Both mothers and fathers mentioned beliefs and knowledge about breastfeeding benefits that were identified facilitators of breastfeeding. Participants discussed that breastmilk was nutritious, would make the baby grow to be smart, and would protect against disease as well as promote healthy growth. These findings are consistent with previous qualitative studies in Nigeria [16], Ghana [17], and Zimbabwe [18] which found that beliefs or knowledge about breastfeeding were facilitators of breastfeeding. Knowledge is an important part of behavior change and is an aspect of social and behavior change communication (SBCC) interventions [19]. The use of SBCC for improving breastfeeding practices has been widely shown to be effective across many countries [19]; however, evidence of the effectiveness of SBCC in protracted settlements and among refugees is limited. Because beliefs and knowledge were facilitators of breastfeeding in this study, it is important that interventions aiming to improve breastfeeding consider these two individual factors. Furthermore, training healthcare staff and community health workers to provide and communicate the benefits of breastfeeding to mothers during their antenatal and postnatal visits would be beneficial.

Fathers described different ways that they support breastfeeding mothers including contributing to household chores, procuring food, and providing emotional support.

Likewise, in Zimbabwe, the presence of a spouse who assisted with chores was a facilitator of breastfeeding [18] and in Ethiopia, fathers supported breastfeeding mothers by providing and contributing to meal preparation [20]. A recent systematic review revealed different ways fathers’ were involved in supporting breastfeeding mothers, including verbal encouragement and helping with household and child care responsibilities [21]. However, none of these studies were conducted among refugees in protracted settlements where fathers may not be present in the household for a variety of reasons including working in their home country or death during conflict. Additionally, a review of 28 projects in 20 low- and middle-income countries did not find consistent associations between male engagement and increases in breastfeeding and noted that there is currently a lack of evidence to make broad recommendations about targeting male engagement to improve breastfeeding [22]. Furthermore, reported defined gender roles among South Sudanese indicate that fathers are responsible for financially providing for their families while the mothers are responsible for household chores [23]. Therefore, future research may consider a more in-depth analysis of local gender norms, fathers’ presence in the protracted settlements, the level of influence they have in breastfeeding decisions, and the type of support they can offer. This information could inform whether father involvement would be an effective factor in supporting breastfeeding. A few participants mentioned community support as a facilitator of breastfeeding. Participants discussed how breastfeeding mothers receive help from relatives, such as grandmothers, and from neighbors. Interestingly, the type of support mentioned included material support such as food, firewood, and drinking water. Similar results have been found among refugee mothers in Syria; those who did not receive social support from relatives stopped breastfeeding [23]. Furthermore, in Ethiopia, breastfeeding mothers received support from grandmothers; however, the support differed in that grandmothers in Ethiopia also provided childcare and housework assistance for breastfeeding mothers [20]. A systematic review that assessed grandmothers’ roles in breastfeeding found that grandmothers can be influential in breastfeeding decisions and recommended that interventions aiming to improve breastfeeding should consider including grandmothers [24]. Future research might explore the family dynamics among refugees living in protracted settlements to better understand the role and influence of grandmothers on breastfeeding in a new environment.

Organizations such as Medical Teams International (MTI) and Plan International were cited as the NGOs providing support to breastfeeding mothers. Plan International provided breastfeeding education and both MTI and Plan International gave flour for porridge for breastfeeding mothers. While NGOs have generally not been mentioned as facilitators of breastfeeding in previous literature, in the context of protracted settlements, the presence of partners and NGOs with breastfeeding initiatives may be more common and might be an important avenue for improving breastfeeding practices among refugees. Interestingly, participants did not mention support from community health workers, medical staff, or peers as facilitators to breastfeeding. Support from peers has been shown to be an effective way to promote breastfeeding [25]. A systematic review and meta-analysis of the effectiveness of community-based peer support for mothers to improve breastfeeding practices, reported that in low- and middle-income countries, community-based peer support increased exclusive breastfeeding, compared to the standard care [26]. Interventions, facilitated by NGOs, or in partnership with the local health care system, involving the use of peers may provide efficient, cost-effective, and sustainable ways to improve breastfeeding among refugees living in protracted settlements.

While knowledge of breastfeeding benefits was an identified facilitator, the lack of knowledge of breastfeeding recommendations was a barrier. Many participants, both mothers and fathers, stated that infants under six months could receive supplemental feedings that included items such as powdered milk diluted with water, cow’s milk, juice, formula, or margarine. Introducing complementary feedings before six months and poor rates of exclusive breastfeeding have been reported previously in this area [10]. These results highlight the need for continued emphasis on education about infant and young child feeding practices at antenatal care, place of delivery, and postnatal care.

Breastfeeding difficulties and inadequate breastmilk supply were among the two main physical barriers preventing mothers from breastfeeding. Both mothers and fathers reported that mothers may not be producing enough breastmilk or may experience issues where the child is not breastfeeding well. While perceived low milk supply has been documented in many different contexts and is a common barrier to breastfeeding [20, 22, 27], it is uncertain if maternal perception of inadequate breastmilk is accurate. In order to overcome this barrier, it would be important for mothers to receive education about maternal factors that influence breastmilk supply and how to identify inadequate production. Ideally, such discussions would be best during antenatal care so that mothers are equipped to identify these issues early in their breastfeeding experience. Furthermore, hospitals and other places of delivery may consider training their staff on solutions to common lactation issues that mothers may face during the postnatal period, as well as expansion of community-based support for mothers who lack access to healthcare facilities.

Socioeconomic factors such as working status and education level were barriers mentioned by a few mothers. Despite only 14.3% of mothers working outside the home, this factor was identified as being a barrier to breastfeeding. A systematic review of factors influencing breastfeeding that included 25 studies from 19 countries found that in the majority of the studies, maternal employment outside the home was negatively associated with exclusive breastfeeding [28] which also is consistent with findings in more recent studies [20, 22, 27]. Overcoming this barrier may be very challenging, depending upon the type of the mother’s work outside the home. More information is needed from breastfeeding mothers about their specific barriers to work outside the home. Policies for working mothers may need to be implemented in both formal and informal settings, to allow them to bring their child to work and to allow time throughout the day for breastfeeding. Implementing policies for breastfeeding mothers in informal sectors may be more difficult and may require the influence of strong governmental policies.

The finding that mothers who have more education will chose other milk for their infants is consistent with a recent study in Uganda where mothers felt that if they have enough money, they should not allow their babies to breastfeed [29]. However, other studies have reported that higher education levels are often positively linked to breastfeeding [30,31,32], and low maternal education has been identified as a risk factor for suboptimal breastfeeding practices [33, 34]. Furthermore, a recent systematic review of 81 low- and middle-income countries found that compared to women with primary, secondary or higher education, women with no formal education had poorer adherence to breastfeeding indicators [35]. The inconsistent findings and variations across countries in the association between education level and breastfeeding may highlight specific cultural or societal beliefs influencing mothers. In a recent study in Uganda, participants reported a belief that breastfeeding was for poor women who could not afford an alternative [29].

In the context of refugees in settlements, formula is often one of the first donations to arrive in settlements and its’ donations remain unregulated. It has been noted that mothers who receive donations of formula may perceive it to be superior to breastmilk, and thus formula donations may serve as an impediment to exclusive breastfeeding among refugees in settlements. This reemphasizes the need for policies to regulate and control wide-spread donations of formula in refugee settlements, as well as provide information and support to breastfeeding mothers [36]. Combined with improvement in policies, future research is needed to better understand why mothers with presumably more knowledge about the benefits of breastfeeding may prefer breastmilk substitutes over breastfeeding. Further understanding of these beliefs would inform interventions designed to improve breastfeeding among mothers regardless of their educational level.

Only a few fathers discussed psychosocial barriers such as marital conflict, mothers’ fear of pain during breastfeeding, and maternal mental health issues. Marital conflict, in the form of intimate partner violence (IPV) [37,38,39] and maternal mental health issues [40,41,42] have a negative influence on breastfeeding. Refugees are at increased risk for mental health issues [43] and refugees living in Uganda’s protracted settlements often suffer from psychosocial difficulties [44,45,46,47,48,49].

Interestingly, none of these psychosocial barriers were reported by the mothers in the FGDs. Possibly the mothers felt uncomfortable disclosing marital conflict or mental health issues as stigma regarding mental health problems has been documented among refugees [50] and specifically, among the South Sudanese population [51]. These results highlight the importance of including FGDs for fathers as well as mothers because both parents may provide additional insights essential to improving breastfeeding practices. Furthermore, screening for IPV and maternal mental health during antenatal and postnatal care may be imperative to improve breastfeeding among mothers living in these protracted settlements. However, for maternal mental health issues to be addressed adequately, reducing the stigma around these types of issues will be necessary so that individuals are willing to access available resources.

A psychosocial factor not mentioned by fathers or mothers is self-efficacy or the confidence in ability to breastfeed which is reportedly a known facilitator of breastfeeding [32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56]. A systematic review and meta-analysis that included 24 randomized controlled trials from 14 countries found that theory-based educational interventions have been effective in improving breastfeeding self-efficacy and breastfeeding rates at 6 months [57]. Assessing self-efficacy concerns of refugee women could inform the design of effective breastfeeding interventions among this population.

Although participants from different protracted settlements were included, the results may not be generalizable across all refugees from other districts. Furthermore, parents who were willing to participate may not be representative of the population. Lastly, limitations arising from social desirability bias were possible due to the nature of qualitative research and may explain some of the differences between the responses of mothers and fathers.