviour. Instead, they often reflect bigger systems of support or barriers affecting mothers differently depending on issues like healthcare access, family roles, culture, and gender expectations. Methodological differences across studies, particularly on how participants were selected, also influenced observed prevalence patterns, showcasing the need for a subtle analysis based on context. To improve EBF outcomes in Nigeria, future interventions must move beyond demographic profiling and engage with the deeper structural realities shaping maternal choices.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSocio-Cultural Beliefs and Practices\u003c/b\u003e\u003c/p\u003e\u003cp\u003eExclusive breastfeeding (EBF) decisions are rarely made by mothers alone. Instead, they are negotiated within a broader socio-cultural ecosystem involving spouses, elders, extended family members, and wider community expectations. Family support was positively linked to EBF practice [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], while disapproval from partners [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], grandmothers [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], or the absence of supportive networks [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] often undermined maternal intent, revealing the ambivalent nature of social influence. In many settings, elderly women assume authority during postpartum care and infant feeding, highlighting the need to consider influential community actors in maternal health efforts.\u003c/p\u003e\u003cp\u003eCultural interpretations of infant well-being further shaped feeding behaviours. Perceptions that breastmilk alone is insufficient and infants require water or other feeds [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] are usually due to fears of dehydration, weakness, or sunken fontanels [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], prompting early introduction of fluids or traditional remedies. These beliefs, while medically inaccurate, come from a genuine maternal concern often reflected in context-specific logics in hot climates where infant distress is readily attributed to thirst or hunger. Furthermore, there is a widespread notion that all living things require water to grow, reinforcing the perception that EBF is a modern or \u0026ldquo;Western\u0026rdquo; practice [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], despite traditional breastfeeding customs often aligning with WHO guidelines in practice.\u003c/p\u003e\u003cp\u003eThis highlights a knowledge gap among mothers regarding the broader biomedical evidence in the literature, indicating that breastmilk comprises 87\u0026ndash;88% water and supplies complete nutrition [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Additionally, definitional inconsistencies, such as whether giving plain water disqualifies EBF, complicate cross-cultural comparisons of EBF data [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In many households, traditional knowledge systems retain stronger credibility than biomedical advice.\u003c/p\u003e\u003cp\u003eTraditional healers also shape practices by advising cessation of breastfeeding in cases such as maternal illness, HIV, or multiple births [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Additionally, rituals such as infant uvulectomy or postpartum seclusion periods delay initiation and disrupt early feeding [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These findings suggest that beliefs surrounding EBF are not merely \u0026ldquo;barriers\u0026rdquo; but part of dynamic care systems, in which authority, tradition, and local logics shape maternal choices.\u003c/p\u003e\u003cp\u003eA recurring issue across the literature is that most interventions target mothers directly through health facilities, often overlooking the wider social actors who significantly shape infant feeding decisions. This narrow focus reveals a critical gap: without engaging those who hold decision-making power within caregiving networks, improving maternal knowledge alone may not lead to sustained behavioural change.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHealthcare Access and Support Systems\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEvidence from multiple studies suggests that the use of health facilities and the support and interactions of health workers positively influence EBF practice [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], highlighting the importance of consistent breastfeeding support over time [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In contrast, visits from lactation experts yielded lower practice rates [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], suggesting that outcomes may vary depending on the study context and other behavioural factors, as well as culturally appropriate counselling. Proximity to health facilities was associated with higher EBF rates[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], while limited access to functional healthcare facilities was a barrier [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], pointing to the need for adequate and accessible health services, especially for mothers in under-represented areas.\u003c/p\u003e\u003cp\u003eSimilarly, studies revealed that attendance or engagement with antenatal care (ANC), either in a hospital setting [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] or with traditional birth attendants [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], had a significant influence on the timely and early initiation of breastfeeding. This suggests that experiences within the health system shape maternal health behaviours and practices. This is corroborated by more extensive data from Rwanda [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], which demonstrated that mothers who gave birth in a hospital had a higher chance of receiving immediate obstetric and postnatal care, as well as breastfeeding education on topics such as benefits, proper positioning, attachment, and breast care. This improved their ability to initiate and sustain EBF.\u003c/p\u003e\u003cp\u003eThis review also found that the place and mode of birthing, mostly hospital-based and via vaginal delivery, contributed to improved EBF practices and outcomes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This may be linked to the prenatal and postnatal feeding advice that mothers received while at health facilities. On the other hand, mothers\u0026rsquo; perception that pain or complications from caesarean delivery limited skin-to-skin contact and early breastfeeding initiation could lead to delayed lactation and the early introduction of other liquids, ultimately discouraging sustained EBF practices.\u003c/p\u003e\u003cp\u003eIn addition, several studies highlighted the role of health workers during antenatal and postnatal care [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and mass media [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] as significant sources of breastfeeding information. These findings suggest the combined influence of both the Socio-Ecological Model (SEM) and the Health Belief Model (HBM) in shaping health behaviours at the individual and community levels.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaternal Knowledge and Perception to Practice\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMaternal knowledge, awareness level, and perception regarding EBF, its nutritional benefits, and the value of colostrum are strong determinants of early initiation and sustained practice [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, these findings also reveal that awareness alone does not guarantee adherence. High awareness levels of EBF did not necessarily translate into practice[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This gap appears to stem from superficial understanding: knowing the term \"exclusive breastfeeding\" without grasping its full definition or implications[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMisconceptions surrounding colostrum further demonstrate how cultural beliefs mediate maternal knowledge. Several studies have found that colostrum is often perceived as \u0026ldquo;bad milk\u0026rdquo; and discarded, particularly among first-time mothers and in lower-income settings [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These perceptions undermine optimal EBF practices, indicating that awareness campaigns must not only convey facts but also address deeply rooted beliefs.\u003c/p\u003e\u003cp\u003eThis implies that actionable advice is still lacking even when informational awareness is highlighted. These results highlight the urgent need for comprehensive, culturally aware breastfeeding instruction that gives mothers confidence and valuable skills in addition to educating them. More than just knowledge is needed to close the knowledge-practice gap; women must be empowered to overcome perceived and actual barriers, and misunderstandings must be dispelled.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaternal Confidence and Cognitions to EBF Practice.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOut of the 19 reviewed studies, three provided evidence that targeted interventions such as community and health facility-based support from M\u0026eacute;decins Sans Fronti\u0026egrave;res (MSF) in a humanitarian context [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], Social and Behaviour Change (SBC) programmes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and drama viewing combined with prenatal and postnatal follow-up [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] are effective motivators for improved EBF outcomes. In other studies, not part of the initial review, the Baby-Friendly Hospital Initiative (BFHI), a notable global intervention, has shown slow progression since being adopted by tertiary health facilities in Nigeria [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. However, when introduced, the findings show higher rates of exclusive breastfeeding at 49% and any breastfeeding at 66% within the ten recommended steps of breastfeeding support. Despite these examples, a notable gap remains in the scholarship on evaluating breastfeeding interventions and their direct effects on exclusive breastfeeding outcomes in Nigerian studies.\u003c/p\u003e\u003cp\u003eWhile a mother\u0026rsquo;s positive intention often predicts actual practice [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], her motivation and confidence to practice are sustained by feelings of self-efficacy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This supports a broader idea in the Health Belief Model (HBM) framework, which posits that EBF practice, like other health behaviours, is essentially a personal choice [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Beyond the reviewed studies, a case study in Australia [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] suggests that most mothers are not only knowledgeable and intentional about EBF but are also driven by self-determination, which fosters optimism and confidence in initiating and sustaining EBF for up to six months. In internally displaced persons (IDP) settings, the limited availability of health workers to support EBF [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] indicates a contextual environmental influence. Within such contexts, the Socio-Ecological Model (SEM) offers further insight into how multiple levels of influence shape health behaviours. To date, these observations suggest the need for additional research on intervention-based EBF practices among mothers in Nigeria.\u003c/p\u003e\u003cp\u003eHowever, studies also indicate that specific barriers and concerns undermine maternal confidence. For instance, postnatal illness was reported as a challenge to EBF [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], alongside worries over body shape [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and breast sagging [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These findings suggest the need for improved maternal care and mental health support to sustain breastfeeding efforts. Other studies reported that mothers stopped EBF while avoiding breastfeeding in public due to being ashamed [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], reflecting the barriers to practice caused by societal pressures and stigma. These further details show how most public infrastructures and organisations in Nigeria do not have designated facilities or private structures to support nursing mothers to breastfeed their babies while in public. Other studies, not part of the initial review, provide additional insight into this barrier; however, they also highlight the cognitive response of \u0026lsquo;not flashing\u0026rsquo; as well as respecting other spaces by always covering up with a blanket and being discreet while breastfeeding in public [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. This further suggests that maternal intentions and adaptability usually supersede pressures when it comes to perceived need for infants\u0026rsquo; health.\u003c/p\u003e\u003cp\u003eSome mothers ceased EBF upon becoming pregnant again[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Aside from this, societal stigma is sometimes associated with the myth that breastfeeding during pregnancy negatively affects the nursing child\u0026rsquo;s development, such as delayed walking or speech or even other social interactions. This highlights a critical knowledge gap within communities and points to the need for clearer public education on infant and child feeding practices within specific social and cultural contexts.\u003c/p\u003e\u003cp\u003eMothers also reported discontinuing EBF due to discomfort or shame associated with breastfeeding in public [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], reflecting how societal pressures and stigma function as barriers. This illustrates a broader infrastructural issue, where most public spaces and organisations in Nigeria lack designated facilities or private areas for nursing mothers. Additional literature, although not part of the initial review, provides further insight into this challenge, highlighting coping mechanisms such as discreet breastfeeding and covering with a blanket to avoid \u0026ldquo;flashing\u0026rdquo; or violating social norms [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. These responses indicate that maternal intentions and adaptability can, at times, override public pressures, particularly when guided by the perceived health needs of the infant.\u003c/p\u003e\u003cp\u003eMoreover, the reviews identified the intensity of the practice itself as a deterrent. Several studies reported EBF to be stressful[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], intensive [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and physically demanding [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], all of which contribute to discontinuation among some mothers. These findings suggest the need for continuous health education and support, as well as policies that promote and facilitate the practice of EBF for mothers.\u003c/p\u003e\u003cp\u003eAdditionally, breastfeeding challenges such as perceived low milk supply [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], nipple pain [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003cb\u003es\u003c/b\u003e, and delayed milk onset [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] were commonly reported barriers to sustained EBF. In contrast, the absence of such lactation difficulties was significantly associated with higher rates of EBF [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], indicating that these challenges are not solely physiological; they often reflect a broader gap in maternal support and practical breastfeeding guidance. For example, inadequate instruction on proper positioning and latching contributed to feeding difficulties[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEvidence from studies in India and Denmark [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] reinforces that breastfeeding technique training is essential in preventing early cessation. Similarly, other Nigerian studies [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] emphasise the role of technique in sustaining EBF, yet such support was rarely addressed in the reviewed interventions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and Limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, this review is the first of its kind to integrate quantitative, qualitative, and mixed studies, as well as studies in developed and less developed areas (rural and humanitarian settings), making it unique in providing an exhaustive insight into the state of EBF in Nigeria. This provides opportunities for general recommendations on intervention and further research to inform policy, practice, and impact.\u003c/p\u003e\u003cp\u003eOn the other hand, the review also has some weaknesses. First, it has been conducted by a lone reviewer, which creates the risk for potential researcher bias in the selection of studies and data interpretation. This limitation was mitigated by adopting a self-assessment approach for quality appraisal, which provided a grounded summary and critique of the relevant literature in response to the research questions.\u003c/p\u003e\u003cp\u003eAdditionally, the 19 studies reviewed present reports on the six geopolitical zones of Nigeria, which comprise 36 states and the Federal Capital Territory; however, the evidence primarily reflects 15 states and the FCT, with limited data or literature available on the other states. Although all the zones are duly represented, this may affect the generalisability of facts since evidence from other states was not represented.\u003c/p\u003e\u003cp\u003eOther limitations were from the reviewed studies which are listed in the table, and include a lack of in-depth insight based on study designs, issues with generalisability due to study setting, and inconsistent presentation of variables and interpretation for missing or excluded responses in the result tables [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] within the socio-demography and health facility use, for instance, marital status, parity, mode and place of birthing, and ANC and PNC attendance, which are likely to indicate barriers for mothers to practice EBF. Another limitation is that studies had limited data on key EBF practices such as skin-to-skin and early initiation and exclusion of data regarding any EBF health outcomes for both mother and infant and interventions, which reduces the ability to generalise on prevalence rates and factors influencing the mother\u0026rsquo;s decision to initiate and continue EBF practice.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecommendations for Policy and Practice\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo strengthen exclusive breastfeeding (EBF) in Nigeria, policymakers should expand and improve antenatal and postnatal care (ANC/PNC) and community‑based breastfeeding support, particularly in underserved areas such as rural communities and IDP camps.\u003c/p\u003e\u003cp\u003eAdditionally, National surveys and health information systems should adopt a single, standardised definition of EBF and early initiation to ensure consistent monitoring and evaluation against WHO and SDG targets.\u003c/p\u003e\u003cp\u003eFurthermore, interventions should be designed to reflect community realities by involving key stakeholders, such as spouses, elders, and traditional leaders, and integrating breastfeeding support into broader family and community systems. Health facilities can complement this by publicising peer‑mentor schemes, creating private lactation spaces, and training staff in culturally sensitive counselling. Workplace policies must also evolve to support lactating mothers through extended maternity leave, flexible schedules, and breastfeeding-friendly environments.\u003c/p\u003e\u003cp\u003eFinally, the ministries of health and their related partners should invest in robust monitoring and evaluation systems that link EBF practices to maternal-child health outcomes, ensuring that programmes are continually refined based on real-world evidence.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFuture Research\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo address the methodological gaps in the EBF literature in Nigeria, future studies should employ qualitative, mixed-method, and intersectional designs to capture mothers\u0026rsquo; in-depth experiences beyond the constraints of Likert-scale surveys, which often fail to capture the complexity of maternal behaviours and challenges. There is a need for further research to consistently collect and report on key variables like skin‑to‑skin contact, early initiation, parity, delivery mode and place, and both antenatal and postnatal care attendance, alongside socio‑demographic and economic indicators such as age, education, occupation, income, religion, ethnicity, and marital status. These approaches will provide a richer understanding of the socio-contextual realities that influence maternal decisions.\u003c/p\u003e\u003cp\u003eClear operational definitions of \u0026ldquo;exclusive breastfeeding\u0026rdquo; and transparent data‑handling procedures (including justifications for exclusions and methods for addressing missing values) are essential to improve comparability and credibility across studies.\u003c/p\u003e\u003cp\u003eLongitudinal and intervention-based studies should be urgently adopted to assess both short- and long-term outcomes of EBF on maternal and child health in Nigeria. Evaluating the effectiveness and scalability of culturally tailored interventions will provide actionable insights for programme design. Priority must be given to under‑represented contexts (rural, humanitarian settings, IDP camps) to ensure findings reflect the full diversity of Nigerian mothers. Finally, building national research capacity through training, standardised methodologies, and institutional support will strengthen the quality and policy relevance of future EBF research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis review enhances the existing literature by providing a context-sensitive, multi-dimensional analysis of EBF practices in Nigeria. It shows a notable increase in EBF adoption and practice in both urban and rural areas. Despite high awareness levels, systemic and relational barriers hinder the sustained practice of EBF. The decision to start and continue EBF varies, influenced by socio-cultural and maternal factors. The review also points out research gaps, such as limited involvement of fathers, informal caregivers, and mothers in displaced or rural settings. It emphasizes the importance of equity-focused policies and interventions that go beyond individual awareness to address structural factors enabling maternal health and breastfeeding.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ante-natal care\u003c/p\u003e\n\u003cp\u003eBF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Breastfeeding\u003c/p\u003e\n\u003cp\u003eBFHI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Baby-Friendly Hospital Initiative\u003c/p\u003e\n\u003cp\u003eCBF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Continued Breastfeeding (up to two years old)\u003c/p\u003e\n\u003cp\u003eCGs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Caregivers\u003c/p\u003e\n\u003cp\u003eEI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Early initiation immediately or few hours after birth\u003c/p\u003e\n\u003cp\u003eEBF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Exclusive breastfeeding\u003c/p\u003e\n\u003cp\u003eFCT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Federal Capital Territory\u003c/p\u003e\n\u003cp\u003eHCWs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health care workers\u003c/p\u003e\n\u003cp\u003eHF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health Facility\u003c/p\u003e\n\u003cp\u003eHV \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hospital visits\u003c/p\u003e\n\u003cp\u003eHWs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health Workers\u003c/p\u003e\n\u003cp\u003eLGA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Local Government Area\u003c/p\u003e\n\u003cp\u003eNEBF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Not exclusively breastfed\u003c/p\u003e\n\u003cp\u003eNDHS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Nigerian Demographic and Health Survey\u003c/p\u003e\n\u003cp\u003ePNC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Postnatal care\u003c/p\u003e\n\u003cp\u003ePHCs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Primary Health Centres (operate at the LGAs and Community level)\u003c/p\u003e\n\u003cp\u003eSHCs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Secondary Health Centres (both public and private at the state level)\u003c/p\u003e\n\u003cp\u003eSTSC \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Skin-to-skin contact\u003c/p\u003e\n\u003cp\u003eTBA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Traditional Birth Attendant\u003c/p\u003e\n\u003cp\u003eTHF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Tertiary Health Facility (at the Federal level, e.g. Teaching hospitals)\u003c/p\u003e\n\u003cp\u003eUNICEF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;United Nations Children’s Fund\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organisation\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e My sincere gratitude to the University of Hull library for the permission and support to extract publications from their database for the review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u003c/strong\u003e UFO conceived the study, collected the data, analysed, interpreted and wrote the initial manuscript. \u0026nbsp;HN and FIJ provided critical input to the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was a dissertation submitted for the award of an MSc in Social Research from the University of Hull, United Kingdom. No organization funded this review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u0026nbsp; \u0026nbsp;The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable. However, the University of Hull's Research Ethics Committee approved to conduct the review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u0026nbsp; \u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details:\u003c/strong\u003e \u003csup\u003e1\u003c/sup\u003eSchool of Criminology, Sociology, and Policing, University of Hull, United Kingdom. \u003csup\u003e2\u003c/sup\u003eDepartment of Paediatrics, University College Hospital, Ibadan, Oyo state, Nigeria.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eUNICEF. Convention on the Rights of the Child-1989 [Internet]. 2022. Available from: https://share.google/f67DfWAcmRqbJtZms\u003c/li\u003e\n \u003cli\u003eWHO. Adolescent Health [Internet]. World Heal. Organ. 2024. 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Available from: https://journals.lww.com/10.4103/0970-0218.66865\u003c/li\u003e\n \u003cli\u003eKronborg H, V\u0026aelig;th M. How Are Effective Breastfeeding Technique and Pacifier Use Related to Breastfeeding Problems and Breastfeeding Duration? Birth [Internet]. 2009;36:34\u0026ndash;42. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1523-536X.2008.00293.x\u003c/li\u003e\n \u003cli\u003eNduagubam OC, Ndu IK, Bisi-Onyemaechi A, Onukwuli VO, Amadi OF, Okeke IB, et al. Assessment of Breastfeeding Techniques in Enugu, South-East Nigeria. Ann Afr Med [Internet]. 2021;20:98\u0026ndash;104. Available from: https://journals.lww.com/10.4103/aam.aam_22_20\u003c/li\u003e\n \u003cli\u003eMbada CE, Olowookere AE, Faronbi JO, Oyinlola-Aromolaran FC, Faremi FA, Ogundele AO, et al. Knowledge, attitude and techniques of breastfeeding among Nigerian mothers from a semi-urban community. BMC Res Notes [Internet]. 2013;6:552. Available from: https://bmcresnotes.biomedcentral.com/articles/10.1186/1756-0500-6-552\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-breastfeeding-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ibfj","sideBox":"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)","snPcode":"13006","submissionUrl":"https://submission.nature.com/new-submission/13006/3","title":"International Breastfeeding Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Exclusive breastfeeding, integrative review, cultural barriers, children, Nigeria","lastPublishedDoi":"10.21203/rs.3.rs-7255627/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7255627/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eExclusive breastfeeding (EBF) remains a key public health strategy for improving infant and maternal outcomes. In Nigeria, despite policy commitments, EBF practice rates remain inconsistent and highly context-dependent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eThis integrative review assesses the prevalence and patterns of EBF in Nigeria, examines the socio-demographic and systemic factors influencing practice, identifies barriers and enablers, and evaluates existing interventions to promote EBF.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eNineteen peer-reviewed primary studies, published between 2013 and 2024, were systematically identified across six geopolitical zones. Data extraction and synthesis followed a deductive coding framework, drawing on qualitative and quantitative findings, and guided by socio-ecological and capability-oriented perspectives.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eEBF prevalence varied significantly across regions and contexts (12.5%–73.8%). Key themes emerged around socio-demographic variability, contextual factors, cultural practices, and structural barriers. Despite high knowledge levels, systemic and relational constraints limited the sustained implementation of EBF practice. The review also identified gaps in research, including the limited inclusion of fathers, informal caregivers, and mothers in displaced or rural communities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThis review advances the literature by offering a context-sensitive, multi-dimensional interpretation of EBF practices in Nigeria. It highlights the need for equity-focused policies and interventions that move beyond individual awareness to address structural enablers of maternal capabilities.\u003c/p\u003e","manuscriptTitle":"Exclusive Breastfeeding Practices and Challenges in Nigeria, Sub-saharan Africa: An Integrative Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 09:30:30","doi":"10.21203/rs.3.rs-7255627/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-24T09:06:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-05T15:42:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-29T05:57:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67733032358411215065477599942991178598","date":"2025-09-11T08:00:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318452292713715607736911811813399279697","date":"2025-09-08T13:49:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-15T09:46:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-01T01:12:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-31T11:09:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Breastfeeding Journal","date":"2025-07-30T18:19:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-breastfeeding-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ibfj","sideBox":"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)","snPcode":"13006","submissionUrl":"https://submission.nature.com/new-submission/13006/3","title":"International Breastfeeding Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a476bc3a-a0c1-4236-9469-b44a3852f7e9","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:04:52+00:00","versionOfRecord":{"articleIdentity":"rs-7255627","link":"https://doi.org/10.1186/s13006-026-00810-3","journal":{"identity":"international-breastfeeding-journal","isVorOnly":false,"title":"International Breastfeeding Journal"},"publishedOn":"2026-02-03 15:59:17","publishedOnDateReadable":"February 3rd, 2026"},"versionCreatedAt":"2025-08-06 09:30:30","video":"","vorDoi":"10.1186/s13006-026-00810-3","vorDoiUrl":"https://doi.org/10.1186/s13006-026-00810-3","workflowStages":[]},"version":"v1","identity":"rs-7255627","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7255627","identity":"rs-7255627","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}