Breastfeeding beliefs and experiences of African immigrant mothers in high‐income countries: A systematic review

Abstract Breastfeeding provides optimal nutrition for the healthy growth of infants and is associated with reduced risks of infectious diseases, child and adult obesity, type 2 diabetes, and other chronic diseases. Migration has been shown to influence breastfeeding especially among migrants from low‐and‐middle‐income countries. This mixed‐methods systematic review aimed to identify, synthesise, and appraise the international literature on the breastfeeding knowledge and experiences of African immigrant mothers residing in high‐income countries. MEDLINE, CINAHL, Embase, PsychINFO, Scopus, and Web of Knowledge databases were searched from their inception to February 2019. Grey literature, reference, and citation searches were carried out and relevant journals hand‐searched. Data extraction and quality assessment were independently carried out by two reviewers. An integrated mixed‐methods approach adopting elements of framework synthesis was used to synthesise findings. The initial searches recovered 8,841 papers, and 35 studies were included in the review. Five concepts emerged from the data: (a) breastfeeding practices, showing that 90% of African mothers initiated breastfeeding; (b) knowledge, beliefs, and attitudes, which were mostly positive but included a desire for bigger babies; (c) influence of socio‐demographic, economic, and cultural factors, leading to early supplementation; (d) support system influencing breastfeeding rates and duration; and (e) perception of health professionals who struggled to offer support due to culture and language barriers. African immigrant mothers were positive about breastfeeding and willing to adopt best practice but faced challenges with cultural beliefs and lifestyle changes after migration. African mothers may benefit from more tailored support and information to improve exclusive breastfeeding rates.


| INTRODUCTION
Breastfeeding provides optimal nutrition for infants for healthy growth and development and can be considered a low-cost intervention. It is associated with much lower risks for infection and long-term outcomes such as child and adult obesity, type 2 diabetes, and other chronic diseases (Binns, Lee, & Low, 2016). The World Health Organisation (WHO) recommends that infants be exclusively breastfed for at least the first 6 months of life (WHO, 2016). Despite this, the WHO still reports that, as of 2010, only 35% of infants worldwide were exclusively breastfed within the first 4 months of life (WHO, 2016).
Breastfeeding has been recognised as beneficial not only to the infant but also to the mother as it is associated with a reduction in the development of various cancers (Collaborative Group on Hormonal Factors in Breast Cancer, 2002;Dewey, Heinig, & Nommsen, 1993;Labbok, 2001;Riman et al., 2002;Tung et al., 2003) and maternal depression (Mezzacappa, 2004). It is also associated with infant-to-mother bonding (Hart, Boylan, Carroll, Musick, & Lampe, 2003) and may aid quicker return to pre-pregnancy weight (Rea, 2004).
There is evidence to show that breastfeeding is more widely practiced in low-and-middle income countries (LMICs) than it is in most high-income countries (HICs) (Victora et al., 2016). A recent systematic review exploring the factors influencing exclusive breastfeeding (EBF) practices in LMICs showed that the existence of barriers to breastfeeding in these countries was insufficient to halt breastfeeding practices (Balogun, Dagvadorj, Anigo, Ota, & Sasaki, 2015). The study found that mothers living in these countries develop strategic plans alongside their inherent personal characteristics to ensure successful breastfeeding. This suggests that breastfeeding is considered by the mother to be an inherent part of an infant's health and growth in LMICs. Conversely, mothers from similar origins residing in HICs, who were faced with the same barriers such as maternal employment and insufficient supply of breast milk, were more likely to compromise previously held infant-feeding beliefs and practices (Landolt & Wei Da, 2005;Ryan, 2007;Wall & José, 2004). This may be the result of prevalent breastfeeding practices observed in their host countries, such as the privacy of breastfeeding which reduced observational learning processes (Giles et al., 2007). Several studies have shown that migration from a lower income country into a HIC may have negative impacts on breastfeeding initiation, exclusivity, and duration (Dancel et al., 2015;Gibson-Davis & Brooks-Gunn, 2006;Harley, Stamm, & Eskenazi, 2007;Hawkins, Lamb, Cole, & Law, 2008;Nguyen et al., 2004;Textor, Tiedje, & Yawn, 2013;Twamley, Puthussery, Harding, Baron, & Macfarlane, 2011;Tyler, Kirby, & Rogers, 2014).
Several factors have been identified to influence breastfeeding practices, such as the mother's beliefs and knowledge about breastfeeding, the support available, the availability of formula milk alternatives, perception of cultural norms, and economic factors (Armstrong & Reilly, 2002;Baghurst et al., 2007;Bhopal, 2007;Dennis, 2006;Earle, 2002;Gallegos, Vicca, & Streiner, 2015;Howie, Forsyth, Ogston, Clark, & Florey, 1990;Meedya, Fahy, & Kable, 2010;United Nations Children's Fund, 2012). Earle (2002) found that many mothers made decisions about infant feeding practices long before conception and most of these decisions were based on hearsay, societal acceptability, and cultural beliefs. Such beliefs and assumptions held tenaciously create resistance to national and international recommendations on infant feeding (Kannan, Carruth, & Skinner, 1999).
Owing to the differences in breastfeeding beliefs and practices between those living in LMICs and HICs, there is evidence to show that immigrant mothers may or may not adopt practices of their host countries (Berry, 1997;Erten, van den Berg, & Weissing, 2018), despite the similarity of influential factors in both home and host countries McFadden, Atkin, & Renfrew, 2014).
A study conducted in Australia showed that African immigrant mothers maintained infant feeding practices from their countries of origin such as eating of special foods to aid milk production and enhance breastfeeding but also adopted some of the practices of the host country such as not breastfeeding in public places, which is contrary to practices in their home country . In the United States, breastfeeding is more commonly practiced among non-Hispanic whites than most minority groups (Louis-Jacques, Deubel, Taylor, & Stuebe, 2017), which is contrary to the United Kingdom, where breastfeeding rates are higher among ethnic minority mothers (McAndrew et al., 2012). Owing to this, an understanding of the factors that influence breastfeeding decisions and practices among different groups of mothers is necessary to understand why there may be differences in practices in different HICs, as well as offer adequate and relevant guidance to mothers regarding breastfeeding.
This mixed-methods systematic review therefore aimed to explore the beliefs, attitudes, knowledge, and practices of African immigrant mothers who reside in HICs and how these may differ from the beliefs and practices in their home countries.

| METHODS
A systematic review was carried out according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines (Moher, Liberati, Tetzlaff, & Altman, 2010). A review protocol was developed detailing the processes and methods to be used in

Key messages
• African mothers living in HICs consider breastfeeding as the natural and typical thing to do but tend to supplement with formula from as early as 3 months.
• Early supplementation with formula was associated with being in a high-income country.
• Lifestyle changes after migration and the cultural beliefs about breastfeeding, including the perceived need to supplement breastfeeding with formula to achieve a bigger baby, were the main factors influencing exclusive breastfeeding rates.
completing the review and was entered onto the National Institute for Health Research PROSPERO database.

| Search strategy
A detailed search strategy with keywords and indexed terms was developed with assistance from an information specialist at Newcas-

| Inclusion and exclusion criteria
Studies were included in the review if they met the following inclusion criteria: (a) primary research studies, (b) study participants were African mothers of childbearing age (16-45 years), who have migrated from an African country and are living in a HIC; (c) study was carried out in a HIC; (d) study was published in the English Language; and (e) study reported on any of the following outcomes: factors affecting choice of infant feeding such as beliefs, attitudes, facilitators, barriers, motivation or experience of breastfeeding, or breastfeeding practices such as initiation and duration of breastfeeding or weaning practices. Studies were excluded if participants were not clearly defined including definitions such as "Black," "African-American," or "Negroid." Immigration status of the mothers was not adequately explained or if human immunodeficiency virus-positive mothers were the sole focus of the study due to the uncertainties around infant feeding practices and options among human immunodeficiency virus-positive mothers (WHO et al., 2010).

| Study selection
All records identified from electronic database screening were imported into Endnote X8 and deduplicated. Screening by titles and abstracts was carried out, with three authors (AO, NE, and JR) independently screening a 10% sample of the identified studies and AO completing the screening of the remaining 90%. The full texts of the potentially relevant studies were assessed for relevance with two authors independently assessing an initial 30% for eligibility: LN screened 20%, WA screened 10%, and AO screened all 30%.
The remaining 70% full text studies were then checked for inclusion by one reviewer AO. Citation and reference searches of all included studies were completed by a single reviewer (AO), and the process was repeated for any additional studies eligible for inclusion.

| Data extraction
Two data extraction tools were developed and piloted for this review, one for qualitative studies and the other for quantitative studies. All data extraction was done independently by two reviewers. One reviewer (AO) extracted data from all included studies, and a second independent reviewer (JR, NE, and LN) each extracted relevant data from a third of the included studies. Discrepancies observed from the independently extracted data of each study were resolved in discussion (n = 2).

| Quality assessment
The Critical Appraisal Skills Programme checklist (Singh, 2013) was used to assess the quality of the qualitative studies included in the review, and the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (National Heart Lung and Blood Institute, 2014) was used to assess the quality of the included quantitative studies. The quality of each study was rated as good, fair, or poor. All included studies were assessed for quality by two reviewers independently: AO assessed the quality for all included studies, and three other reviewers (JR, NE, and LN) divided the included studies between themselves and each assessed a portion of the included studies for quality.

| Data synthesis
An integrated mixed-methods approach with elements of framework synthesis was used to synthesise the findings from individual studies. An integrated mixed-methods approach combines both quantitative and qualitative data into a single synthesis by either converting qualitative data into numerical format and included in statistical analysis or converting quantitative data into themes that can be coded and presented with qualitative data (The Joanna Briggs Institute, 2014). An a priori framework was identified, providing a pre-existing structure for the organisation and analysis of data, which is referred to as the framework synthesis approach (Barnett-Page & Thomas, 2009). The a priori framework was informed from existing literature and included themes from the existing literature, and additional themes that emerged from the review data were included during the analysis process as shown in Table 1. The data synthesis involved the following stages: familiarisation with the data, coding, identifying a thematic framework, charting the data into the framework matrix, and interpretation and was completed by one researcher with the guidance of an experienced qualitative researcher.

| RESULTS
A total of 6,005 studies were identified from database searching, and an additional 2,836 studies were retrieved from reference and citation searching, hand-searching of relevant journals, and grey lit- Note. Themes were adapted from existing a priori framework and emergent data from studies included in the review and developed into a final framework used in the qualitative data synthesis. Themes that were present in the a priori framework and absent from the studies included in the review were not included in the final framework used in the synthesis.
summary of the key characteristics and quality rating of the included studies is presented in Table 2.
The majority of the participants under study were immigrant mothers from Somalia Hill et al., 2012;Ingram et al., 2008;Steinman et al., 2010;  Face-to-face interviews and focus groups Cultural beliefs, traditional practices, barriers and enablers, and personal experiences in both the country of origin and Australia regarding breastfeeding.

Cross-sectional survey
Type of feeding mode used, relation of country of birth to feeding mode, duration of breastfeeding, time of introduction of solids, type of solids given, and vitamin supplements.

Good
Note. Quality assessment rating description: A study was rated "good" if the risk of bias was considered minimal, "fair" if there was some risk of bias but not sufficient to make the results invalid, and "poor" if there was substantial risk of bias that could significantly affect the interpretation of the results. Abbreviation: BME, Black and minority ethnicity; NHB, Non-Hispanic black.

| Breastfeeding initiation
Breastfeeding initiation rates are presented in Table 3. The average initiation rate across studies calculated using the corresponding sample sizes from each study was 90.2% for the 4,345 participants across all of the included studies. One study reported the odds of initiating breastfeeding of African as compared with "White" mothers to be 10 times more after adjusting for covariates . Timing for initiation of breastfeeding was reported in one study as 93% initiation within 24 hr .

| Breastfeeding duration
Breastfeeding rates between 1 week and 6 months are presented in Table 4. Studies describing breastfeeding rates at hospital discharge were reported as breastfeeding in the first week of life. Breastfeeding rates at 5 and 6 months of age were presented together. Total duration of exclusive breastfeeding or any breastfeeding is presented in Table 5 and ranged from 12 weeks  to 3 years .

| Complementary feeding
The age at which mothers introduced solids to their infants ranged from 3  to 6 months or more (

| Strategies to encourage breastfeeding
Among Somali mothers, ways to recognise infants' hunger and satiety were discussed. These included the infant's body language, ability of the infant to sleep and timing of infants' feeding, with timing of infant feeding being the most common method adopted . Mothers who did not adhere to specified timings to feed their infants expressed difficulty in understanding infant's feeding needs or hunger status Steinman et al., 2010). This contributed to early cessation of breastfeeding among Moroccan mothers in one study . Other infant-related reasons leading to early cessation of breastfeeding were colic, constipation, and vomiting . Mothers in the included studies further highlighted strategies they employed to increase their milk supply during lactation, such as the consumption of certain foods Steinman et al., 2010), having a healthy appetite , breastfeeding more , increasing fluid intake , or simply focusing on the child's needs . In some cases, however, the mothers were not certain how milk supply could be increased and suggested that it may be dependent on an individual's make-up and cannot be modified . Two cohorts studied. d Cohort 1 (C1) = an infant cohort of 9-month-old children. e Cohort 2 (C2) = a chid cohort of 9-year-old children.

T A B L E 3 Breastfeeding initiation rates
f Not included in aggregate percentage calculation. g Crude odds ratio (OR). h OR adjusted for gender of baby, parity, age of mother, housing tenure, household income, mother's education, mother's occupational social class, smoking status, mother's employment status, one or two parent household, and child care arrangements, i OR further adjusted for language spoken at home.
T A B L E 4 Breastfeeding rates in percentages according to type of feeding practices between 1 week and 6 months after birth OR adjusted for gender of baby, parity, age of mother, housing tenure, household income, mother's education, mother's occupational social class, smoking status, mother's employment status, one or two parent household, and child care arrangements.
f OR further adjusted for language spoken at home. and "reduced chances of breast cancer for the mother" in one study , "strong bones," "strength," and "good immunity" in another (Hufton & Raven, 2016), being "easier on the baby's digestive system" and "prevent illness" in another .

| Knowledge, beliefs, and attitudes towards
The "economic benefit of not having to purchase formula", "the emotional connection with the infant", "weight loss of mother", "the convenience of having a 'supply ready to go'", and "the developmental benefits to the infant" were other benefits highlighted in one study . Knowledge about EBF was not reported in most studies, but one study

| Beliefs around breastfeeding
The mothers described breastfeeding as "the natural thing to do" were presented in one study and included mother-infant closeness, infant's preference, soothing crying baby, and putting baby to sleep .
Beliefs around colostrum varied across studies. Two studies Textor et al., 2013) reported that Somali mothers believed in the tradition that the colostrum is "dirty milk" or danbar in Somali language because it has stayed too long in the breasts  and could make a baby sick . On the contrary, Somali mothers in another study considered colostrum as being fresh because it is the first milk the mother produces . Notwithstanding, these mothers held strongly to the belief that milk that sits in the breasts longer than 2 hr is old . Some of the Somali mothers had only given colostrum to their infants after migration and being informed by health professionals of its benefits . Among other African mothers from Sierra Leone, Congo, Burundi and Liberia, colostrum was deemed useful in cleansing the infant's intestines .
The mothers held strong opinions about giving an infant water within the first week of life. Some believed it was necessary because breastfeeding makes the infant thirsty , others used it for cleansing the infant's intestines , whereas others reported giving sweetened water, containing either sugar or honey at breastfeeding initiation . Some mothers reported that they only gave water in the summer when the weather was warmer, believing that the infant will need the extra fluid .

| Attitudes towards breastfeeding
A study on Somali mothers reported that mothers "displayed great affection" towards breastfeeding , and another study stated that the mothers "like breastfeeding and consider themselves good at it" . One study  indicated that Somali mothers often practice sexual abstinence during the first year of an infant's life to encourage breastfeeding.
Attitudes towards the use of breast pumps showed that the mothers were not familiar with breast pumps and its use Steinman et al., 2010 ;Wandel et al., 2016). They described breast pumps as being too cumbersome , difficult, and not a viable option if they were to breastfeed for as long as 2 years , as was the usual practice of the mothers.
Some mothers expressed interest in using breast pumps to continue breastfeeding for longer by saving up milk and increasing supply, but they either had limited experience with its use or were sceptical due to the belief that "breast milk spoils after too much time in the breasts" . One study, however, reported that some African mothers had fed expressed milk to their infants .
With respect to breastfeeding in public, the mothers stated that some stigma and shame were associated with breastfeeding in public in their host countries, resulting in the mothers feeding formula milk to their infants when in public Steinman et al., 2010;Textor et al., 2013;Twamley et al., 2011;Wandel et al., 2016).
Factors such as the lack of visibility of public breastfeeding , traditional unacceptability Twamley et al., 2011), being Black , and their religion (Islam) Wandel et al., 2016) were highlighted as reasons they felt "ashamed" to breastfeed in public.
Mothers who felt comfortable breastfeeding in public appeared to be mostly Muslims, who stated that their clothing helped them in such situations . Notwithstanding, they sought private places such as changing rooms and toilets, preferring places where they would not be seen by men, particularly because they felt the men of their host countries got offended seeing a breastfeeding lady .
Other negative emotions regarding breastfeeding in the HICs were reported. Mothers highlighted feelings of vulnerability and discrimination when interacting with health professionals, due to their minority status . They also expressed a fear of fitting in and doing things right  and fear and concerns around lactation, work, and their health . One study  highlighted that some mothers felt sadness, anger, and fear in relation to psychological violence within their families, as well as traumas following religious persecution in their native context, which led them to stop breastfeeding.
3.4 | Influence of socio-demographic, economic, and cultural factors

| Socio-demographic factors
The mothers reported a higher likelihood to practice EBF for 6 months in their home countries than to supplement  and described the use of formula as "a need to adopt the western approach" . Although one study  related the EBF for 6 months in their home country to a lack of finance to purchase required supplements, or the availability of adequate family and friends support to make the breastfeeding process easier and more effective, five studies Ingram et al., 2008;Steinman et al., 2010 ;Wandel et al., 2016) attributed supplementing with formula milk to being in a Western society. Not having enough milk to meet the baby's demands was seen as a problem associated with lifestyle changes and increased stress levels in HICs Steinman et al., 2010;Wandel et al., 2016). Although some mothers perceived the need to supplement as "copying the Western culture" , others saw it as being more convenient to balance their lifestyle demands with the care of their infants Steinman et al., 2010;Wandel et al., 2016), as a way to involve fathers and other family members , as a means to achieve a big "healthy" baby that is the acceptable standard within their communities Ingram et al., 2008;Steinman et al., 2010), or as the result of having insufficient knowledge of the strategies to overcome breast refusal .
Additionally, competing demands such as returning to work Castaldo et al., 2017;Fabiyi et al., 2016;Hill et al., 2012;Steinman et al., 2010), other children or becoming pregnant again Steinman et al., 2010), housekeeping Steinman et al., 2010), and other family members  were highlighted as factors that encouraged early supplementation with formula in order to receive assistance with feeding the infant from others, or in some cases, stop breastfeeding altogether. The mothers believed that returning to work led to reduced milk supply from insufficient time to breastfeed Steinman et al., 2010). Additionally, the mothers described the exhaustion they felt after childbirth Textor et al., 2013), such that the nurses sometimes had to help with feeding their infants . This contributed to the decision to stop breastfeeding among some mothers . Others indicated that in the absence of practical support in HICs, it was difficult to combine breastfeeding with everyday life , work, and necessary personal care including having a proper diet and adequate rest , two factors that were emphasised for achieving adequate milk supply . These demanding situations were said to result in exhaustion, loneliness, and depression but equally served as a source of encouragement for the women .

| Cultural factors
One of the major cultural factors affecting breastfeeding practices was the belief that infants need to be big or fat Gallegos et al., 2015;Ingram et al., 2008;Steinman et al., 2010;Textor et al., 2013;Twamley et al., 2011;Wandel et al., 2016).
The mothers believed that a big or "plump" baby is healthier and has more protection from illnesses, and having the ideal plump was linked to health, strength, and beauty Steinman et al., 2010;Twamley et al., 2011). The desire to achieve a bigger baby resulted in concerns about the sufficiency of the breast milk they produced for their infants' growth Gallegos et al., 2015;Steinman et al., 2010;Textor et al., 2013;Wandel et al., 2016) and was one of the reasons for breastfeeding cessation . Not being able to measure the milk from the breast was considered a challenge, which often led to early supplementation with formula milk Steinman et al., 2010;Textor et al., 2013).
The mothers often received praises from older women in their community for doing a good job when their infants were of a certain size , described by some as "just the right plump, not over-fat like obesity, just middle" .
Two studies Wandel et al., 2016) noted that the desire to have a big baby was strongest during infancy, particularly between 0 and 6 months , and reduced as the child approached school age to avoid being teased by peers.

| Economic factors
Only one study  discussed on the economic factors influencing breastfeeding. African mothers expressed a sense of increased financial security and financial freedom while living in a HIC, which contributed to early supplementing with formula milk.
The mothers expressed that formula milk was more accessible and affordable to them, and they were more likely to use it while in their host country compared with when they were in their home countries.
3.5 | Support system 3.5.1 | Support from friends and family African mothers reported having a strong support system as a traditional practice in their home countries, particularly from female friends and family members Gallegos et al., 2015;Ingram et al., 2008;. The most important source of support and information for most of the mothers was their own mothers (infant's grandmother; Gallegos et al., 2015;Hill et al., 2012;. A new mother may live with her mother for 1 to 2 years in order to get necessary help with childcare and housekeeping  or have the relative(s) or hired help to help out during the initial 40 days after birth . After migration to a HIC, they noted the absence of this kind of support but highlighted the possibility of replicating such practice by turning to female friends and relations . However, the busy schedules of most individuals in HICs meant that replicating this support system was often challenging and anyone who managed to get some sort of support similar to this was considered "lucky" . The support and information from female family and friends was given more recognition that health professionals' advice was often considered redundant .
Fathers were equally vital in offering support, often in the form of encouragement by recognising breastfeeding as part of the mother's job , and in providing assistance within the household . Traditionally, there was no expectation from African men to get involved with household chores or childcare , but the fathers had increased their involvement in household responsibilities after migration, taking the role of female family and friends in the absence of such support Twamley et al., 2011).
The kind of support mothers living in HICs received from friends and family included a wide range of information on breastfeeding Hill et al., 2012;Ingram et al., 2008;Steinman et al., 2010;Textor et al., 2013) and milk supply Hufton & Raven, 2016;Wandel et al., 2016), encouragement to breastfeed , and practical support such as feeding and caring for the infant Hufton & Raven, 2016;Ingram et al., 2008;Wandel et al., 2016) and assistance with household chores . Although, mothers were sometimes encouraged by friends and family to offer formula to infants from birth Wandel et al., 2016), infants' grandparents were said to be generally supportive of breastfeeding Hufton & Raven, 2016;Ingram et al., 2008;Wandel et al., 2016). However, the mothers felt pressured to listen to and act on breastfeeding advice and information received from friends and family Gallegos et al., 2015;Ingram et al., 2008;Textor et al., 2013;Wandel et al., 2016), and feared the stigma and criticism that could result from nonadherence . Whether it was encouraging breastfeeding or supplementing with formula, mothers explained that they lacked the confidence to go against the advice from the women in their community .
On the other hand, employers were said to be discouraging of breastfeeding .

| Support from health professionals
The mothers highlighted the information and support they received from health professionals in the host country Ingram et al., 2008;Steinman et al., 2010;Textor et al., 2013;Twamley et al., 2011;Wandel et al., 2016), which included information on the benefits of breastfeeding, breastfeeding positions, breastfeeding on demand, amount of breast milk needed, skin to skin contact, and rooming in with their babies.
Although this information was valued, the information received from health professionals sometimes conflicted their traditional beliefs and information from friends and family Ingram et al., 2008;Steinman et al., 2010;Textor et al., 2013;Twamley et al., 2011;Wandel et al., 2016), reducing the value of the Health professionals' advice . However, some mothers reported using their own judgements to make decisions between health professionals' advice and their traditional beliefs Wandel et al., 2016), especially women with previous experiences. Visits to the health clinics to obtain health professionals support, particularly in urban areas were sometimes considered stressful and worthless, and other times, they were reported as being very positive .
One major barrier identified by the mothers to receiving adequate support in the host environment was their language, as they were not fluent in the language of the host country Steinman et al., 2010;Wandel et al., 2016) and could not always get an interpreter Wandel et al., 2016). The absence of an interpreter potentially led to feelings of loneliness .
The mothers expressed a desire for additional and more "concrete" information, such as an understanding of "supply and demand" in breastfeeding and breast milk sufficiency to help them understand and deal with the challenges of breastfeeding Hufton & Raven, 2016;Ingram et al., 2008;Wandel et al., 2016), preferably in their native languages for easier comprehension . Mothers also discussed the desire for additional support in terms of peer support groups (Hufton & Raven, 2016), support from employers and workplaces , lactation support following discharge from hospital , as well as support groups set up for women of their culture .
Health professionals' perceptions were in agreement with the reports of the mothers, stating that African mothers had a tendency to introduce formula to their infants early, mainly due to their cultural beliefs Twamley et al., 2011). One such belief was that breast milk is not produced in the initial few days after delivery and that the first breast milk produced (colostrum) was "bad" or "dirty" , which resulted in delayed initiation of breastfeeding and the use of formula within the first few days of the infants' life . Another such belief was the desire to have a big baby, which resulted in mixfeeding or "topping-up," an on-going and common practice among African mothers .
The health professionals also acknowledged the influence of family and friends in encouraging supplementation with formula among African mothers, a practice that led to disappointment and frustration among health professionals . They explained that their biggest challenge in counselling immigrant mothers about breastfeeding was the cultural differences . Health professionals reported feeling unprepared to support women with different beliefs because the women sometimes were not interested in what they had to say or did not trust them  and seemed to value advice from their mothers more than from the nurses. They also reported that the presence of other family members during support sessions with the mothers interfered with their session and the mothers were reluctant to divulge information or breastfeed in such settings, due to their beliefs about exposing body parts . Health professionals felt that the cultural competence seminars they attended did not provide them with sufficient information and confidence to support immigrant mothers. Some health professionals reported supplying formula to the mothers because they were uncertain on how to alley their concerns .
Language was also highlighted by health professionals to be a major barrier to supporting immigrant mothers, even with the use of interpreters as they worried whether the interpreters were passing across the right messages. Additionally, most of the interpreters were male, which was considered inappropriate for breastfeeding support, and was therefore counterproductive . The need for increased awareness at local and national levels, as well as additional support and resources for immigrant mothers, especially those of refugee status was also identified by health professionals (Hufton & Raven, 2016).

| DISCUSSION
This mixed-methods systematic review presents a synthesis of the evidence on the factors influencing breastfeeding practices among mothers of African origin who have migrated to a HIC.
Breastfeeding initiation was high among the African mothers in this review but reduced considerably within the first few weeks. Data available on mode of feeding adopted and the duration varied widely across studies. However, it was clear that breastfeeding was fairly common among the mothers studied, but EBF for up to showed that EBF rates are low as a result of cultural practices such as discarding colostrum and pre-lacteal feeding (Engebretsen et al., 2014). Although EBF appears not to be widely practiced in African countries, formula feeding was not considered a common practice (Issaka et al., 2017). Breastfeeding in public was considered a factor influencing breastfeeding practices in HICs, and the mothers expressed the embarrassment and stigma associated with breastfeeding in public. However, some mothers found strategies to continue breastfeeding despite the inconvenience, whereas others resorted to formula feeding.
A review of the literature on the attitudes towards breastfeeding showed that some countries in Northern Europe and North Africa are beginning to accept public breastfeeding, whereas contrary to popular beliefs, some countries in Africa and Asia are discouraging of the practice (Komodiki, Kontogeorgou, Papastavrou, Volaki, & Genitsaridi, 2014). Similarly, a lack of adequate support in HICs influenced the breastfeeding practices of the mothers in this review and resulted in a change of roles for both fathers and mothers. The fathers got more involved in household responsibilities, whereas mothers had to work to support the family income. Friends and family were also usually too busy to offer much support, and when the mothers received the support they required, it became challenging to navigate information from varying sources such as health professionals and family members. Infants' grandmothers and other older mothers within the family were the most influential in the decisions around breastfeeding, similar to findings from studies of other immigrant populations (Lindsay, Le, & Greaney, 2017), and the mothers did not feel confident enough to go against their suggestions.
The health professionals' findings were in agreement with what the mothers reported, and they expressed that they faced challenges working with African mothers due to their cultural beliefs and the influence of their family members whose advice and opinion were more valued. This is contrary to the findings from a review of the belief, attitudes, and practices of Chinese immigrant mothers in developed countries (Lindsay et al., 2017) where the opinions of health professionals was found to be highly valued by the mothers. Language barrier was equally a major challenge highlighted by the health professionals, and the use of interpreters was sometimes perceived as inappropriate due to gender concerns.

| Quality of the evidence
The majority of the included studies had fair (n = 19) or poor (n = 3) ratings compared with 12 good-rated studies, suggesting that the findings should be interpreted with caution. Among fairly rated studies, most (n = 12) were rated so due to missing information on sampling strategy suggesting that there may be existing bias in the populations within individual studies and certain groups of individuals may have been over-or under-represented. Additionally, not adjusting for confounding variables and an absence of description of the analysis process was common among fair-rated studies (n = 8), and their results should be interpreted cautiously.
Three Textor et al., 2013;Tyler et al., 2014) of the included studies were rated as poor, and although they have been included in the synthesis, there was evidence from other better rated studies to support their findings. Despite the variability of data reported across studies and the poor rating of some studies, it was still possible to make some inferences from the data presented.

| Strengths and limitations
The methodological strengths of this review include the robustness of the searches that involved searching 12 databases, reference and citation searches of all included studies, and percentage double screening, data extraction, and quality assessment. Adopting an integrated mixed-methods approach meant that all elements of the data presented in individual studies were presented in the analysis and adopting elements of framework synthesis helped to capture existing evidence while identifying the gaps in the evidence. All studies meeting the inclusion criteria were included irrespective of the year or publication or study design (qualitative or quantitative), with the majority of quantitative studies being cohorts, strengthening the available evidence for the review.
However, limiting included studies to only studies published in the English language or with existing translations implies that some relevant information may have been missed from the review. Additionally, it was not possible to contact all the authors where required either because the authors did not respond to several attempts at making contact or author contact information could not be retrieved.
One potentially relevant quantitative study (Merten, Wyss, & Ackermann-Liebrich, 2007) was not included in the review because the data presented in the study was unclear, and the authors could

| CONCLUSION
African mothers who have migrated to HICs are faced with challenges to their breastfeeding practices and experiences. Although these mothers appear keen to exclusively breastfeed, they are unable to, and additional support and information may be required to increase breastfeeding rates among African mothers living in HICs. An improved understanding of how migration influences breastfeeding, and how health professionals can better support African mothers who have migrated to HICs, may improve breastfeeding success. However, the contradictions in the beliefs and attitudes among the mothers show that there is no singular belief system among all African mothers and the approach to supporting mothers needs to be individualised. Future research should aim to explore the evidence gaps identified in this review such as studying a more varied population of African mothers including those with refugee and non-refugee status.