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 benefits concluded that there is strong evidence for many public health benefits (2). The benefits 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 defined 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 defined as the initiation of breastfeeding as soon as the mother regains consciousness (5).
Breastfeeding initiation is a simple intervention that has the potential to significantly improve neonatal outcomes and should be universally recommended (6). TIBF improves child survival in the first 28 days of life by lowering the risk of mortality from all causes.(7–9). 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 (11–19). 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 (21–23). Delayed skin-to-skin contact, fatigue, postoperative pain, anesthetic drugs may lead to delayed initiation of breastfeeding (21–25). On the other hand, mothers with a vaginal delivery are devoid of the deleterious effects of surgery and anesthetic drugs on breastfeeding initiation.
Other factors identified from a literature review with both delivery modalities include age, educational status, residence, place of birth, employment status, socio-economic status, knowledge on breastfeeding, antenatal care (ANC), infant sex, colostrum, and pre-lacteal feeding status, access to media, parity, counseling on breastfeeding, and singleton births (19, 20, 27–37).
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 first 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.