Timely initiation of breastfeeding and associated factors among mothers with vaginal and cesarean deliveries in public hospitals of Addis Ababa


 Background

WHO and UNICEF recommend breastfeeding to be initiated within the first hour of birth. It is possible to initiate breastfeeding within an hour of birth regardless of the method of delivery. Despite this, the practice of timely initiation of breastfeeding remains low in Ethiopia with both delivery modalities. Therefore, this study aims to compare timely initiation of breastfeeding and associated factors with cesarean and vaginal deliveries in public hospitals of Addis Ababa, 2021.
Methods and materials:

Comparative cross-sectional study was conducted from January 2021 to February 2021 in public hospitals of Addis Ababa. 322 mothers within three days of delivery at the postnatal ward of the respective public hospitals were selected. A multi-stage sampling method was employed with the final participants being recruited by systematic random sampling. Data was entered to Epi data Version 4.6 and analysis was performed by SPSS Version 26. A Binary and multivariate logistic regression statistical model was used. Adjusted odds ratio with 95% CI was computed to see the strength of association.
Result

Timely breastfeeding initiation was 79 (51.2%) and 123 (80%) for cesarean and vaginal deliveries. With a vaginal delivery, pre-lacteal feeding (AOR= 5.50, 95% CI:1.83-16.57) was significantly associated with timely initiation of breastfeeding. Multiparty (AOR= 2.14, 95% CI: 1.02-4.50), support from health care worker (AOR= 2.602, 95% CI: 1.16-5.82), and pre-lacteal feeding (AOR= 2.55, 95% CI: 1.13-5.75) were significantly associated with timely initiation of breastfeeding with cesarean delivery.
Conclusion

The rate of timely initiation of breastfeeding differs according to the mode of delivery. Cesarean delivery, as compared to vaginal delivery, was associated with a higher mean and median time for initiation of breastfeeding.


Introduction
Breast milk is the most nutritious food for a baby. It contains all the energy and nutrients in optimal amounts the infant requires (1). Recent World Health Organization (WHO) reviews of breastfeeding's short-and long-term bene ts concluded that there is strong evidence for many public health bene ts (2). The bene ts for the infant include improved cognitive development, decreased rate of necrotizing enterocolitis, common childhood infections, and decreased risk of sudden infant death syndrome (2-4).
Breastfeeding helps the mother to return to pre-pregnancy weight and improves birth spacing.
Additionally, it is important in decreasing rates of chronic illnesses, ovarian and breast cancer (4).
Timely initiation of breastfeeding (TIBF) is de ned as breastfeeding within an hour of birth for mothers with vaginal delivery (VD) and cesarean delivery (CD) with spinal anesthesia; if general anesthesia was used for the procedure, It is de ned as the initiation of breastfeeding as soon as the mother regains consciousness (5).
Breastfeeding initiation is a simple intervention that has the potential to signi cantly improve neonatal outcomes and should be universally recommended (6). TIBF improves child survival in the rst 28 days of life by lowering the risk of mortality from all causes. (7)(8)(9). Through direct touch with the mother, it also decreases newborn hypothermia and develops attachment and bonding. (10).
Several factors related to the mother and the baby affect the initiation of breastfeeding. Mode of delivery is one of these factors (11)(12)(13)(14)(15)(16)(17)(18)(19). When a mother has a cesarean section, she becomes a surgical patient, with all the dangers and complications it entails. Mothers with cesarean section have to cope with having surgery just as they are also trying to care for their newborn children (20). Cesarean delivery is known to affect the normal physiology of labor and the process that comes after delivery (21)(22)(23). Delayed skin-toskin contact, fatigue, postoperative pain, anesthetic drugs may lead to delayed initiation of breastfeeding (21)(22)(23)(24)(25). On the other hand, mothers with a vaginal delivery are devoid of the deleterious effects of surgery and anesthetic drugs on breastfeeding initiation.
Globally more than 80% of neonates receive breast milk in nearly all countries, however only about half of them begin breastfeeding within an hour of life (37). In Africa, the timely initiation of breastfeeding (TIBF) varies regionally. It is 35% in North Africa, 65% in Eastern, and Southern Africa, 40% in West and Central Africa (38). In Ethiopia, the national prevalence of timely initiation of breastfeeding is 73% with the lowest prevalence in Afar regional state (42%) and the highest prevalence in Diredawa city administration (90.5%) (39).
When the mode of delivery is taken into account, the rate of TIBF varies globally, regionally, and nationally. Globally the TIBF for CD and VD is 33.9% and 64.2% respectively (40). The one-hour breastfeeding initiation rate among cesarean delivered mothers ranged from 16.4-85.4% across the 33 sub-Saharan African countries with one-third of these countries having a prevalence of less than 50% (17). With the vaginal mode of delivery, the rate of timely initiation of breastfeeding is 35.1% in Nigeria (41), 78.8% in Malawi (18), and 84.4% in Namibia (35). In Ethiopia, the trend from 2000-2016 Ethiopian demographic and health survey (EDHS) showed that only 38.8% of mothers with cesarean delivery and 61.5% with vaginal delivery initiated breastfeeding (14).
The Ethiopian Ministry of Health had a plan to increase the proportion of newborns to start breastfeeding within the rst hour of life to 92% by 2015 as one strategy to improve child health (42). Despite the plan data from EDHS 2016 showed that the national rate is 67.5% and which is well below the plan (39). On the other side, studies have indicated that it is possible, successful, and feasible to breastfeed within an hour of birth after a CD (29,43). A quality improvement approach alone has shown to increase the rate of TIBF from 0-93% and interventions to improve breastfeeding initiation rates following CD can improve overall breastfeeding rates (23,43). Despite this, comparative studies on the TIBF with regards to the mode of delivery in the Ethiopian context are lacking and therefore this study will compare the timely initiation of breastfeeding and associated factors among mothers with cesarean and vaginal deliveries in public hospitals of Addis Ababa.

Study setting and design
A comparative cross-sectional study design was conducted in Addis Ababa from January to February 2021. 12 public hospitals provide both cesarean and vaginal deliveries according to data from the city administration health bureau.

Study population
Mothers with cesarean or vaginal deliveries who had ANC follow up in the same hospital and currently at the post-natal ward of selected public hospitals.

Sample size
The double population proportion formula was used to calculate the sample size. The following assumptions were made to determine the required sample size: desired precision (d)= 5%, Con dence level= 95% (Z α/2 = ±1.96 value), power (β) = 80% ,the prevalence of TIBF with VD was 75% (44), and the prevalence of TIBF with CD was 56.2% (33). Hence the nal sample size with a 10% non-response rate and a design effect of 1.5 was 322. Accordingly, equal proportions of mothers were employed from both delivery modalities.
Sampling procedure 12 public hospitals provide both cesarean and vaginal deliveries. A multi-stage sampling procedure was employed. To make the samples representative 30% of the public hospitals were selected by simple random sampling technique. As a result, Gandhi Memorial hospital, Zewditu Memorial hospital, Ras Desta Damtew hospital, and Dagmawi Menelik referral hospital were selected. Data from the city administration health bureau showed that a total of 6623 mothers were expected to give birth in the twomonth data collection period. This was proportionally allocated based on the number of deliveries. Study participants were nally recruited by systematic random sampling from the respective post-natal ward of the hospitals.

Data collection tool & procedure
Interviewer-administered face to face structured questionnaire was used for data collection which was adapted from previous works of literature. The study tool contained ve parts with 40 items for CD and 39 items for VD. The data was collected by midwives and nurses after explaining the purpose of the study. Continuous follow-up and supervision were made by a facilitator and Principal Investigators (PI) throughout the data collection period.

Data quality assurance
The data was checked daily for completeness and consistency throughout the data collection period by the facilitator and PI. A unique code was given to each questionnaire. Before commencing the data collection, a pre-test was conducted on 5% of the total sample size at Tirunesh Bejing hospital. The participants recommended no change be made in the questionnaire. The one-day training was given to the facilitator and the data collector by the PI.

Study variables Dependent variable
Timely initiation of breastfeeding.
In this study, rst, the time elapsed for initial breastfeeding after delivery was asked and then it was categorized as a mother who initiated in less than or equal to an hour after delivery or not.

Independent variables
The independent variables were socio-demographic characteristics (age, marital status, Mothers and spouse/ partners educational level, employment status, Infant sex, and income level ), Obstetric and healthcare-related factors (Parity, Antenatal care (ANC), health care provider support, previous obstetric history, and labor history), traditional belief factors (colostrum avoidance, pre-lacteal feeding, and family support), and awareness related factors (awareness on TIBF & colostrum).

Operational de nition
Timely initiation of breastfeeding de ned as putting the newborn on the mother's breast to suckle within one hour of birth with VD and CD (if spinal anesthesia used) or putting the newborn on the mother's breast to suckle within one hour of regaining consciousness with CD (if general anesthesia used) as reported by the mother.
Health care provider support health care professionals, who counsel and assist the mother for proper attachment and positioning to initiate breastfeeding within one hour of birth.
Pre-lacteal feeding feeding an infant with something other than breast milk after birth to three days.
Good awareness about the timely initiation of breastfeeding If the mother can answer ve or more questions asked to measure the timely starting of breastfeeding awareness.
Poor awareness about the timely initiation of breastfeeding If the mother answers less than ve questions asked to measure the timely starting of breastfeeding.

Data processing and analysis
All the questionnaires were checked for completeness, coded, and entered into EpiData version 4.6 and then exported to SPSS version 26 for data analysis. The descriptive statistics were presented in the form of tables and text using frequencies and numerical summary statistics such as mean and median. Variables in the bivariate analysis with a p-value ≤ 0.25 were further considered in the nal logistic regression analysis. The degree of association between independent and dependent variables was assessed by using an adjusted odds ratio at a 95% con dence interval.

Socio-demographic characteristics
A total of 322 mothers with vaginal or cesarean delivery at the postnatal ward of selected public hospitals in Addis Ababa were interviewed with a response rate of 307 (95.3%). The mean age of respondents with cesarean delivery was 31.  Table 1.

Timely initiation of breastfeeding
Timely initiation of breastfeeding regardless of the method of delivery was 204 (66.5%). With CD, 79 (51.2%) initiated breastfeeding within an hour of birth whereas 123 (80%) with VD initiated timely. The reasons stated for delayed initiation of breastfeeding by mothers with CD were the effect of anesthesia 25 (33.3%), lack of assistance 20 (26.6%), baby sickness 15 (20%), inadequate breast milk 8 (10.6%), and maternal sickness 7 (9.3%). Respondents with VD identi ed baby sickness 14 (46.6%), maternal sickness 6 (20%), inadequate breast milk 6 (20%), and lack of assistance 4 (13.3%) as a cause for delaying breastfeeding initiation. Obstetric and healthcare-related factors With both delivery methods, ANC coverage was high. Other obstetric and healthcare-related characteristics of the respondents are displayed in Table 2.

Traditional belief related factors
The majority of the mothers with CD 113 (73.4%) and VD 125 (81.7%) fed colostrum to the neonate. Giving pre-lacteal feeding was avoided by the majority of the mothers with CD 96 (62.4%) and VD 133 (86.9%). Table 3 displays the traditional belief related factors.

Awareness on timely initiation of breastfeeding
Participants were offered to answer nine questions that assess their awareness of timely initiation of breastfeeding. Per the operational de nition, 68% of mothers with CD and 58% of mothers with VD had good awareness about the timely initiation of breastfeeding.

Discussion
This study aimed to compare the timely initiation of breastfeeding by the mode of delivery. The study identi ed TIBF was higher for mothers with VD (80%) than mothers with CD (51%). The rate of TIBF for mothers with CD was higher from studies done in Sudan (16), Nigeria (41), Saudi Arabia (45), United Arab Emirates (UAE) (46), and China (47). The TIBF rate was low from studies done in Dese, Ethiopia (48), and Brazil (49). For the vaginally delivered mothers, the TIBF was higher as compared to studies from different parts of Ethiopia (14,50), Sudan (16), Nigeria (41), Saudi Arabia (45), UAE (46), while it was low from a study done on Namibia (35). The inconsistency of ndings could be as a result of differences in the study area, study period, or socio-cultural factors which may lead to differences with the practice of breastfeeding initiation.
Multiparity and support from the health care provider were signi cantly associated with the timely initiation of breastfeeding among mothers with CD. While pre-lacteal feeding status was signi cantly associated with TIBF among mothers with VD. Colostrum feeding status was signi cantly associated with the practice of timely initiation of breastfeeding with both delivery methods.
With cesarean delivery, multiparous mothers were 2.14 (AOR=2.143, 95% CI: 1.020-4.504) more likely to initiate breastfeeding within an hour than primiparous mothers. Breastfeeding experiences for women who have previously breastfed differ signi cantly from those of primiparous women (51). Multiparous mothers could have a personal experience on the practice of timely initiation of breastfeeding while primiparous mothers are devoid of any personal experience. Our nding was supported by studies done in the South Gondar zone in Ethiopia and Sudan (16,52). This can be justi ed by the fact that multiparous mothers will have more information exposure regarding the importance of timely initiation of breastfeeding while receiving care at ANC, labor, and delivery or post-natal services.
Mothers with CD who got support from health care worker were 2.602 (AOR=2.602, 95% CI: 1.163-5.823) times more likely to initiate breastfeeding than those mothers who didn't get support. Breastfeeding di culties in mothers with CD could be multifactorial. Some of the di culties can be decreased from support and professional counseling from the health care provider about attachment and positioning of breastfeeding. Our study nding was consistent with studies done in the South Gondar zone and Goba, Ethiopia (28, 52). While breastfeeding is a natural human behavior, most mothers need practical help in learning how to breastfeed (53). This might be the reason for the consistent nding between our study and other studies.
For mothers with VD, those who didn't give pre-lacteal feeding were 2.546 (AOR= 2.546, 95% CI: 1.126-5.754) times more likely to initiate breastfeeding timely than their counterparts. Pre-lacteal feeding is one of the sociocultural malpractice which may interfere with breastfeeding initiation. Our study nding was supported by studies done in different parts of Ethiopia (32,54). The similarities of the ndings could be a result of the perception of mothers about the harmfulness of pre-lacteal feeding.
The limitation of this study is it lacks a qualitative approach that will help to know how the mode of delivery affects breastfeeding initiation. Additionally, the nature of the study by itself doesn't assess the cause-and-effect relationship of factors affecting breastfeeding initiation rates.

Conclusion
The study showed that the rate of timely initiation of breastfeeding was low from the plan set by the Ministry of Health, Ethiopia to increase the proportion of newborns to start breastfeeding within the rst hour of life by the year 2015. The breastfeeding initiation rate was different with the mode of delivery. Cesarean delivery was associated with a lower breastfeeding initiation rate and a higher mean time of breastfeeding initiation. Therefore we would like to recommend the health care providers in the maternity ward of public hospitals of Addis Ababa to give appropriate and adequate support to the mothers for timely initiation of breastfeeding with emphasis for cesarean delivered and rst-time mothers. College, facilitator, data collectors, and study participants.

Funding
No funding was obtained for this study.

Availability of data and material
The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Ethical considerations
Ethical clearance was obtained from Addis Ababa public health research and emergency management directorate and the Ethical Committee of Kotebe Metropolitan University Menelik II Medical and Health Science College. A formal letter was submitted to the public health hospitals. Data collection was conducted after receiving written consent from the participants following an adequate explanation about the purpose of the study.

Competing interests
The authors declare that they have no competing interests.  Figure 1 Awareness of respondents towards timely initiation of breastfeeding