Prevalence and Associated Factors of Early Initiation of Breastfeeding

Getnet et al. Maternal Health, Neonatology, and Perinatology (2020) 6:6 Maternal Health, Neonatology, https://doi.org/10.1186/s40748-020-00121-3 and Perinatology

RESEARCH ARTICLE Open Access Prevalence and associated factors of early initiation of breastfeeding among women delivered via Cesarean section in South Gondar zone hospitals Ethiopia, 2020 Bekalu Getnet1* , Alemu Degu1 and Fantahun Yenealem2

Abstract Background: Early initiation of breastfeeding is putting the newborn to breast within one hour after birth. This study was aimed to assess prevalence of early initiation of breastfeeding and its associated factors among mothers who delivered by cesarean section in South Gondar Zone hospitals Northwest Ethiopia, 2020. Methods: An institutional based cross-sectional study was employed in South Gondar Zone hospitals from June 12 to July 03, 2020. A total of 356 cesarean delivered mothers were included. Data were collected using interviewer administered questionnaire and entered in to Epi Data version 4.2 and then exported to SPSS version 23.0. Logistic regression statistical analyses were used to identify factors associated with the outcome variables. Results: The prevalence of early initiation of breastfeeding among mothers who delivered by cesarean section was 51.9%. Mothers who had intended pregnancy [AOR = 2.69, 95% CI (1.34–5.38)], had professional guidance [AOR = 2.68, 95% CI (1.18–6.10)], had breastfeeding experience [AOR = 2.25, 95% CI (1.35–3.75)], and had four and above antenatal care visits [AOR = 2.20, 95% CI (1.24–3.91)] were positively associated with early initiation of breastfeeding among mothers who delivered by cesarean section. Conclusion: Type of pregnancy, professional guidance, had four or more antenatal care and breastfeeding experience were significantly associated with early initiation of breast feeding among mothers who delivered by cesarean section. Community based breastfeeding education and counseling to pregnant mothers and encouraging all mothers to follow recommended ANC visit is should be recommended. Keywords: Early initiation of breastfeeding, Cesarean delivery, Ethiopia

Introduction Early breastfeeding initiation (EIBF) is described as Breastfeeding (BF) is the process of feeding the infant breastfeeding of the newborn within one hour of birth with the mother’s milk either pumped or expressed [1]. and is the easiest, most cost-effective, and most success- It also a key public health strategy to reduce infant, ful intervention. It is one of the 10 steps of successful BF child, and maternal morbidity and mortality and helps to practice and one of the key indicators for assessing ap- control health care costs [2]. propriate infant and young child feeding practices [3]. The importance of early initiation of breastfeeding could increase the likelihood of success in breastfeeding * Correspondence: [email protected] 1Department of Midwifery, College of Health Sciences, Debre Tabor [4–6]. University, P. Box: 272, Debre Tabor, Ethiopia Full list of author information is available at the end of the article

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Getnet et al. Maternal Health, Neonatology, and Perinatology (2020) 6:6 Page 2 of 9

Delivery by cesarean section is an operational ap- South Gondar Zone Hospitals, North West Ethiopia, proach that substitutes the natural delivery process. Its 2020. rate has continued to rise over the last few decades, and further research has also shown that delivery by cesarean Methods and materials section is associated with non-initiation or delayed initi- Study area and period ation of breastfeeding as well as with discontinuation of The study was conducted in South Gondar Zone Hospi- exclusive breastfeeding [7]. tals from 12 June 2020 to 03 July 2020. South Gondar ’ According to UNICEF s recent survey, 78 million or Zone, which is located in the central part of the region 60 % of infants were not breastfed within the first hour of Amhara and the north-western part of Ethiopia. The of birth, results putting them at risk of illness and even area is situated about 668 km away from the capital city death [8]. of Ethiopia, Addis Ababa, and 103 km away from the Neonatal hypothermia and infection are among the Bahir Dar city of Amhara. Debre Tabor is the adminis- different causes of neonatal death due to delayed breast- trative town of the South Gondar Zone. The area has 18 feeding initiation (DIBF) [9]. Woredas with a population of 2,609,823 (1,304,911 fe- In developing countries alone, an EIBF could save as males and 1,304,912 males). The area also includes eight many as 1.45 million lives each year by reducing deaths government hospitals, 96 public health centers, 140 pri- mainly due to diarrheal disorders and lower respiratory vate clinics, and 403 health centers [28]. tract infections in children [10]; However, children also die from diarrheal disorders and low respiratory tract infections in the area due to DIBF [11]. Study design In Ethiopia, making it 6th highest neonatal mortality in An institutional-based cross-sectional study was conducted. the world, and children are still dying in large numbers from preventable and treatable causes, like DIBF [12]. Population The prevalence of early initiation of breastfeeding The source population was all mothers who delivered by increased from 48.8% in 2000 to 75.7% in 2016 in cesarean section in South Gondar Zone hospitals; while Ethiopia [13]. all mothers who delivered by cesarean section in South Cesarean Delivery (CD) is also one of the factors that Gondar Zone hospitals during the study period were may influence the initiation and continuation of breast- considered as the study population. feeding, however findings are inconsistent and showed ’ that CD had a detrimental effect on the mother s ability Eligibility criteria to initiate and sustain breastfeeding [14, 15]. All mothers who gave birth and registered in the deliv- Other factors following the review of the literature ery registration book in South Gondar Zone hospitals have also shown that residence, maternal education, and were included in the study. Whereas mothers delivered occupation, maternal knowledge of the EIBF, breastfeed- under general anesthesia and baby have any health prob- ing experience, visit the ANC, number of visits to the lem which requires separation from the mother; which ANC, EIBF support during the ANC visit, parity, type of needs admission to NICU were excluded from the study. pregnancy, EIBF professional support, infant sex, colos- trum feeding status and family support had such a significant impact on early breastfeeding [4, 16–25]. Sample size determination By recognizing the unquestionable role of the EIBF in The sample size was calculated using the single population reducing infant mortality, the Ethiopian Ministry of proportion formula and the required sample size for this Health was targeting to increase the proportion of new- study was determined using the following assumptions; α born babies breastfeeding to 92% by 2015 in the first desired precision (d) = 5%, Confidence level = 95% (Z / hour of life [26]; however, the Ethiopian Demographic 2 = ±1.96 value), and the prevalence of early initiation of and Health Survey (EDHS) showed that the proportion breastfeeding was 66% [27]. Hence, the final calculated of children who were breastfed in the first hour of life sample size with a 5% non-response rate was 356. was 73% and the EIBF region of Amhara was 66% [27]. Although evidence on the prevalence and associated Sampling procedures factors of EIBF in different parts of the world, there has All hospitals that provide a cesarean section were taken been a lack of information on the proportion and associ- to get a sufficient sample. Then, a sample from each ated factors of early breastfeeding among cesarean deliv- hospital was determined using proportional allocation to ered mothers to date. Therefore, this study aimed to size (PAS). Finally, simple random sampling was used to assess the proportion of EIBF among cesarean delivered select all mothers who delivered by cesarean section to mothers and to identify the factors affecting EIBF in got the desired sample size (see Fig. 1). Getnet et al. Maternal Health, Neonatology, and Perinatology (2020) 6:6 Page 3 of 9

Fig. 1 . Schematic presentation of sampling procedures in selecting CD mothers in South Gondar zone hospitals, 2020. NB: DGH- Debre Tabor General Hospital, NMH- Nifas Mewucha Hospital, MEH- M/eyesus Hospital, AZHA/Zemen Hospital, EBH- Ebenat Hospital, AGH- Arba Gebeya Hospital, SH- Simada Hospital and AH- Andabet Hospital.

Study variables was dichotomized into good knowledge ≥ mean, poor Dependent variables knowledge < mean [29]. Early initiation of breastfeeding (yes/no) Professional guidance to initiate BF Independent variables Professionals, who counsel and assist the mother by Maternal and husband socio-demographic factors (age, showing how to hold the baby, how to practice position- religion, marital status, residence, educational status, oc- ing and attachment to initiate breast feeding within one cupation); Maternal knowledge on EIBF and breastfeed- hour. ing experience; Obstetric & health service-related factors (history of ANC visit, place of ANC, number of ANC Social/family support to EIBF visits, parity, counseling on EIBF during ANC, profes- Any attendant who encourages, assist the mother and sional guidance to initiate BF, type of pregnancy and share experience for the mother to initiate breast feeding duration of labor pain) and Social related factors (social/ within one hour. family support on EIBF). Data collection procedures Instrument Operational definitions A pretested and structured questionnaire was used for Early initiation of breast feeding data collection. The questionnaire was adopted after Mothers who had initiated breastfeeding within one reviewing similar work in professional literature. The hour after birth [28]. tool first prepared in English then translated to Amharic and back to English by a language expert to maintain Knowledge about early initiation of breast feeding the consistency of the instrument. Mothers were asked eight knowledge related questions regarding EIBF and each correct answer was given a Data collector’s selection and training value of 1 and an incorrect answer a value of 0. After Eight diploma holder nurses conducted the face to face computing the sum for each respondent and mean, it interviews and four BSc degree midwives supervised the Getnet et al. Maternal Health, Neonatology, and Perinatology (2020) 6:6 Page 4 of 9

data collection process. The data collectors and supervi- Maternal knowledge on early initiation of breastfeeding sors were trained for 1 day about the contents of the and breastfeeding experiences questionnaire, methods of data collection, and the aim Two hundred fifty-one (71.9%) of mothers heard about of the study. EIBF. Regarding the source of information about EIBF, 314 (90%) of mothers reported that the main source of information about EIBF was health professionals. Almost Data collection all mothers, 347 (99.4%) reported that breast milk must The study participants were given an introduction about be given first for the baby after delivery. Two hundred the study as well as the opportunity to ask questions thirty-one (66.2%) of mothers knew about the recom- about the study and questionnaires were disseminated. mended time of initiating BF. Concerning maternal knowledge on EIBF, two hundred fifty-one (71.9%) of mothers had good knowledge about EIBF. Regarding BF Data quality management experience, 179(51.3%) of mothers were experienced in The data collectors were trained for one day about the BF (see Table 2). contents of the questionnaire, methods of data collection, and the aim of the study. Any error, ambiguity, or Obstetric and health service-related characteristics of the incompleteness identified was corrected immediately. A respondents pre-test was conducted on 36 mothers who gave birth Regarding the type of pregnancy, 264 (75.6%) of mothers by cesarean section in Felege Hiwot referral hospital; reported that their pregnancies were intended. Almost then the instrument was amended accordingly. The data all mothers 346 (99.1%) of mothers had a history of collection process was supervised by the supervisor and ANC visits during their pregnancy. Seventy-two (19.8%) the investigator throughout the data collection period. of mothers had got EIBF counseling during ANC visit. Concerning professional guidance to EIBF, two hundred Data processing, analysis, interpretation and presentation ninety-seven (85.1%) of mothers had professional guid- Once all necessary data obtained, data were checked for ance to EIBF. One hundred eighty-four (52.7%) of completeness. The collected data were entered and mothers were multigravida. Regarding the duration of ’ cleaned using Epi data version 4.2, then exported to labor pain, 322 (92.3%) of mothers labor pain was less SPSS version 23 for analysis. Descriptive analysis was than 12 h (see Table 3). conducted to summarize the data and the final result of the study was interpreted in the form of text and tables. Prevalence of early initiation of breastfeeding among Binary logistic regression analysis was executed to see mothers delivered by cesarean section the association between independent and dependent var- The prevalence of early initiation of breastfeeding among iables. All explanatory variables with p < 0.2 in bivariable mothers who delivered by cesarean section in South Gon- logistic regression were entered into multivariable logis- dar Zone hospitals were 51.9% with 95% CI (47, 57%). tic regression analysis and significant association was identified based on p < 0.05 and odds ratio with 95% CI Reasons for late initiation of breast feeding in multivariable logistic regression. The main reasons for delayed initiation of breastfeeding claimed by the study participants were 58% of cesarean surgery-related pain and discomfort, 34.6% of delayed Result milk secretion, and 2.8% of late shifting from the recov- Socio-demographic characteristics of the participants ery room. Among the total of 356 mothers, 349 mothers were participated in the study making a response rate of 98.03%. Factors associated with EIBF among mothers delivered by The highest proportion, 138(39.5%) mothers were in the cesarean section age group of 25–29 years. The mean age of the mother On multivariable logistic regression analysis: Factors was 26.85 (SD ± 5.26) years. More than three fourth such as professional guidance to early initiation 268(76.8%) of mothers were urban residence. Almost all breastfeeding, type of pregnancy, number of ANC mothers, 341 (97.7%) were Amhara in ethnicity and visits, and breastfeeding experience were significantly 261(74.8%) mothers were Orthodox Christian followers. associated with EIBF among mothers who delivered Regarding the educational status of mothers, 196(56.3%) by cesarean section. Mothers who had received pro- mothers were completed at least secondary school. fessionalguidancetoEIBFwere2.68times(AOR= Concerning the educational status of the husbands, 2.68, 95% CI = 1.18, 6.10) more likely to initiate 244(69.9%) husbands of mothers were attending at least breastfeeding early as compared to those mothers secondary school (see Table 1). who had not received professional guidance to early Getnet et al. Maternal Health, Neonatology, and Perinatology (2020) 6:6 Page 5 of 9

Table 1 Socio-demographic characteristics of mothers and their husbands in south Gondar zone hospitals, Northwest, Ethiopia, 2020. Variable EIBF(n=349) Yes No Frequency Percent Frequency Percent Maternal age 15-19 5 1.4 18 5.2 20-24 47 13.5 48 13.8 25-29 80 22.9 58 16.5 30-34 40 11.5 32 9.2 35 and above 9 2.6 12 3.4 Residence Urban 156 44.7 112 32.1 Rural 25 7.2 56 16 Marital status Married 175 50.1 150 43 Unmarried# 6 1.7 18 5.2 Religion Orthodox 134 38.4 127 36.4 Muslim 37 10.6 38 10.9 Others* 10 2.9 3 0.9 Maternal education Not formal education 24 6.9 46 13.2 Primary school 47 13.5 48 13.8 Secondary school and above 110 31.5 74 21.2 Husband education Not formal education 16 4.6 33 9.5 Primary school 20 4.7 36 10.3 Secondary school and above 145 41.5 99 28.4 Maternal occupation Government employed 37 10.6 24 6.9 Self employed 43 12.3 22 6.3 Daily laborer Housewife 5 1.4 15 4.3 Farmer 70 20.1 53 15.2 others 26 7.4 54 15.5 Husband occupation Government employed 73 22.5 39 12 Self employed 72 22.2 52 16 Daily laborer 7 2.2 10 3.1 Farmer 23 7.1 48 14.8 Other* protestant, catholic, Jehovah, no religion; # Single, divorced and widowed

initiation of breastfeeding. Mothers who had intended and above ANC visits were 2.20 times (AOR = 2.20, pregnancy were 2.69 times (AOR = 2.69, 95% CI = 95% CI = 1.24, 3.91) more likely to initiate BF early as 1.34, 5.38) more likely to initiate BF early as com- compared to those mothers who had less than four pared to their counterparts. Mothers who had four ANC visit. Mothers who had breastfeeding experience Getnet et al. Maternal Health, Neonatology, and Perinatology (2020) 6:6 Page 6 of 9

Table 2 Maternal knowledge on EIBF and BF experience in Table 3 Obstetric and health service-related characteristics of south Gondar zone hospitals, northwest Ethiopia, 2020. mothers versus EIBF among cesarean section mothers in south Variable EIBF & BF(n=349) Gondar zone hospitals, Northwest Ethiopia, 2020. Yes No Variable EIBF & BF(n=349) Frequency Percent Frequency Percent Yes No Did you hear about BF? Frequency Percent Frequency Percent Yes 189 54.2 62 17.7 Type of pregnancy No 35 10.02 63 18.05 Intended 161 46.1 103 29.5 Source of Information Unintended 120 5.7 65 18.6 Health professional’s 172 49.3 142 40.7 Place of ANC follow up Media 21 6.02 14 4.01 Public institution 71 20.5 137 39.6 Did you know recommended timing of initiating of BF? Private clinic 63 18.2 18 5.2 Yes 178 51 53 15.2 NGO maternity center 47 13.6 10 2.9 No 21 19.2 51 14.6 Number of ANC visit Maternal knowledge on EIBF & BF Less than four visits 51 14.7 21 6.1 Good 227 65.04 24 6.9 Four and above visits 130 37.6 144 41.6 Poor 77 22.1 21 6.01 EIBF counseling during ANC visits Breast feeding experiences Yes 227 65.04 24 6.9 Yes 144 14.3 35 10.02 No 77 22.1 21 6.01 No 120 34.4 50 14.3 Duration of labor Less than 12 hours 172 49.3 150 43 were 2.25 times (AOR = 2.25, 95% CI = 1.33, 3.75) Greater than 12 hours 9 2.6 18 5.2 more likely to initiate breastfeeding within one hour Received professional Guidance for EIBF as compared to their counterparts (see Table 4). Yes 169 48.4 128 36.7 No 12 3.4 40 11.5 Discussion Parity The study was aimed to determine the prevalence of Primi 66 18.9 99 28.4 early initiation of breastfeeding and associated factors among mothers who delivered by cesarean section in Multi 115 33 69 19.8 South Gondar Zone hospitals in Northwest Ethiopia. This study revealed that the prevalence of early initi- Mothers who were received professional guidance for ation of breastfeeding within one hour among mothers early initiation of breastfeeding were 2.68 times more who delivered by cesarean section was found to be likely to initiate breastfeeding early [AOR = 2.68, 95% 51.9%. This is lower than the study conducted in differ- CI = (1.18–6.10)] as compared to their counterparts. ent parts of Ethiopia [22, 27, 30]. The variation might be This finding was supported by a study conducted in due to differences in the study setting, study population, Brazil [35], Indonesia [16], Bangladesh [17], and Uganda and time period of the study. [18]; which showed that professional assistance or guid- This level of early initiation of breastfeeding was found ance after delivery increase early initiation of breastfeed- to be high as compared to the studies done in Bangladesh ing by mothers. [31], India [32], Kenya [33], and Egypt [34]. The possible This might be because encouragement and motivation reason for this variation might be variation in the study from health workers help mothers to take a stand in period, sample size, maternal socio-demographic charac- EIBF practice. A skilled and properly trained health care teristics like access to information, educational status, the provider can motivate mothers to initiate early breast- cross-cultural difference in breastfeeding practice, and feeding and explain its advantages, counsel on dangers health service utilization characteristics. of pre-lacteal feeding and its long-term risk, and the Received professional guidance for early initiation of benefits of EIBF and continuation of breastfeeding [36]. breastfeeding, the number of antenatal care visits, types ANC frequency was another factor that was signifi- of pregnancy, and previous breast-feeding experience cantly associated with EIBF among CD mothers. Those were significantly associated with the practice of early cesareans delivered mothers who had four and above initiation of breastfeeding among mothers who delivered ANC visits were two times more likely to initiate breast- by cesarean section. feeding early [AOR = 2.20, 95% CI = (1.24–3.91)] as Getnet et al. Maternal Health, Neonatology, and Perinatology (2020) 6:6 Page 7 of 9

Table 4 Multivariable analysis of EIBF among mothers who delivered by cesarean section in south Gondar zone hospitals, Northwest, Ethiopia, 2020(n= 349). Variable EIBF COR, 95%CI AOR, 95%CI P value Yes No Residence Urban 156 112 3.12 (1.83, 5.30) 1.57 (0.56, 4.39) 0.38 Rural 25 56 1 1 Maternal education No formal education 24 46 1 1 Primary school 47 48 1.87 (0.99, 3.54) 0.81 (0.32, 2.07) 0.67 Secondary & above 110 74 2.84 (1.60, 5.06) 0.45 (0.16, 1.28) 0.14 Received professional guidance to EIBF Yes 169 128 4.40 (2.21, 8.72) 2.68 (1.18, 6.10) 0.019* No 12 40 1 1 No of ANC visit > Four 139 79 3.72 (2.35, 5.90) 2.20 (1.24, 3.91) 0.007* ≤ Four 42 89 1 1 Duration of labour ≤ 12 hours 172 150 2.29 (1.1, 5.25) 1.57 (0.56, 4.40) 0.38 > 12 hours 9 18 1 1 Type of pregnancy Intended 161 103 5.08 (2.90, 8.88) 2.69 (1.34, 5.38) 0.005* Unintended 20 65 1 1 Knowledge on EIBF Good 140 111 1.75 (1.09, 2.81) 1.47 (0.83, 2.61) 0.17 Poor 41 57 1 1 BF experience Yes 111 68 2.33 (1.51, 3.58) 2.25 (1.35, 3.75) 0.002* No 70 100 1 1 *p- value <0.05, ** p-value <0.01 compared to those who had less than four ANC visit. the fact that a woman’s attitude toward her baby can This finding was consistent with a study conducted in affect her likelihood of baby-care and consequently her Dembecha [37] and western Ethiopia [20]. This could be decision to initiate breastfeeding. because mothers who had frequent antenatal care visits Mothers who had previous breastfeeding experience during their pregnancy could access frequent counseling were 2.25 times more likely to initiate breastfeeding sessions on the importance of EIBF, and thereby more within one hour [AOR = 2.25, 95% CI = (1.35–3.75)] as likely to practice it. But the finding of this study was in- compared to their counterparts. This finding was sup- consistent with a study conducted in Axum [38] and ported by studies conducted in Tabriz, state of eastern Debre Birhan [24] which showed that number of ANC Azerbaijan [19] and Egypt [39]. The reason for this visit did not influence EIBF. might be due to mothers whose breastfeeding experience Type of pregnancy was also significantly associated might have exposure to professional counseling, their with early initiation of breastfeeding among mothers experience on how to breastfeed the baby and experi- who delivered by cesarean section. According to this ence how to position, and attach the baby might help finding mothers with intended pregnancy were more the mothers to initiate breastfeeding early. likely to initiate BF early [AOR = 2.69, 95% CI = (1.34– The limitations of this study include; the cross- 5.38)] as compared to mothers with unintended preg- sectional nature of this study limits to set a causal-effect nancy which was consistent with a study conducted in relationship between dependent and independent vari- Turkey [25] and Nigeria [21]. This could be explained by ables. Since it is based on mothers report the exact time Getnet et al. Maternal Health, Neonatology, and Perinatology (2020) 6:6 Page 8 of 9

that is the first one hour after birth might be difficult to Consent for publication measure. Selection bias might be also the limitation of Not applicable. the study. Competing interests The authors declare that they have no competing interests. Conclusions The prevalence of early initiation of breastfeeding in the Author details 1 study area was high. Professional guidance to EIBF, type Department of Midwifery, College of Health Sciences, Debre Tabor University, P. Box: 272, Debre Tabor, Ethiopia. 2Department of Midwifery, pregnancy, previous breastfeeding experience, and the College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, number of ANC visits were significantly associated with Ethiopia. early initiation of breastfeeding among mothers who de- Received: 21 September 2020 Accepted: 25 November 2020 livered by cesarean section.

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