The aim of this study was to determine whether perinatal healthcare delivery was associated with age-appropriate IYCF breastfeeding coverage and early breastfeeding initiation amongst Nepali mother-infant dyads. Our analysis showed that the infant’s age, mother’s age and province, were significantly associated with age-appropriate IYCF breastfeeding practice. However, none of the antenatal or perinatal healthcare delivery factors examined significantly influenced the odds of age-appropriate breastfeeding practice after adjustment for potential confounders. By contrast, several perinatal healthcare factors were associated with the early initiation of breastfeeding: vaginal delivery, the observation of breastfeeding within the first two days after delivery and early skin-to-skin contact.
Age-appropriate IYCF breastfeeding practice
Our finding that the odds of age-appropriate IYCF breastfeeding practice were significantly greater from 9-23 months compared to 0-1 months may reflect the lesser difficulty of some breastfeeding compared with exclusive breastfeeding. Age-appropriate breastfeeding practice up to the sixth month of life constitutes exclusive breastfeeding, with the exemption of all other non-breastmilk liquids. However, age-appropriate breastfeeding practice from 6-24 months (UNICEF, 2011), involves some breastfeeding with the addition of complementary foods. Indeed, multiple physiological and financial barriers to exclusive breastfeeding can be conceptualised. Work has been identified as a barrier for continued exclusive breastfeeding in Nepal (Singh Bhandari et al., 2019) and physiologically, breastmilk supply issues may also be considered. Previous research has identified diminished breastmilk supply with time post-delivery as a barrier to exclusive breastfeeding amongst Nepali mothers (Ulak et al., 2012). Our finding that at 4-5 months, the odds of age-appropriate breastfeeding practice (i.e., being exclusively breastfed) are at their lowest, may reflect this phenomenon. Indeed, less than half of infants (40.8%) were exclusively breastfed in this age-group. This finding is also consistent with other studies that demonstrate decreased exclusive breastfeeding approaching six months post-birth (Khanal et al., 2013; Ulak et al., 2012). Given the cross-sectional nature of the present study, the aetiology of this nadir in exclusive breastfeeding cannot be definitively determined. However, our findings that no antenatal or perinatal healthcare delivery factors were associated with age-appropriate breastfeeding practice suggests that additional support for exclusive breastfeeding, including postnatal support, is necessary for women with infants nearing 4-5 months of age, where appropriate IYCF breastfeeding practice is lowest.
Breastfeeding within the first hour after delivery
Our analysis identified vaginal delivery, early skin-to-skin contact and the observation of breastfeeding by a healthcare worker, as significant perinatal healthcare factors associated with the early initiation of breastfeeding. Although vaginal delivery has been associated with early breastfeeding in Nepal previously (Ghimire, 2019; Pandey et al., 2010), the latter two findings have not previously been demonstrated in this population. The relationship between early skin-to-skin contact and breastfeeding initiation is of note, given it is the WHO’s first evidence-based recommendation for supporting the initiation and establishment of breastfeeding (WHO, 2017). This recommendation was based on moderate-quality evidence from two Cochrane Pregnancy and Childbirth systematic reviews (Moore et al., 2016; Conde-Agudelo et al., 2016). Moore et al., (2016) reviewed 46 separate trials with 3850 infant-mother pairs and found that immediate or early skin-to-skin contact improved the likelihood of exclusive breastfeeding at hospital discharge to 1 month of age (RR: 1.30, 95% CI: 1.12,1.49). Although the present study did not demonstrate significantly improved odds of exclusive breastfeeding to six months in mother-infant pairs with early skin-to-skin contact, it did suggest these mothers had improved odds of initiating breastfeeding early; a finding also observed in other South Asian countries (Karim et al., 2018), thereby further underscoring the importance of this practice. The low rate of early skin-to-skin contact after caesarean delivery observed in our study (37.4%; data not shown) may help explain the lower rate of breastfeeding within the first hour after caesarean section.
Unlike previous research that demonstrated improved odds of early breastfeeding with health facility delivery (Ghimire, 2019), higher maternal education (Adhikari et al., 2014; Acharya & Khanal, 2015) and large infant size at birth (Adhikari at al., 2014), these were not identified as significant explanatory variables in the present study after adjustment. However, the observation of breastfeeding by a healthcare provider within the first two days post-delivery (and similarly, counselling of breastfeeding by a healthcare provider within the first two days post-delivery), was significantly associated with early breastfeeding. These practices, along with early skin-to-skin contact, were more common for births within a health facility (data not shown) and may explain the contrasting findings. Although the temporality of the relationships cannot be discerned here, it is plausible that early initiation of breastfeeding may be better facilitated when health professionals are available for observation and troubleshooting post-delivery. The low rate (55.6%) of Nepali newborns being breastfed in the first hour of life could be related to gaps in some of these perinatal services. Further research in this area is indicated.
Strengths and limitations
The NDHS is a large-scale population-based survey that attempts to be nationally representative by means of multi-stage sampling. However, some limitations warrant consideration. By nature of the cross-sectional design, this study cannot determine whether relationships between explanatory and outcome variables are causal. Similarly, respondents were asked to recall specific details regarding their most recent pregnancy. Although this study attempted to minimise potential recall bias by including only last-born children born in the 24 months preceding the survey, it should be acknowledged that recall bias may still exist. Unmeasured confounders may also have influenced the associations observed. Future longitudinal observational studies may offer opportunities to demonstrate cause-effect relationships between antenatal and perinatal healthcare delivery and breastfeeding outcomes.