Abstract
Background
Breastfeeding as a determinant of infant health and nutrition saves up to 1.5 million infant lives annually. Though breastfeeding is mostly universal in sub-Saharan Africa, early initiation of breastfeeding is rarely practiced.
Objective
To determine magnitude and factors associated with delayed initiation of breastfeeding among mother-infant pairs who deliver in Mulago hospital.
Methods
We carried out a descriptive cross sectional study, where 665 mother-infant pairs were interviewed within 24 hours following delivery; with additional qualitative data collected using focus group discussions to understand reasons for delaying initiation. The data was analysed by identification and coding of themes.
Results
In this study, 31.4% mothers delayed initiation of breastfeeding. This was associated with maternal HIV positive status (AOR 2.3; 95% CI 1.3–4.2), inadequate prenatal guidance, (AOR 3.6; 95% CI 1.9–6.8), inadequate professional assistance to initiate breastfeeding (AOR 1.8; 95% CI 1.2–2.8) and caesarean section delivery (AOR 8.6; 95% CI 4.7–16.0). Other reasons were perceived lack of breast milk, need of rest for both mother and baby after labor, and negative cultural beliefs.
Conclusion
In Mulago Hospital 1:3 mothers delayed initiation of breastfeeding. The reasons for delayed initiation include; inadequate information during ANC, HIV positive serostatus, caesarian section delivery and negative cultural ideas.
Keywords: Breastfeeding, initiation, delayed, HIV
Introduction
Delayed initiation of breastfeeding is the failure of the mother to initiate breastfeeding within one hour of delivery or within one hour of recovery of post-operative consciousness in case of those who delivered after spontaneous vaginal delivery and Caesarean section respectively1.
Breastfeeding is almost universal in Uganda, with 99% of all children breastfed for some period of time after birth2. However, timing of breastfeeding for all children indicated that initiation to breastfeeding was rather late. Only 42% of ever-breastfed children are initiated within the first hour of birth, and 14.5% are not even put to the breast within 24 hours of their birth3. We report results of a study which determined the magnitude and factors associated with delayed initiation of breastfeeding in Mulago hospital, Uganda, in order to contribute to interventions to prevent it.
Methods
Study design and setting
This was a descriptive cross-sectional study, conducted from January to February 2011 in the maternity ward of Mulago hospital, Uganda's National referral and teaching hospital. A total of 618 and 47 mothers participated in quantitative and qualitative study groups. Mothers with contraindications to breastfeeding or health problems that affected breastfeeding were excluded from the study. Babies with postpartum health problems, and those hospitalized in the newborn intensive care unit were also excluded. Written informed consent was obtained from all participating mothers.
Sample size estimation
Based on a proportion of mothers who delayed initiation of breastfeeding in Ugandan lactation clinic4, and using the Kish Leslie formula5 to obtain the sample size for magnitude of delayed initiation to breastfeeding, and the Fleiss formula6,7 to calculate sample size for factors associated with delayed initiation to breastfeeding, a sample size of 618 mother-infant pairs was found adequate for the study.
Enrolment of patients
After obtaining informed consent, 618 volunteer mothers and five Focus Group Discussion (FGD) groups were enrolled. A structured questionnaire was used to collect data by research assistants 24-hours' postpartum. A focus group discussion session comprised 8 – 12 participants, where an assistant took notes while another made observations. There were 5 FGD groups, two comprised primipara mothers, two multipara mothers and one comprising female caregivers who had escorted mothers to the hospital for labour and delivery.
Data management
Data was entered into Epidata 3.1 and then exported to SPSS version 11.0 for analysis. The chi-square test and binary logistic regression analysis were used to examine the relationship between delayed initiation of breastfeeding and different variables. P values below 0.05 were considered significant and confidence intervals of 95% used. The analysis of qualitative data was by identifying themes and sub-themes from the information obtained from focus group discussions. Direct quotations from the respondents were used in the presentation of the study findings.
Ethical considerations
Written informed consent was obtained from all participating mothers. The study was approved by the School of Medicine, Research and Ethics Committee of Makerere University College of Health Sciences; Mulago Hospital Ethics Committee and, the Uganda National Council for Science and Technology.
Results
Study population and magnitude of delayed initiation of breastfeeding
As shown in Table 1, 31% (194/618) of the newborns were breastfed more than one hour from birth with median time of initiation of 30(IQR: 20–120) minutes postpartum. 54.7% of infants were male (338/618), 89.2% (551/618) had a birth weight greater than 2,500gm and 85% (525/618) infants received breast milk as their first meal. 31.5% of mothers were <20 years old, 40.3% had no previous breastfeeding experience, 9.2% were HIV seropositive, 89.6% had vaginal delivery, 76.4% had labor lasting <18 hours and 40.9% had >4 ANC visits.
Table 1.
Facility and mother-infant pair characteristics
| Characteristics | N | % |
| Maternal age (years) | ||
| <=20 | 195 | 31.5 |
| 21–29 | 318 | 51.5 |
| >30+ | 105 | 17.0 |
| Parity | ||
| 1 | 249 | 40.3 |
| 2–3 | 294 | 47.6 |
| 4+ | 75 | 12.1 |
| Duration of labour (hours) | ||
| < 18 | 472 | 76.4 |
| > 18+ | 146 | 23.6 |
| Maternal HIV status | ||
| Positive | 57 | 9.2 |
| Negative | 556 | 90.0 |
| Unknown | 5 | 0.8 |
| Gestational age (weeks) | ||
| < 37 | 67 | 10.8 |
| 37+ | 551 | 89.2 |
| Mode of delivery | ||
| SVD | 554 | 89.6 |
| Caesarian | 64 | 10.4 |
| Frequency of antenatal care attendance | ||
| Not recommended (0–3) | 365 | 59.1 |
| Recommended (4+) | 253 | 40.9 |
|
Prenatal guidance on advantages of breastfeeding |
||
| Yes | 559 | 90.5 |
| No | 59 | 9.5 |
Maternal, infant, health unit and socio-cultural factors associated with delayed initiation of breastfeeding
As shown in Table 2, on Bivariate analysis delayed initiation was attributed to night delivery, HIV sero-positivity, prolonged labor, caesarean section delivery, paternal occupation, lack of prenatal guidance on advantages of breast feeding, failure to perform rooming-in or skin to skin practice.
Table 2.
Factors associated with delayed initiation of breastfeeding on Bivariate analysis
| Characteristics | Frequency N=618 (%) |
Late initiators N=194 (%) |
OR (95% C1) |
P-value |
| Maternal age (years) | ||||
| < = 20 | 195 (31.6) | 60(30.9) | 0.9 (0.7–1.5) | 0.821 |
| > 21+ | 423 (68.4) | 134 (69.1) | ||
| Parity | ||||
| 1 | 249 (40.3) | 80 (41.2) | 1.1(0.7–1.3) | 0.746 |
| 2+ | 369 (59.7) | 114 (58.8) | ||
| Duration of labour (hours) | ||||
| 18+ | 146 (23.6) | 58 (29.9) | 1.6 (1.2–2.8) | 0.013 |
| < 18 | 472 (76.4) | 136 (70.1) | ||
| Maternal HIV status | ||||
| Positive | 57 ( 9.3) | 25 (13.0) | 1.8 (1.0–3.1) | 0.035 |
| Negative | 555 (90.7) | 168 (87.0) | ||
| Gestational age (weeks) | ||||
| < =37 | 67 (10.8) | 24 (12.4) | 1.3 (0.7–2.1) | 0.408 |
| 37+ | 551 (89.2) | 170 (87.6) | ||
| Hour of birth (hours) | ||||
| Night ( 19–05) | 285 (46.1) | 102 (52.6) | 1.5 (1.0–2.1) | 0.029 |
| Day (06–18) | 333 (53.9) | 92 (47.4) | ||
| Mode of delivery | ||||
| SVD | 64 (10.4) | 46 (23.7) | 7.0 (3.9–13) | <0.01 |
| Caesarian | 554 (89.6) | 148 (76.3) | ||
|
Prenatal guidance on advantages of breastfeeding |
||||
| No | 59 ( 9.5) | 37 (19.1) | 0.2 (0.1–0.4) | <0.01 |
| Yes | 559 (90.5) | 157 (80.9) | ||
|
Mother received professional assistance to initiate breast feeding |
||||
| No | 327 (52.9) | 125 (64.4) | 2 (1.4–2.8) | <0.01 |
| Yes | 291 (47.1) | 69 (35.6) |
Table 3 shows that factors independently associated with delayed initiation of breastfeeding were inadequate information to mothers during ANC, HIV positive serostatus and caesarian section delivery.
Table 3.
Factors independently associated with delayed initiation of breastfeeding
| Variable | Frequency | Late initiators (194)% |
COR* (95% CI) |
p-Value | AOR* (95% CI) |
p-Value |
| Maternal HIV Positive status |
57 (9.2) | 25 (12.9) |
1.8 (1.0–3.1) | 0.035 | 2.3 (1.3–4.2) | 0.006 |
| Lack of prenatal guidance on advantages of breastfeeding |
59 (9.5) | 37 (19.1) |
0.2 (0.1–0.4) | <0.01 | 3.6 (1.9–6.8) | <0.01 |
| Mother's who didn't receive professional assistance to initiate breast feeding |
327 (52.9) |
125 (64.4) |
2.0 (1.4–2.8) | <0.01 | 1.8 (1.2–2.8) | |
| Delivery by Caesarian section |
64 (10.4) |
46 (23.7 |
7.0 (3.9–13) | <0.01 | 8.6 (4.7–1.6) |
COR* - Denotes Crude Odds ratio
AOR* - Denotes Adjusted Odds ratio
Focus group discussion reasons for delaying initiation
Lack of breast milk was a reason given by most mothers who reported delaying initiation. As one mother said, “…I didn't give breast milk because there was none in the breast, so I squeezed it and realized that nothing at all was coming out…” A few mothers who reported insufficient milk held that: “…the explanation given was that it would be unfair to give the baby an empty breast to satisfy the infant…”
Maternal HIV infection also contributed to delayed initiation. One affected mother said. “…before delivery I had decided to breastfeed immediately as we had been taught during ANC but after seeing my baby I delayed to decide on whether to start breast feeding or not….”
Mother's beliefs about colostrum too were linked to delayed initiation. One respondent said,… “ I didn't give the first breast milk to my baby on the first day after birth because I had been told by my mother to wait until the next day when the first breast milk mixes with the second breast milk…”
Another reason given about belief on colostrum was that it is “dirty” as said by one respondent…“I squeezed the first breast milk away until the white milk came because the former wasn't good; my mother-in-law prepared mushroom soup mixed with local butter and gave my baby about 3 drops until the third day when the first milk mixes with the second…”
Mothers who delivered by caesarean section delayed initiation. One said…“I was exhausted, sleepy and had severe abdominal pain from the wound and feared to breastfeed, so my sister-in-law prepared some sugar water solution for my baby until abdominal pain subsided before I started to breastfeed…”
Some mothers and babies needed to rest after labor. One mother said: …“I started to breast feed after the abdominal pain, dizziness and weakness had reduced and l could sit to breastfeed the baby…” Another mother said “…after delivery my mother-in-law bathed it with hot water, wrapped it and put it to sleep. My mother-in-law told me not to touch him because he needed rest…”
Discussion
The magnitude of delayed initiation of breastfeeding of 31.4% in this study is considered “good” by the World Health Organization.8 This rate is much lower than that of previous studies in Uganda which reported 83.7% and 43.3% respectively4,9. However, data from our study and previous studies are comparable, since they were obtained using same methodology. This was a cross-sectional design where information on breastfeeding was gathered directly from the mothers within 24 hours after delivery. The progressive decline in the rate of delayed initiation of breastfeeding in Uganda may be due to generative positive attitudes and activities by a series of governmental and non-governmental initiatives aimed at promoting early initiation of breastfeeding.
Similar to our results, caesarean section was the main contributor to delayed initiation of breastfeeding7,10. The respondents attributed it to being exhausted, sleepy and severe abdominal pain from the wound. Some studies have however failed to show such a relationship.10, 11 In Mulago hospital, the trends indicate a marked and increasing divergence with caesarean section rates on the private ward rising to around 50% compared to 20% among public deliveries12; possibly suggesting that measures preventing caesarean section without medical indication should be implemented. These measures may also aim at preventing elective cesarean sections performed for indications including mothers delivery phobia, or who prefers delivery comfort, requests cesarean section, or when she is influenced by the gynecologist.13 Babies delivered by caesarean section were usually given some sugar-water solution until the mothers pain has subsided after which she begins to breastfeed. Prelactal feeding should therefore be avoided and mothers who have delivered by caesarean section should be given extra support while still in the labour suit to ensure early breastfeeding initiation.
As noted in FGDs, inadequate information to mothers during ANC visits was associated with delayed initiation, probably since the focus is on exclusive breastfeeding, PMTCT and encouraging mothers to deliver from health facilities. This focus needs to be broadened to include early initiation of breastfeeding. This is in agreement with Scot J et al who indicated that “implementation of pre-natal and postnatal support programs, along with prenatal education programs among low-income women” had a positive effect on initiation of breastfeeding14. The use of peer counselors has been found to be an effective strategy for increasing the practice of exclusive breastfeeding in Africa15, and though not yet studied, it is possible that the peer educators can similarly be utilized to educate and improve on reduction of the current high rates of delayed initiation to breastfeeding. The benefits of frequent counseling shown earlier in increasing uptake of exclusive breastfeeding practices16,17, can be leveraged in improving early initiation of breastfeeding. This can be done either through community based group counselling15, or as individualized peer counselling18.
Negative cultural beliefs on colostrum and traditional rituals especially performed on twins before initiation of breastfeeding also exist in many other African cultures10,19. The beliefs may also be addressed through peer counselling. HIV positive mothers said they feared to infect their infants with HIV in spite of assurances to the contrary from ANC lessons. Similar circumstantial evidence has been reported among South African women who feared to spread HIV to their infants through breast milk20 despite recent studies on the overwhelming benefits of antiretroviral drugs for PMTCT21,22.
Conclusion
One in three women who deliver from Mulago hospital delays to initiate breastfeeding. Reasons for late initiation include inadequate information to mothers during antenatal clinic visits, caesarean section delivery, maternal HIV positive serostatus and cultural factors.
Acknowledgement
This work was part of a Thesis submitted by Dr. Richard Kalisa in partial fulfillment of the requirements for award of Makerere University Masters of Medicine (M.Med) degree in Paediatrics and Child Health. Many thanks to Ivan Lyazi for statistical assistance; the research assistants and all mothers and infants who participated in the study.
Competing interests
The authors declare that they have no competing interests.
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