Assessing pooled prevalence of exclusive breastfeeding practice and addressing principal barriers to its practice in North African countries: A systematic review and meta-analysis [version 1; peer review: awaiting peer review]

Background: Exclusive breastfeeding (EBF) is a public health priority globally. According to the World Health Organisation (WHO), the global prevalence of EBF during the first six months of life remains low particularly in low- and middle-income countries. In this systematic review (SR) and meta-analysis (MA) we examine the existing evidence of the pooled prevalence and determinants of EBF during the first 6 months of infants' lives in North African (NA) countries. Methods: This SR and MA followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. International databases were systematically searched. Inclusion criteria included studies conducted among mothers in NA countries (Tunisia, Algeria, Morocco, Libya, Egypt, Sudan) on breastfeeding prevalence. Meta-analyses were conducted using R (version 4.2.3). Results: 16 studies with a total of 7,849 participants were included in the analysis. The global pooled prevalence of EBF during the first six months in NA countries was 29.0% (CI95% [18.0; 42.0]) with heterogenous results (Tau2 = 1.41, I2 = 99%, p < 0.01). Tunisia had the lowest prevalence of EBF (11%) while Sudan (63%) and Morocco (48%) had the highest. The prevalence of EBF until the first six months of life (among infants aged at least 6 months) was 30.0% (CI95% [14.0; 52.0]). Barriers to EBF practice were examined, including mother's educational level, maternal employment, and mode of delivery. However no statistically significant factors were identified. Conclusion: EBF in NA countries falls below the recommendations of the WHO. Concerted efforts and adoption of a multi-dimensional approach is needed to promote and support EBF practices. EBF rates in NA vary widely, and efforts to promote and support this practice need to be context-specific and tailored to each country's unique challenges and opportunities. Implementation of Baby-Friendly Hospital Initiatives can contribute to the improvement of breastfeeding practices in this region.