Globally, 15 − 20% of all live births are low birthweight (LBW) newborns, and many mothers with LBW newborns experience feeding difficulties. Efforts to understand and mitigate the barriers to breastfeeding among this vulnerable group are urgently needed.

Mother-newborn pairs were recruited from eight facilities from the government’s Saving Little Lives initiative in Amhara Region, Ethiopia. We conducted a qualitative study using in-depth interviews among 30 mothers of LBW newborns (10 with very low birthweight [VLBW, < 1500 gm]; eight with LBW [< 2000 gm] who experienced breastfeeding difficulties, and 12 without difficulties). Data was collected from June to July 2022. The interviews were thematically analyzed to describe the breastfeeding experience, barriers, and facilitators for mothers with and without feeding difficulties.

Despite strong plans to exclusively breastfeed during pregnancy, many mothers of LBW newborns had difficulties initiating and continuing breastfeeding after delivery. Self-reported insufficient milk, suboptimal breastfeeding support in hospitals, prolonged mother-newborn separation in Neonatal Intensive Care Units (NICUs), and limited knowledge of effective feeding techniques were the most common barriers. Further, mothers with multiple births reported greater feeding difficulties; they were more likely to adopt formula feeding compared to those with single births. The primary facilitators of LBW breastfeeding were the synergy between health workers and mothers, mothers’ peer counseling, and family support. However, health worker support varied widely across facilities.

The findings from this study provide contextual insights into maternal LBW breastfeeding barriers and facilitators of successful and sustained breastfeeding. For example, creating NICU expectations to minimize maternal-newborn separation, targeting newborns’ feeding support for mothers with VLBW newborns and/or multiple births, and designing a standardized protocol for LBW nutritional support to guide health worker support are critically needed.

Low birth weight (LBW), defined by the World Health Organization (WHO) as birth weight below 2500 g regardless of gestational age [1], remains a major public health problem (emerging research has begun to define LBW as less than 2000 g) [2,3,4]. Globally, 15 − 20% of all live births are LBW newborns, with low- and middle-income countries accounting for 95% of reported cases [1, 5]. Full-term LBW newborns are at increased risk of long-term complications such as cognitive impairment and higher susceptibility to non-communicable diseases like diabetes and cardiovascular disease in adulthood [6,7,8]. By contrast, preterm LBW newborns face additional challenges due to organ immaturity, including severe respiratory distress, feeding difficulties, higher neonatal mortality, and a greater risk of neurodevelopmental disorders [9]. In Sub-Saharan Africa and Ethiopia, the majority of LBW newborns are also premature.

In Ethiopia, the national pooled prevalence of LBW is 18% [10], and an estimated 5% of the total under-five deaths in the country are attributable to LBW [11]. Despite the numerous government programs designed to improve infant and young child feeding practices, exclusive breastfeeding—strictly defined as feeding a newborn with nothing at all other than breastmilk [12]—has not increased substantively in the past two decades; only 59% of newborns are exclusively breastfed, which is substantively lower than the WHO’s coverage target of 70% by 2030 [13,14,15]. Although there are no nationally representative data on breastfeeding for newborns in Ethiopia, a recent study using data from Ethiopia’s Demographic and Health Survey showed that LBW is strongly associated with late initiation of breastfeeding [16], which increases the risk of newborn mortality [17, 18]. Furthermore, there is no standardized breastfeeding care or education protocol for mothers with LBW newborns, nor is there adequate, locally specific evidence to support interventions that can be targeted at mothers or health facilities to improve the quality of feeding support given to mothers, particularly those with breastfeeding difficulties in Ethiopia or the Amhara Region.

Although the importance of breastfeeding in the neonatal period are well established [15, 19], there is still a critical knowledge gap on optimal feeding strategies for small and vulnerable newborns, particularly those who experience breastfeeding difficulties. There is evidence suggesting that the uptake and duration of breastfeeding among LBW newborns are decreased compared to newborns with normal weight [20,21,22]. For example, Campbell et al. showed that compared to normal weight infants, LBW infants have 28% lower odds of ever breastfeeding and 53% lower odds of breastfeeding for six or more months [22]. Furthermore, research from sub-Saharan Africa shows that lack of quality support from health workers substantially affects breastfeeding uptake, particularly among mothers with LBW newborns [23, 24]. Breastfeeding counseling and standardized lactation support, including advanced medical support for premature newborns, have shown promise in addressing the specific breastfeeding challenges experienced by mothers with LBW newborns. In addition, other studies on the feeding experiences of mothers with LBW newborns show that the high burden of care due to the lack of resources essential for the management of LBW newborns and prolonged mother-infant separation during hospitalization are key factors that negatively influence breastfeeding experience [25,26,27]. However, these studies primarily focused on the drivers of breastfeeding from one perspective, drawing from the experiences of mothers often selected from one hospital, with no systematic attempt to recruit mothers with different feeding experiences. Hence, to design more effective interventions rooted in social and health policies and backed by the government’s political will and financial support, robust evidence is needed to understand the determinants of breastfeeding success among LBW newborns [15].

To improve survival for vulnerable LBW newborns, the Federal Government of Ethiopia, in collaboration with the Global Financing Facility, WHO, United Nations Children’s Fund, and a consortium of universities, rolled out the “Saving Little Lives (SLL)” initiative in 2021. This 3-year program, currently being implemented in Ethiopia’s four largest regions that account for three-quarters of the total annual national births, targets key drivers of mortality among preterm and LBW newborns. To optimize routine clinical care of LBW newborns, the consortium is implementing the SLL Minimum Care Package that constitutes care packages at birth, at Labor and Delivery Units, Neonatal Intensive Care Units (NICU), Kangaroo Mother Care (KMC) units, and Quality Improvement interventions in SLL-supported hospitals [28].

This study will describe the breastfeeding experiences of mothers with vulnerable LBW newborns by assessing existing practices, strategies, and support for early feeding in government SLL health facilities in the Amhara region. To achieve this, we collected data using qualitative methods from two groups of mothers with experience with breastfeeding. We sampled mothers who successfully breastfed or provided expressed breastmilk and those who had difficulty providing breastmilk to their newborns. Data from this study will be valuable in informing the design and implementation of targeted interventions to improve the quality of feeding support for vulnerable newborns.

This is a descriptive qualitative study that describes the breastfeeding challenges experienced by mothers of LBW newborns with varying breastfeeding experiences. We aimed to generate evidence of successes and barriers to LBW breastfeeding as the first step in developing potential intervention strategies to improve LBW newborns’ exclusive breastfeeding (EBF) rates. Participants were selected from facilities implementing the SLL project across 12 zones and three town administrations of the Amhara region. The Amhara region is the most populous in Ethiopia, with a population of 22,877,366 and an estimated 770,967 annual births, 23,129 of which are LBW [29]. To reflect the clinical care diversity at government hospitals, we recruited mothers from various facilities—including primary, general, and referral hospitals.

Health services in Ethiopia are provided by a “network of health facilities arranged in a three-tier health care delivery model”—primary, secondary, and tertiary services [30]. The primary level services are provided by health posts, health centers, and primary hospitals, collectively called a “primary health care unit”; general hospitals provide secondary level services; and specialized hospitals provide tertiary services. A health post is the lowest-level health facility at the community/kebele level, and a health center is a referral site for five catchment health posts and serves between 15,000 and 25,000 people. Primary Hospitals serving a population of 60,000–100,000 are referral centers for health centers [30]. Similarly, general hospitals serve 1–1.5 million people and are referral centers for PHs. Finally, specialized hospitals serve 3.5–5 million people and are Ethiopia’s highest level of hospital care. For this study, we collected data from eight of the 20 facilities currently implementing the SLL package of newborn survival services in the Amhara Region. Health facilities were purposefully selected to represent three levels of hospital care in Ethiopia based on geographical location and availability of NICU services.

After securing ethical clearance and a support letter from Amhara Public Health Institute to conduct this study, the process of recruiting mothers for the qualitative part of the study began. The research coordinator informed each facility’s medical director about the research objectives and secured permission to recruit eligible mothers. These mothers met the inclusion criteria: LBW delivery, ability to communicate in Amharic or English, and willingness to provide verbal and written consent to participate in the study. The research team approached mothers who expressed their willingness to participate in the study and selected a convenience sample (n = 30) [31]. We collected in-depth interviews on participants’ breastfeeding plans, practices, and experiences in three categories: 10 mothers with VLBW newborns, with a few multiple births; eight mothers with LBW newborns who experienced breastfeeding difficulties; and 12 mothers with LBW newborns without breastfeeding difficulties. According to operational definitions of newborns’ birth weight specific to this study, LBW newborns were < 2000 g at birth, and VLBW newborns were < 1500 g at birth [3, 32].

Data was collected from June to July 2022. The questionnaire included open-ended questions that focused on capturing data on prenatal newborn feeding plans, breastfeeding practices, barriers and facilitators of EBF, and breastfeeding support. The research team developed this questionnaire, pre-tested it on a sample of mothers at a hospital in Bahir Dar City (not part of the main study), and modified it with inputs from Emory-Ethiopia teams based in Amhara and Atlanta. Two social science experts were trained by a senior researcher from Bahir Dar University using a semi-structured interview guide before administering the questionnaires at the health facilities. The training ensured reflexivity and reduced potential bias in the data collection process. All interviews lasted 35–60 min and were conducted in person at the hospital—with only the mother, sometimes the newborn, and interviewer in the room—using the local language, Amharic.

The audio-recorded interviews and field notes were transcribed/translated verbatim into English by the two research assistants. The translated versions were de-identified and entered into MAXQDA 2022 Software, version 22.3.0, (VERBI Software, Berlin, Germany). The data was thematically analyzed using predetermined research themes derived from the interview guide and inductive themes that surfaced from the interview data [33]. Two team members (MCE and YAT) developed the codebook using the study questionnaire and identified data segments relevant to our research question. The larger research team met to discuss iterations of the codebook. YAT conducted the first line of coding, and MCE double-coded 20% of the interviews to compute inter-coder agreement [34]. We further explored the patterns and relationships between the codes to develop broader themes, which were reviewed by the study team to ensure they accurately reflect the data.

We report on mothers’ breastfeeding perspectives and experiences before delivery and after delivery and use the key findings from themes and sub-themes to present a summary of the key barriers and facilitators of breastfeeding among mothers with LBW newborns. Breastfeeding experience before delivery resulted in three main themes: (1) mothers’ feeding plan before delivery; (2) Breastfeeding counseling at prenatal visits; and (3) Mothers’ knowledge of different newborn feeding options and practices. Breastfeeding experience after delivery had three main themes: (1) First day feeding practices; (2) Challenges when initiating and continuing feeding; and (3) Feeding support (at facilities) after delivery.

Mothers’ feeding plans before delivery

All mothers who participated in the study, regardless of their newborn’s birth weight or the severity of breastfeeding difficulties, asserted that their goal was to exclusively breastfeed for the first six months of life. Although a few mothers noted that health workers played a crucial role in influencing their feeding decisions before delivery, they highlighted that they did not get any specific information about effective strategies for providing breast milk to newborns, particularly those with LBW. Mothers’ decision to exclusively breastfeed was primarily influenced by their past experiences or by observing their friends and family members (primarily mothers or mothers-in-law). When discussing her feeding plan before delivery, a young mother of a LBW newborn stated:

“When I was pregnant, I was thinking that I would breastfeed my child for the first six months of her life. After that, I will add supplementary foods such as cow’s milk and other fruits. During my pregnancy, my friends told me that breastfeeding was extremely important, so I planned accordingly based on what they had told me.” (Participant 21, LBW without breastfeeding difficulty).

Three of the 30 participants got most of their knowledge on the importance of breastfeeding from online sources. “I am influenced by social media, readings, and health professional education from the media. Health professionals have suggested that breastmilk is crucial for the baby’s healthy growth. I know that if the baby gets the mother’s breastmilk, the baby would be healthy and not susceptible to disease” (Participant 17, LBW with breastfeeding difficulty).

Breastfeeding counseling at prenatal visits

The content of the prenatal counseling sessions that mothers had received during pregnancy differed between participants, regardless of birth weight or the severity of feeding difficulties experienced. Only seven of thirty mothers received breastfeeding-specific counseling from health workers during their prenatal visits; this counseling focused on the need for exclusive breastfeeding, the benefits of providing breastmilk (versus other feeding options), feeding duration, latching techniques, frequency of feeding, and the avoidance of household foods for the first 6 months. One notable example came from a 32-year-old mother who had an LBW baby without breastfeeding difficulty. She reported:

“They [the health workers] advised me on how to breastfeed my baby using the proper protocol including how I should attach my baby to my nipple area, proper baby positioning, and proper handling of my baby during breastfeeding…. and they also advised me that newborn babies should not be fed with any additional food except breast milk until they are six months old. I was also advised that breastmilk volume would increase when the baby fed the breast continuously and frequently.” (Participant 26, LBW without breastfeeding difficulty).

The twenty-three mothers who were not counseled explicitly on breastfeeding still received some form of counseling during their prenatal visits to the health facilities. The counseling these mothers received primarily centered around consuming a “balanced diet” during pregnancy for optimal weight gain and development of the embryo, avoidance of physically demanding work, and taking supplements. The counseling experience of a 25-year-old mother adequately captured the key points of the messaging received by these mothers:

“The nurses in the hospital where I went for ANC service did not inform me of anything concerning the feeding of the newborn child. However, they told me I must eat a balanced diet of fruit and liquid foods. Similarly, the nurses advised me to avoid heavy work and take iron medicine.” (Participant 21, LBW without breastfeeding difficulty).

Mothers’ knowledge of different newborn feeding options and practices

Despite the lack of counseling on the substantial advantages of breastfeeding over other prevalent feeding options reported by most mothers, they all demonstrated a fair understanding of the advantages and disadvantages of several feeding options. Most mothers knew about the benefits of exclusive breastfeeding for newborns’ physical growth and development, cognitive development, prevention of common illnesses, and mothers ‘mental satisfaction’ due to having a healthy baby. This knowledge was primarily due to prior breastfeeding experience, advice from health workers, and education by peers. A 30-year-old mother with breastfeeding difficulty highlighted the importance of breastfeeding:

“In addition to providing minerals necessary for their development, breastfeeding is of the utmost importance for babies up to six months old. Once they reach the age of six months, babies should begin drinking cow’s milk regularly. Breastmilk is incredibly vital for the strength of the child’s body.” (Participant 1, LBW with breastfeeding difficulty).

The most common alternatives to breastmilk reported among mothers were cow’s milk or infant formula. When asked about the risks associated with different feeding practices of newborns, all mothers stressed the absence of any risk with breastfeeding as it is the ‘most natural’ feeding method. Notwithstanding, over half of them repeatedly cited “heaviness”—the inability of newborns’ less-developed digestive tract to digest certain foods—as a reason for not providing cow’s milk until after ‘6 months’. Some mothers who had experimented with giving cow’s milk in the past highlighted that it caused ‘gastrointestinal disturbance’ for their newborn, which could result in other dangerous health outcomes. A 25-year-old college mother highlighted the detriments of feeding cow milk from her experience with an older child:

“However, I have prior experience from having my first child. I was giving him cow’s milk. He was frequently ill as a result of a high intake of animal milk.”(Participant 19, LBW without breastfeeding difficulty).

Infant formulas were perceived to be less dangerous by mothers. They saw it as an alternative to breastmilk in situations where mothers may be unable to breastfeed effectively, especially among those with multiple births. However, most mothers were not as knowledgeable about the potential hygiene risks of providing infant formula. Mothers tend to limit their responses to “I do not know” when asked about the risks or potential downsides of other newborn feeding practices. This was effectively summarized by a 30-year-old mother who had a VLBW delivery:

“Regarding formula milk, I do not know more about it. If breast milk is not productive, we may not have any other options except formula milk, so we should use it when the breast milk is not productive. In the past (i.e., the experience of our mothers and grandmothers), animal milk, including butter, was good and considered very important to give to the newborn. Nowadays, the health care professional informs and teaches us not to give them to babies under six months.” (Participant 4, VLBW with breastfeeding difficulty).

Overall, all the mothers in our study had plans to breastfeed their newborns exclusively. However, only a few received detailed breastfeeding counseling, particularly about the feeding difficulties encountered by mothers with LBW delivery. Table 1 summarizes the five key findings from Theme 1.

First-day feeding practices

After delivery, the feeding practices of mothers in this study differed substantially since we recruited those with LBW and VLBW newborns, with and without feeding difficulties. While a few mothers adhered to their feeding plans before delivery despite having breastfeeding difficulties, others reported having no option but to introduce formula after delivery. Despite having very positive views on the benefits of exclusive breastfeeding, several barriers limited their ability to initiate and continue breastfeeding.

At the time of the interview, all VLBW newborns were admitted to the NICU, separated from their mothers, and taken care of by neonatal nurses. The ten VLBW newborns in this study were also born preterm, and their mothers highlighted their inability to suckle due to prematurity. Most of the mothers of these newborns gave birth at other facilities (mostly health centers) and were referred to SLL hospitals to access the NICU services. The feeding experience of mothers with VLBW newborns was similar in this study, as most were unable to initiate breastfeeding during the first few days of their children’s lives. All VLBW newborns received medicines or supplements from neonatal nurses through a nasogastric tube during this period. While separated from their newborns in the NICU, very few mothers were supported to immediately express breastmilk for future feedings once their newborn became stable and able to suck. This support was very inconsistent across facilities, with some mothers noting that they were only supported to express breastmilk three days after delivery. One reported,

“The baby did not feed on my breastmilk on the first day of birth because he was born prematurely. They took him to the NICU, and after three days, we were told to bring breastmilk through hand expression, but that was unsuccessful. When it was problematic to get breastmilk, we gave formula/milk powder.” (Participant 11, VLBW with breastfeeding difficulty).

Furthermore, some of the VLBW newborns were multiple births. Clinical stabilization in the NICU for these newborns was longer, which further delayed breastfeeding (either directly at the breast or by expression). VLBW newborns who were late preterm and more clinically stable but unable to suck at the breast received expressed breastmilk using feeding bottles or nasogastric tubes in the NICU until they were able to breastfeed directly from the breast and transferred to the KMC clinic. All mothers with these newborns highlighted the key support from health workers on establishing and maintaining breastfeeding:

“Currently, I am trying to breastfeed if my breast produces milk. Sometimes my newborn sucks and gets milk, and other times she tries to suck but fails. If she cannot get milk from my breast, I provide expressed milk through a syringe into the nasogastric tube. Therefore, I am using direct breastfeeding and pumping to provide expressed milk… Furthermore, the doctors and nurses also showed us how to feed my child through a nasogastric tube. I had no idea how to feed my child for the first time, so the doctors helped me by showing me how to do it.” (Participant 9, VLBW with breastfeeding difficulty).

The doctors advised me to get a feeding bottle when the newborn was unable to suck my breast milk, and I am currently giving my infant expressed milk using the feeding bottle. (Participant 12, VLBW with breastfeeding difficulty)

Other mothers with VLBW newborns, especially the three who had multiple births (twins and triplets), and the eight mothers with LBW newborns who experienced feeding difficulties noted that their breastmilk volume was insufficient after delivery. These mothers cited self-reported insufficient milk production as the main obstacle to breastfeeding. They all opted to supplement their newborns with formula until they could produce enough breastmilk. Hospital staff support for formula feeding was quite variable. While some neonatal nurses expressly advised mothers with multiple births to adopt formula feeding, others forbade the use of the formula for LBW newborns. When inevitable, they encouraged mothers to breastfeed first before supplementing with formula. A 23-year-old mother of two shared her experience feeding LBW twins:

“My breasts were not producing enough milk… Hence, I feed my children utilizing both bottle feeding and breastfeeding. I first provide breastmilk, then I use infant formula afterwards. However, I have always breastfed since it is the most significant feeding.” (Participant 10, twin LBW with breastfeeding difficulty).

The experience of eighteen of the twenty mothers with LBW newborns was similar to those with VLBW delivery, regardless of whether they had breastfeeding difficulty or not. The newborns were admitted to the NICU for clinical stabilization and were either reportedly unable to feed at the breast or were preemptively bottle-fed, mostly with expressed breastmilk, for the first few days of life. After stabilization in the NICU, the mothers without feeding difficulty reported being able to directly breastfeed or provide sufficient expressed milk to their newborns, while those with feeding difficulty still lamented their inability to produce sufficient milk. After clinical stabilization in the NICU, newborns were transferred to the KMC wards, where they had unrestricted access to their mothers. At the KMC ward, they were breastfed directly or fed their mothers’ expressed breastmilk or infant formula. Most mothers without feeding difficulties were satisfied with their breastmilk production and could breastfeed their newborns exclusively. Only a few had issues with inconsistent suckling, latching, and an overall lack of breastfeeding knowledge and experience. Hence, they expressed much milk and achieved some success using bottles or nasogastric tubes. A 22-year-old summarized her breastfeeding experience:

“Currently, the baby does not suckle well, so I feed him using a feeding bottle of extracted milk. My body trembles when the baby touches my breast because it is my first child, and I have no experience with feeding. I progressively overcame the problem with the help of advice and direction from others and the good fortune of experience.” (Participant 16, LBW without breastfeeding difficulty).

Whether newborns were directly breastfed at the breast or through a nasogastric tube in the KMC unit, mothers reported feeding every three hours and a latch time ranging from 2 to 10 min. These feeding experiences were consistent across the three groups of mothers after newborns were clinically stable (those with LBW with and without feeding difficulties and those with VLBW newborns). Among newborns who were VLBW and preterm, mothers reported a higher feeding frequency: “I am providing the expressed milk (at least) once an hour and more than 12 or 13 times per day” (Participant 9, VLBW with breastfeeding difficulty). However, mothers initiated direct breastfeeding once the newborns were discharged from the NICU and enrolled in the KMC care. Consequently, they reported feeding “once every 3 hours” like most mothers.

Challenges when initiating and continuing feeding

The primary challenge experienced by all mothers who had difficulty initiating breastfeeding is insufficient breastmilk production. Regardless of whether a newborn can suckle effectively, most mothers in the study reported that their breastmilk volume was insufficient to meet the nutrient needs of their newborn. All mothers with VLBW newborns and most mothers of LBW newborns with feeding difficulty reported having this problem. Newborns in these categories were immediately separated from their mothers after birth and placed in the NICU, making it more difficult for mothers to establish and maintain breastmilk flow. Further, some mothers began expressing breastmilk 2–3 days after delivery. Some believed the forced separation may have contributed to delays in breast milk flow even after multiple hand expressions. Most mothers in these two categories gave birth to preterm newborns, some as early as seven months. These newborns still struggled to breastfeed after discharge from the NICU because of developmental problems.

“There were two major problems I faced: my breast was unable to produce milk for my child, and the newborn child could not suck my breast because he was a preterm child.” (Participant 6, VLBW with breastfeeding difficulty).

“…this time, I could not feed my child directly because the doctors fed her. By the way, my breast still does not provide enough milk, so if she had been with me, I could not breastfeed her. However, if she were with me, maybe my breasts would produce milk if she tried to suck.” (Participant 9, VLBW with breastfeeding difficulty).

Despite mothers’ hesitance to breastfeed solely due to their concern about insufficient milk production, healthcare workers in one facility encouraged mothers to breastfeed exclusively, leading to positive breastfeeding experiences.

“The physicians assisted me in resolving the problems since they admitted my child to the NICU and encouraged me to begin breastfeeding and feed my newborn with expressed milk. They are still working with me to get my breasts to produce adequate milk. They also encouraged me to eat a well-balanced diet and drink plenty of liquids to produce adequate milk for my child.” (Participant 9, VLBW with breastfeeding difficulty).

Another important challenge faced by mothers of LBW newborns who had breastfeeding difficulty was expressing breastmilk, particularly among first-time mothers. Since most mothers did not have prior experience with breastmilk expression, a few had “wounds at the tip of their breast” and/or “inverted nipples”, and most of the mothers who expressed milk did so by hand. They experienced pain during the process, and this made the expression of breastmilk more challenging than they anticipated.

“Unfortunately, I felt pain in my breast when I expressed my breast when the doctor asked me to give milk to feed my child.. and the top of my breast also became wounded.” (Participant 2, LBW with breastfeeding difficulty).

A few mothers noted that they had significant psychological stress, primarily because of their newborn’s low weight and inability to breastfeed (unable to suckle). While discussing her biggest challenge, a 35-year-old mother who is a teacher states:

“My blood pressure was very high, and it had several negative effects on my child’s feeding. Stress and worry were also a problem for me, especially when I saw my preterm baby and his very small size. It was very troubling to me; It confused me.” (Participant 6, VLBW with breastfeeding difficulty).

Feeding support after delivery

Feeding support after delivery varied by facility. Most mothers highlighted the lack of breastfeeding education and support during ANC and Postnatal Care visits. Many mothers were unaware of the risks of giving birth to a LBW or premature infant, and most had difficulty coping with a LBW newborn’s needs when they arrived. A few mothers highlighted the tremendous support they received from health workers while they struggled to breastfeed. However, this was not the case for most participants, who lamented that neonatal nurses seemed to lack the skills or knowledge needed to support mothers struggling to breastfeed, were reluctant to help, or lacked the adequate number of staff needed to provide individualized breastfeeding support. These mothers in facilities where staff provided ‘helpful assistance’ and ‘compassionate care’ could return to exclusively breastfeed their infant after discharge from the NICU. They reported that newborns could suckle and attach better than mothers who received limited support at facilities. Mothers who received support were also more able to establish and maintain feeding at the breast and reported less milk expression. Most of these mothers attributed the survival of their newborns to the “attention and support of all hospital staff.”

“The hospital staff provides me with all the support I need to care for my child, including medication and glucose for the infant…No, I do not express breastmilk… Depending on the baby’s satiety, the time frame at the breast can range from 20 to 30 minutes.” (Participant 12, VLBW with breastfeeding difficulty).

Furthermore, most mothers who successfully breastfed reported synergy between their family members—primarily friends, mothers, and husbands—and healthcare workers made their breastfeeding experience much more successful as time progressed. Instrumental familial and peer counseling and support often came from sharing experiences and stories about those family members who had overcome breastfeeding difficulties themselves.

“My family and doctors are still supporting me in breastfeeding my child. I am also supported by the nurses at [deidentified] Hospital in feeding my child effectively. My husband is always by my side when I give my breast milk to the doctors. Furthermore, the doctors and nurses also showed us how to feed my child through a nasogastric tube. I had no idea how to feed my child for the first time, so the doctors helped me by showing me how to do it” (Participant 10, VLBW without breastfeeding difficulty).

“I am grateful to my family since they continue to support me by reassuring me that there is no need to be concerned about anything.” (Participant 15, LBW with breastfeeding difficulty).

Furthermore, all mothers who reported having insufficient breastmilk volume noted receiving similar advice on addressing the problem: “Drink enough water, consume hot liquid food, and eat a balanced diet.” Liquid foods like porridge, tea, coffee, and ‘atmite’ (Amharic for soup) were highly recommended. In addition, some mothers were encouraged to adopt formula feeding by health professionals, indicating that healthcare workers confirmed the reported breastmilk insufficiency. However, only a few health workers educated their clients on properly feeding newborns with formula and the hygiene risks involved.

“When my breast was unable to flow, they (doctors and nurses) advised me to eat a variety of liquid foods, pump milk frequently, and stroke my nipples. My breast produced enough milk after I began to eat these liquid foods.” (Participant 19, LBW without breastfeeding difficulty).

“Despite the doctors’ advice that breastfeeding is healthy for children and you should feed your child this, my breasts did not produce milk. Therefore, I was unable to feed my newborn child. For this reason, they consulted me before buying the formula food. Currently, I am providing this food for my child. My doctor helped me purchase this formula milk for my child.” (Participant 5, VLBW with breastfeeding difficulty).

Overall, the breastfeeding experience of mothers after delivery did not match their plans before delivery. Most of the mothers with LBW and VLBW delivery did not breastfeed for the first few days, and bottle-feeding with formula was very prevalent. The primary breastfeeding challenge that was reported was insufficient breastmilk production, and the support from health workers to address this challenge varied across facilities. Table 2 summarizes the five key findings from Theme 2.

The findings from exploring mothers’ experiences before and after delivery revealed several barriers and facilitators to breastfeeding at the individual and health systems levels. Table 3 shows these barriers and facilitators across three categories—counseling and support, resources and supplies, and technical concerns.

The present study describes the breastfeeding experiences of mothers with LBW newborns from the Amhara Region of Ethiopia. We identified several context-specific barriers and facilitators to breastfeeding, including self-reported milk insufficiency, suboptimal maternal nutrition, limited breastfeeding-specific counseling at ANC and postnatal clinics, inadequate breastfeeding and milk expression support after delivery, inadequate support with hand expression of breastmilk, and the lack of a standardized protocol and practices to ensure rapid initiation of direct milk feeding or hand expression of breastmilk after birth.

Before delivery, all the mothers in this study planned to exclusively breastfeed for the first six months of life as recommended by the WHO. Most mothers had a remarkable understanding of the importance of breastfeeding to improve newborn health outcomes; however, they had less familiarity with the hygienic and other risks of alternative feeding options such as infant formula. This strong plan to breastfeed primarily stemmed from mothers’ personal experiences, observations of peers/friends, the influence of key family members, advice from health workers, and social media. These findings parallel evidence that mothers’ social network influences their plans to initiate and continue breastfeeding [35, 36]. The plan to breastfeed was least influenced by health workers’ recommendations before delivery, even though health workers often mentioned the importance of breastfeeding for newborns. Evidence from the literature is variable, and some studies show that mothers who received support and education from healthcare workers were more likely to initiate and maintain breastfeeding [37].

In contrast, others suggest that supporting mothers to breastfeed adequately is a complex process dependent on various contextual factors [38], which traditional breastfeeding education classes may not typically address. However, breastfeeding-specific counseling and practical techniques to employ should mothers experience feeding difficulties were limited and inconsistent during prenatal visits and across the health facilities used for this study. The historically low uptake of ANC in Ethiopia may further exacerbate the problem, as facilities that provide adequate counseling cannot reach their coverage target of at least four ANC visits. Only 27% of Ethiopian pregnant women attend four or more ANC visits [39]. We found that prenatal counseling on EBF is not standardized, particularly for LBW newborns. This Amhara finding aligns with other global studies [40]. It highlights a missed opportunity for health workers to provide evidence-based education that may support EBF among vulnerable newborns, especially for LBW newborns.

Despite mothers’ plans to breastfeed exclusively, most mothers with LBW newborns did not exclusively breastfeed after delivery due to extensive barriers. The primary barrier to breastfeeding initiation, continuation, or exclusivity in this study was mothers’ perception that their breastmilk volume was inadequate to meet the nutritional requirements of their vulnerable newborn. Globally, insufficient breastmilk production is the most cited reason for introducing formula; concerns for insufficient breastmilk production are widespread among mothers with LBW or preterm newborns [15, 41, 42]. Although self-reported insufficient breastmilk production is often interpreted as an outcome solely based on mothers’ perceptions, evidence suggests that biological factors specific to mothers and newborns, sociocultural factors, and hospital-level factors influence this phenomenon [43]. In a comprehensive systematic review of 120 studies conducted across varying country income levels globally, four key risk factors of insufficient breastmilk production were reported: delayed initiation of breastfeeding, separation of mother and child in NICUs, suboptimal and non-specific breastfeeding counseling, and in-hospital formula feeding [44]. Although in-hospital formula feeding was less prevalent in this study, the other drivers of insufficient breastmilk production were standard in this study context. They present a unique opportunity to design interventions targeting these four drivers of insufficient breastmilk production in Amhara.

Furthermore, we observed that most mothers who reported milk insufficiency noted that healthcare workers in their facility acknowledged their concerns. Consequently, some mothers reported that these health workers counseled them to consume foods that could increase breastmilk volume—primarily hot liquid soups—and in extreme cases of insufficiency (especially among mothers with multiple births), some mothers reported being explicitly advised by health workers to supplement breastmilk with formula. Hence, dismissing reported milk insufficiency as merely a mother’s ‘perception’ may be a rather simplistic approach, particularly based on evidence from the 120-study systematic review [44]. Instead, juxtaposing the breastfeeding experiences of mothers with LBW newborns with the health worker perspectives may provide a powerful and unique opportunity to more deeply explore the causes and potential solutions to insufficient breastmilk production for LBW mothers in Amhara.

In line with extensively documented evidence, we found that mother-newborn separation in NICUs greatly limited breastfeeding initiation in this study [45,46,47,48]. The WHO recommends initiating breastfeeding within the first hour of birth; it decreases the risk of all-cause mortality, infection from pathogens in foods, and maternal postpartum hemorrhage [17, 49,50,51]. Nevertheless, it is still very commonplace for NICUs to separate mothers and their newborns for prolonged periods globally and in Ethiopia [47, 52], and these NICUs are not usually open all day to give mothers unlimited access to their newborns [53]. Separation is known to influence mother-infant bonding and may promote psychological stress that may hinder optimal breastfeeding outcomes, especially among mothers with VLBW newborns with substantively higher rates of postpartum depression compared to mothers of healthy-term newborns [27, 52, 54]. Despite this, there was no standardized protocol across all health facilities selected for this study to ensure that mothers of LBW newborns immediately initiate breastfeeding or express breastmilk after delivery.

Early initiation and frequent on-demand feeding or breastmilk expression are associated with increased milk production [50]. Specifically, early research has shown that expressing breastmilk before 6 h postdelivery and for ≥ 5 times per day substantially increases breastmilk volume among mothers with preterm and VLBW newborns [55, 56]. The average daily breastmilk volume at 8 weeks postpartum was 96 ml greater for mothers who expressed breastmilk ≥ 5 times/day than those who expressed breastmilk < 2 times per day [55, 57]. In addition, daily breastmilk production of ≥ 500 ml among mothers of VLBW newborns within the first 2 weeks of birth is a strong predictor of sustained lactation [58]. These studies provided mothers with efficient double electric breast pumps that pump milk faster than manual pumps or hand expression. In our study, only three mothers had access to manual pumps. Hence, there is an opportunity to further support lactation for mothers with vulnerable LBW newborns, particularly those separated from NICU care, with manual or electric pumps to improve milk production and sustained breastfeeding.

In addition to the delayed initiation of breastfeeding among mothers with LBW newborns, there was inconsistent support for breastfeeding or breast milk expression in facilities. In the early days after delivery, there was inadequate breastfeeding support. Some mothers did not receive EBF assistance until after their newborns were clinically stable and discharged from the NICU. This support is beneficial for mothers with preterm newborns who have problems with suckling and swallowing. Therefore, it is essential to provide comprehensive support to these mothers in facilitating the transition of their newborns from nasogastric feeding to cup feeding and, ultimately, direct breastfeeding. These findings are consistent with previous studies highlighting the challenges encountered by mothers of LBW and preterm newborns in establishing regular and routine breastmilk feeding strategies [42, 52, 59, 60]. This separation challenge was more profound among mothers with multiple births, who require additional time and effort to care for multiple newborns in the hospital and have the additional responsibility of fulfilling household responsibilities upon discharge from the hospital [61].

The feeding support provided to mothers with vulnerable newborns after delivery varied greatly between facilities. In hospitals where mothers received targeted postnatal care, breastfeeding challenges were more readily addressed, and some mothers were able to continue breastfeeding exclusively. Furthermore, healthcare workers in these facilities were less likely to suggest introducing formula than in facilities with limited postnatal support. Mothers with multiple births who deemed their breastmilk supply as inadequate to meet the needs of the newborns were supported to provide mixed milk feeding—breastfeeding first before providing formula as a supplement. However, this is not a recommended practice and ironically is associated with decreased breastmilk production, early cessation of breastfeeding, and increased health risks associated with feeding preterm newborns with formula [62, 63]. By contrast, in situations where mothers were unable to produce sufficient breastmilk and in facilities with more limited support, health workers did little to encourage exclusive breastfeeding among mothers experiencing feeding difficulties. Some health workers recommended formula as the sole solution to the problem. This practice can result in medicalizing newborn feeding problems—a situation that heavily favors formula marketing [64].

In Ethiopia, healthcare workers have numerous opportunities to interface with pregnant and lactating mothers. The health extension workers provide antenatal and postnatal services at health posts (the lowest level of the primary health system and during community-level outreach services). In contrast, maternal and child health nurses provide complementary services in the clinics at health centers (one level above health posts) and hospitals. Hence, strengthening the health systems to be more effective in reaching mothers with LBW and vulnerable newborns with targeted support, such as educational messaging and in-facility support, may be targeted system strategies to improve breastfeeding uptake, duration, and sustained practice. These system-level supports may enable mothers to handle any EBF challenges experienced after birth more effectively.

This is one of the first known studies to explore the breastfeeding experience of mothers of vulnerable LBW newborns in Ethiopia by recruiting mothers with different breastfeeding experiences. Documenting these experiences across the country’s clinical continuum of care (primary, general, and referral hospitals) is a significant strength of this study. Thus, the study documents diverse experiences from the Amhara region. The separation of thirty mothers into three categories—10 with VLBW newborns, 8 with LBW newborns who experience breastfeeding difficulties, and 12 with LBW newborns without difficulties—enabled us to explore the challenges mothers face and provide insights into interventions that can be targeted to specific groups of mothers with varying levels of breastfeeding difficulty. Furthermore, using highly skilled local interviewers ensured that the in-depth interviews generated detailed information about breastfeeding experiences, challenges, and mothers’ perspectives in this context.

However, our study has a few limitations. We collected data from facilities participating in the government’s national SLL initiative within the Amhara Region. Hence, the breastfeeding experience of mothers and the support provided by healthcare workers may differ from those at other health facilities outside the SLL program, facilities in other regions, or private hospitals. As with many qualitative studies, there is potential for recall and social desirability bias since data were self-reported. However, given that mothers’ selection was based on the degree of feeding difficulty they experienced and interviews were completed a few days after delivery, it is plausible that the experiences shared are accurate and minimally impacted by social desirability.

Furthermore, we explored the breastfeeding experience based on the mothers’ perspective alone. Further research is needed to triangulate mothers’ experiences with the perspective of health workers to thoroughly understand the factors affecting breastfeeding initiation, continuation, and exclusivity in Ethiopia, Amhara, and similar contexts. More investigation is warranted to comprehensively explore maternal perspectives on optimal breastfeeding support mechanisms or interventions required for the successful initiation and continuous sustenance of breastmilk feeding among vulnerable newborns. In addition, there is a need to conduct more research to comprehensively describe the barriers to ANC attendance in the region so that potential mothers can be targeted with timely breastfeeding education and support. Future research should also prioritize collecting maternal sociodemographic characteristics systematically.

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Conceptualization; AG, JC, MYF. Data curation; MCE, YAT, DA, MA. Formal analysis; MCE, YAT, MYF. Funding acquisition; AG, JC, MYF. Investigation; MCE, YAT, AG, JC, MYF. Methodology; AG, JC, MYF. Project administration; MLB, YAT, MA, DA Resources; Software; Supervision; Validation; Visualization; MYFRoles/Writing - original draft; and Writing - review & editing. MCE, YAT, MYF, JC, AG.

Correspondence to Moses Collins Ekwueme.

The Research Ethics Committee of the Amhara Public Health Institute approved the study (Reference Number: NoH/R/T/T/D/5/9, Date:12/13/2021). The Institutional Review Board (IRB) of Emory University determined that the study did not require additional IRB oversight, as primary ethical approval was obtained from the local ethics committee.

The authors declare no competing interests.

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