Predictors of early initiation of breastfeeding in women who birth in government hospitals in Sri Lanka: an assessment across socio-demographic and clinical measures

doi:10.21203/rs.3.rs-1962361/v1

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Predictors of early initiation of breastfeeding in women who birth in government hospitals in Sri Lanka: an assessment across socio-demographic and clinical measures

https://doi.org/10.21203/rs.3.rs-1962361/v1

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Introduction

Early initiation of breastfeeding can be predicted by socio-demographic and clinical characteristics of birthing women, and health care support for breastfeeding. However, the relative influence of many of these characteristics on early initiation of breastfeeding has not been established in Sri Lanka. Therefore, we aimed to identify predictors of early initiation of breastfeeding across a wide range of socio-demographic and clinical characteristics.

Methods

A cross-sectional survey was conducted with women who had a live baby across four government hospitals in Sri Lanka. Women who were 12 hours post-birth and still admitted to the hospital were invited to participate. Data were collected by eliciting quantitative data through participant interviews and extracting additional information from their medical records. Contribution of socio-demographic and clinical characteristics to explaining variations in early initiation of breastfeeding was estimated using binary logistic regression analysis with simultaneous adjustment.

Results

The response rate was 83.8%, with 302 women participating. The proportion of women who initiated breastfeeding within one hour of birth was 64.5% (n=195). Women were more likely to initiate breastfeeding within one hour of birth if their body mass index was < 18.5 kg/m² (OR: 4.17; 95% CI: 1.23-14.05), and less likely if they gave birth by elective caesarean section (OR: 0.27; 95% CI: 0.14-0.51), were administered antibiotics (OR: 0.4; 95% CI: 1.05-4.73) and had a baby with respiratory distress (OR: 0.08, 95% CI: 0.01-0.57).

Conclusion

Current intrapartum care practices associated with elective caesarean and antibiotic administration, and immediate care of babies with respiratory distress, should be critically reviewed for understanding the mechanisms underlying their negative impact on breastfeeding initiation in Sri Lanka.

Birth

Caesarean section

Colostrum

Maternity care

Medication

What is already known about this subject? Early initiation of breastfeeding is globally recommended to ensure colostrum feeding within one hour of giving birth. Disparities across demographic and clinical characteristics related to pregnancy and childbirth have been observed globally. In Sri Lanka, though the population rate of early initiation of breastfeeding appears to be high, there are inconsistencies in early initiation of breastfeeding and the factors explaining these variations remains unexplored.

What does this study add? This study identifies pre-pregnancy body mass index <18kg/m², elective caesarean section, administration of antibiotics, and respiratory distress in babies as significant predictors of early initiation of breastfeeding in Sri Lankan women. Health care practices associated with these characteristics and experiences should be closely examined to identify opportunities for ensuring equitable breastfeeding initiation opportunities in Sri Lankan health services.

Early initiation of breastfeeding is the foundation of successful breastfeeding and critical to infant health (Victora et al., 2016). The World Health Organization recommends infants receive colostrum within one hour of birth (World Health Organization [WHO] and United Nations International Children’s Emergency Fund [UNICEF], 2018). Colostrum is the “first milk” secreted by the human breast (Sharma & Byrne, 2016; Yilmaz et al., 2017) containing protective and growth-promoting factors (Wambach & Cole, 2000) which improve immunity and development in babies (Sharma & Byrne, 2016; Wambach & Cole, 2000). Early initiation of breastfeeding reduces risk of death in babies during the first month of their life (Yilmaz et al., 2017) and increases the likelihood of exclusive breastfeeding to six months of age (WHO & UNICEF, 2018).

Inconsistencies in early initiation of breastfeeding have been reported across the world and associated with the socio-demographic profile of birthing women, pregnancy and childbirth characteristics, and health care support for breastfeeding (Sharma & Byrne, 2016; Yilmaz et al., 2017). Globally, women living in urban areas, aged 20-35 years, with a higher level of education, unemployed, married, primiparous, without complications during pregnancy and after birth, who are not administered medications during labor, and have babies after 37 weeks gestation without complications are more likely to initiate breastfeeding early. (Betran et al., 2021; Hobbs et al., 2016; Pinheiro & Goldani, 2018; Sharma & Byrne, 2016). Sri Lankan women are from multi-ethnic and socio-demographic backgrounds and receive health services from different types of health facilities (Family Health Bureau [FHB] - Sri Lanka, 2019). Understanding the determinants of early breastfeeding initiation in Sri Lankan women may help to identify the characteristics of women who are least likely to initiate breastfeeding early. These women and circumstances can therefore be targeted with interventions to support early breastfeeding initiation across Sri Lanka.

Associations between early initiation of breastfeeding and many socio-demographic and clinical characteristics have not been established in Sri Lanka. Early breastfeeding is more likely with babies who weighed ≥2500g, who were born vaginally, in government hospitals, and were home-visited by a Public Health Midwife (Senarath et al., 2012), consistent with global literature (Sharma & Byrne, 2016; Yilmaz et al., 2017). The role of a wider range of possible circumstances that explain variations in early initiation of breastfeeding in Sri Lanka is not clear (Lokeesan et al., 2022).

In this research, we aimed to identify significant predictors of early breastfeeding initiation from a wide range of women’s socio-demographic and clinical characteristics related to pregnancy and childbirth. We also sought to assess the relative contribution of these variables to explaining variations in early breastfeeding initiation so that priority sub-populations and points of intervention for early breastfeeding support could be identified.

Study design and setting

A cross-sectional survey was conducted from September to December 2021 in four Sri Lankan government hospitals. In Sri Lanka, 94% of births occur in government hospitals and they are the major maternity care service providers (DCS-Sri Lanka, 2017,2019). Stratified cluster random sampling was applied to select hospitals from which to draw the study sample. Government hospitals in Sri Lanka where women give birth (n= 385) were stratified into two groups. Stratum 1 were hospitals in the urban sector of Sri Lanka (n=54) and stratum 2 were hospitals in the rural sector (n=331). Hospitals with a minimum of 2200 births in 2018 (n=49) (DCS-Sri Lanka, 2019) were clustered from each stratum to increase sampling efficiency. This meant we could collect the most amount of data from women admitted to each hospital during the limited data collection period. Clusters of strata 1 and 2 included 41 and 8 hospitals respectively. Two hospitals were randomly selected from each cluster.

Participants

Women who (1) had live single or multiple births from 19^th September to 20^th December 2021 in selected hospitals, (2) did not have a neonatal death, (3) could understand and speak one of three languages (Sinhala/Tamil/English), and (4) were physically and mentally capable to consent to participate in this study, were approached and invited to participate at least 12 hours after birth. Women were eligible to participate until discharged from hospital.

Sample size

The required sample size for regression analysis was determined according to Green’s rule of thumb (Green, 2010) that N>50+8m is needed for multiple correlations and N> 104+m is needed for testing individual predictors, where ‘N’ is the required sample size, and ‘m’ is the number of independent variables (18 in our study). According to Green’s rule, the minimum number needed for testing multiple correlations and individual predictors were 195 [N>50+(8×18) =N>194] and 123 [N>104+18= N>122] respectively. Data collection feasibility was also considered. The principal researcher had 60 days available for data collection, approximately four hours permitted by the hospitals for data collection each day, and 30 to 40 planned with each participant. Approximately six women could be approached each day, with five women expected to participate based on a 90% estimated response rate (Wickramasinghe et al., 2019). Therefore, the research team aimed to approach a total of 360 women to achieve an expected sample of 300, providing sufficient power for planned statistical analyses.

Survey instrument

A structured electronic survey instrument including a questionnaire and data entry tool (Table S1) was used to collect self-reported data from postnatal women and clinical data from their medical records. Survey questions were selected from previously validated surveys (Table S1) and a review of previous research. Survey questions asked women’s socio-demographic details, and information about their pregnancy, labor and childbirth, and infant feeding practices.

Survey procedure

A health care worker who was either the nurse in-charge or one of the nursing officers of the postnatal wards of the selected hospitals assisted the principal researcher identify eligible women by providing their bed numbers. The health care worker also informed eligible women about the presence of the researcher in the postnatal ward, and that the researcher was independent from hospital staff. The researcher approached eligible women and invited to participate at their bedside. If women provided informed consent to participate, the researcher conducted a face-to-face interview and clinical data extraction. The researcher conducted the interview at each woman’s bedside and recorded participants’ responses on the survey. Clinical data regarding pregnancy, labor and childbirth were extracted from participants’ medical records and recorded in the survey. To assess sample representativeness, aggregate data for all women who had live babies in the selected hospitals from September to December 2021 were accessed from birth registers maintained in labor rooms of the selected hospitals.

Measures

Early initiation of breastfeeding was assessed as breastfeeding within one hour of birth. Participants were asked when they started feeding colostrum for the very first time after giving birth. Responses were recorded as: < 10 minutes after birth, 10-30 minutes after birth and 31-60 minutes after birth, later combined into “early initiation of breastfeeding”. More than 1 hour and not yet initiated were recoded as “no early initiation of breastfeeding”. Responses of “do not know/ do not remember” were excluded from analyses.

Independent variables were women’s socio-demographic and clinical characteristics. Socio-demographic factors collected via maternal self-report included age, area of residence, level of education, employment, annual household income, ethnicity, and relationship status. Maternal age and household income were collected continuously, and later categorised into six categories for age (“15-19 years”, “20-24 years”, “25-29 years”, “30-34 years”, and “35 years and older”) and four categories for income (“<100, 000”, “100, 000 – 500,000”, “501,000 – 1,000,000”, or “> 1,000,000” Sri Lankan Rupees). Clinical characteristics included pregnancy (antenatal clinic visits, parity, pregnancy complications) and childbirth (mode of birth, gestational age, baby’s birth weight, postpartum maternal complications, neonatal complications) factors. Self-reported data regarding antenatal clinic visits were transformed into dichotomous variables (“visited” / “not visited”). Dichotomous variables sourced from clinical data were derived for parity (“primipara” / “multiparous”), infant gestational age at birth (“<37 weeks”/ “≥37 weeks”), and infant birthweight (“< 2500 grams”/ “≥2500 grams”), consistent with standards commonly used to assess associations with early breastfeeding initiation. Standard Body Mass Index (BMI) categories for Asians were used to define pre-pregnancy BMI as “<18.5 kg/m², “18.5-22.9 kg/m²”, “23-27.49 kg/m²”, and “≥27.5 kg/m²” (Senarath et al., 2012).

Dichotomous variables of “administered” / “not administered” were derived for assessing the administration of medications and “presented” / “not presented” were derived for pregnancy, birth and postpartum complications. Mode of birth was categorised into “unassisted vaginal birth”, “vaginal birth assisted with forceps”, vaginal birth assisted with vacuum”, “vaginal birth assisted with both forceps and vacuum”, “planned caesarean section” and “emergency caesarean section”.

Statistical Analysis

Data were analysed using SPSS for Windows version 28.0.1.0. Sample representativeness was determined by comparing participants’ characteristics with different populations for which comparable data was available: a) women who gave birth to a live baby in the selected hospitals from September to December 2021, b) live births that were registered in Sri Lanka in 2015, and c) live births reported in 2019. This approach enabled assessment of the generalisability of the study sample to birthing women of both the national population and our selected hospitals. Characteristics of participants were compared with populations using one-sample chi-square tests.

Multivariable logistic regression was used to identify independent significant predictors of early breastfeeding initiation. Socio-demographic characteristics and clinical measures related to pregnancy and childbirth were added to the model as independent variables. The association between early initiation of breastfeeding and every independent variable was assessed with univariate logistic regression, followed by multivariable modelling for all variables simultaneously using binary logistic regression with stepwise backward elimination to estimate odds ratios (OR) after adjustment for independent variables. Residuals and standard errors for multicollinearity were examined for independent variables. Variables that were significant at α < 0.05 were retained in the final model and results were expressed as crude and adjusted ORs of early initiation of breastfeeding, with 95% confidence intervals (CI).

Of 360 eligible women who were invited, 302 (83.8%) consented to participate. There were no missing data in this sample. Participants’ characteristics are presented in Table 1. The majority of participants were aged 30-34 years (n=89, 29.5%), were Sinhalese (n=199, 65.9%), had a secondary education (n=258, 85.4%), were unemployed (n=240, 79.5%), had previously given birth to a live baby (n=173, 57.3%), and had given birth to a single, term baby this time (n=282, 93.4%).

[Insert Table 1 here]

The sample under-represented 25 to 29 year old women, and over-represented women aged under 25 years when compared to all birthing women from selected hospitals, but was representative of the national population of birthing women (DCS - Sri Lanka, 2015) in terms of age. Women living in rural areas and Sri Lankan Tamil women were over-represented and Sinhalese women were under-represented, compared to the national distribution of birthing women (DCS-Sri Lanka, 2015).

Women with a BMI >23 kg/m², who had gestational diabetes mellitus (GDM), anaemia, and pregnancy complications were over-represented in our sample, and more women attended antenatal clinic visits compared to the national distribution of pregnant women in Sri Lanka (FHB-SriLanka, 2019). The proportion of women who gave birth to a single baby after 37 weeks gestation was similar in our selected hospitals. Women who were multiparous, had a vaginal birth, and had a baby weighed ≥2500g were over-represented in our sample compared to birthing women from selected hospitals and the national distribution (FHB-Sri Lanka, 2019) (see Table 1).

Eleven women did not know or remember the time when their baby was fed colostrum for the very first time after birth and were excluded, leaving data from 291 women that were used for measuring associations with early initiation of breastfeeding. Early breastfeeding initiation was reported by 64.5% of women. Assumptions for logistic regression were met by the data with no evidence of multi-collinearity between variables, and observations independent of each other.

Associations with early initiation of breastfeeding are presented in Table 2. In univariate regression, only BMI <18 kg/m² significantly increased the odds of early breastfeeding initiation. Women aged >35 years, who were Sri Lankan Tamil ethnicity, had an elective or emergency caesarean section, were administered spinal anaesthesia and antibiotics, and whose babies had respiratory distress after birth had decreased odds of early breastfeeding initiation (Table 2). After adding all variables to the regression model simultaneously, only BMI <18 kg/m² (OR: 6.17, 95% CI: 1.42-26.81) and elective caesarean section (OR: 0.08, 95% CI: 0.01-0.43) remained significant.

[Insert Table 2 here]

Following backward stepwise elimination of the least significant independent variables listed in Table 2, variables that had the most significant association with early initiation of breastfeeding were identified in the final model, which was highly parsimonious and explained 17.9-24.9% of the variance in early initiation of breastfeeding (Nagelkerke’s pseudo-R²at 0.249 and Cox and Snell pseudo R² at 0.179). Women with a BMI <18.5 kg/m² had higher odds of early breastfeeding initiation (aOR: 4.17 95% CI: 1.23-14.05) than women with a BMI of 18.5-22.9kg/m². Women who had an elective caesarean section had lower odds of early breastfeeding initiation (aOR: 0.27; 95% CI: 0.14-0.51) than womenwho had a vaginal birth. Women who were administered antibiotics (aOR: 0.4; 95% CI: 1.05-4.73) and had a baby with respiratory distress (aOR: 0.08, 95% CI: 0.01-0.57) had lower odds of early breastfeeding initiation than those who were not administered medication and who had babies with no complications after birth, respectively.

This is the first known study conducted in Sri Lankan government hospitals to assess the association between socio-demographic and clinical characteristics related to pregnancy and childbirth and early initiation of breastfeeding. Findings revealed that 64.5% of women started early breastfeeding which was higher than the prevalence reported in South Asian countries (Sharma & Byrne, 2016; Zong et al., 2021) and globally (Zong et al., 2021), but lower than the reported national prevalence in Sri Lanka (90.3%) (DCS-Sri Lanka, 2017). Our estimates may be more reliable than alternative data collections because women were approached close to childbirth. The reported national prevalence of early initiation of breastfeeding in Sri Lanka and other countries are derived via women’s self-report from a few months to years after giving birth (DCS-Sri Lanka, 2017; Sharma & Byrne, 2016). Maternal short-term recall of breastfeeding initiation is more reliable due to recall bias towards over-estimating breastfeeding practices when surveyed days or months after giving birth (Amissah et al., 2017; Bland et al., 2003).

Elective caesarean section, administration of antibiotics, respiratory distress in babies after birth, and maternal BMI <18 kg/m² were significant predictors of early initiation of breastfeeding. Findings that women who birthed by elective caesarean section were less likely to initiate early breastfeeding is consistent with studies conducted in Canada (Hobbs et al., 2016) and Bangladesh (Roy et al., 2022). In contrast, Zanardo et al (2010) reported that early initiation of breastfeeding is less likely after emergency caesarean section. Regardless of whether it was planned, or unplanned, caesarean section is considered a major barrier for early initiation of breastfeeding in Sri Lanka (Senarath et al., 2012). This may be due to delayed mother-baby skin to skin contact as a result of post-operative care or increased maternal stress especially in unplanned caesarean section (Row-Murray & Fisher, 2002; Roy et al., 2022). Elective caesarean section may reduce the likelihood of early initiation of breastfeeding as an absence of labor means there are fewer hormonal drivers responsible for lactogenesis (Zanardo et al., 2010;Hobbs et al., 2016). Women who undergo elective caesarean section are also more likely to have neonates who are between 34 and <37 weeks gestation, with poor sucking skills, lower birth weight and low level of alertness which can affect early initiation of breastfeeding (Hobbs et al., 2016).

We found that women who had babies with respiratory distress were less likely to initiate early breastfeeding, regardless of gestational age. Similar results were observed in babies born in Bangladesh (Roy et al., 2022) who had asphyxia. In these scenarios, mothers and babies may be separated due to medical interventions and breastfeeding may not be recommended until recovery (Roy et al., 2022). We also found that women who were administered antibiotics were less likely to initiate breastfeeding early. Antibiotics are commonly administered during caesarean section, or operative vaginal births. Antibiotics are compatible with lactogenesis (Chung et al., 2002), while spinal anaesthesia suppresses lactogenesis. We did not find a significant association between administration of spinal anaesthesia and early initiation of breastfeeding. However, delayed initiation of breastfeeding in women who were administered antibiotics in our study might be an additional effect associated with caesarean section. In our study, we have been able to strengthen the theory that caesarean section is associated with delayed breastfeeding initiation, particularly in Sri Lanka, due to our wide sampling frame, high response rate, and results that are mostly consistent with others’ internationally. Women who birth by caesarean section in Sri Lanka should receive targeted support to initiate breastfeeding early, as elective caesarean section is a barrier in multiple ways. Furthermore, as the rate of caesarean section is increasing in Sri Lanka (FHB-Sri Lanka, 2021), the risk of delayed breastfeeding initiation is likely to persist unless mitigating support programs are designed, funded, and implemented.

In our study, women were with BMI <18kg/m² (underweight) were more likely to initiate early breastfeeding compared to women with BMI 18.5-22.9kg/m²– normal weight. In Italy, Giovannini et al (2007) also found that underweight women were more likely to put babies on breast as early as possible than normal-weight women. Underweight women were more likely to be primiparous and have a vaginal birth, and less likely to birth underweight babies and have GDM and gestational hypertension (Giovannini et al., 2007). Significant associations between early initiation of breastfeeding and these factors have been previously established (Buckman et al., 2020; Huang et al., 2019; Senarath et al., 2012). However, Tao et al (2017) reported no significant variations in early initiation of breastfeeding across pre-pregnancy BMI in China. There is also contrasting evidence that BMI <18kg/m² may be negatively associated with early initiation of breastfeeding (Thompson et al., 2013). In other studies (Campbell & Shackleton, 2018; Pinheiro & Goldani, 2018) which reported negative associations between pre-pregnancy underweight and early initiation of breastfeeding, BMI was calculated using women’s self-report of weight and height. Women usually overstate their height and underreport their weight which may result in the incorrect calculation of BMI (Huang et al., 2019), and introduce misclassification bias in assessing associations between women’s BMI and early breastfeeding. We obtained BMI data from women’s medical record where it is generally determined by health staff directly measuring women’s weight and height. The different methods for measuring BMI may explain the variation in results across studies.

Strengths and Limitation

In our study, Sri Lankan women who gave birth in selected government hospitals were approached close to childbirth. Therefore, we were able to minimise over-reporting of early breastfeeding practices associated with later recall (Amissah et al., 2017). Our data on women’s characteristics and early breastfeeding practices is likely to be more reliable than inconsistently documented Sri Lankan patient admission data, since maternal self-report data about newborn care is more reliable than clinical records (Gartland et al., 2012). Our sample of 291 women exceeded the minimum sample size required to confidently assess the associations in our study. However, this study in only four hospitals affected the generalisability of the study to all of Sri Lanka and population data was not available for all relevant characteristics to comprehensively assess sample representativeness. The significant predictors of early breastfeeding reported here, especially pre-pregnancy BMI of women and administration of antibiotics, should be tentatively considered until replicated in broader research across Sri Lanka, particularly given their inconsistency with existing evidence globally.

Elective caesarean section, administration of antibiotics and respiratory distress in babies after birth negatively predicted, and pre-pregnancy BMI <18kg/m² positively predicted early initiation of breastfeeding in Sri Lankan women. Elective caesarean section was a negative predictor, with both direct and indirect drivers of delayed breastfeeding initiation. A trend of delayed breastfeeding initiation in Sri Lanka may persist due to the increasing rates of caesarean section (FHB-Sri Lanka, 2019), and requires immediate attention.

The Sri Lankan health system can review and renew policies and practices to better support women, and particularly at-risk women, to initiate early breastfeeding. Women should be supported to make informed choices around use of medication in labor and planned mode of birth, to manage their impact on early breastfeeding initiation (Goldberg, 2009). Training can be provided to facilitate mother-baby skin-to-skin contact following birth, particularly for surgical births, while also performing other postpartum care (Row-Murray & Fisher, 2002). There is a need to evaluate health service implementation of breastfeeding support practices in Sri Lankan health facilities, given inadequate and inconsistent data available on compliance with breastfeeding supportive care. The extent to which those specific practices further explain variations in breastfeeding initiation in Sri Lanka remains unclear.

aOR : adjusted Odds Ratio

BMI : Body Mass Index

CI : Confidence Interval

ERC : Ethics Review Committee

FHB : Family Health Bureau

GDM : Gestational Diabetes Mellitus

NWP : North-Western Province

OR : Odds Ratio

Funding: Faculty of Health, Queensland University of Technology [QUT], Australia funded Laavanya Lokeesan for conducting data collection in Sri Lanka

Conflict of Interest: The authors declare that they have no conflict of interest

Ethics Approval: Ethics approval was obtained from the University Human Research Ethics Committee [UHREC] of Queensland University of Technology (Approval number – 2000001001), Ethics Review Committee of Faculty of Health-Care Sciences, Eastern University, Sri Lanka (Approval number – E/2021/05), and the Ethics Review Committee of Department of Health Services, North-Western province, Sri Lanka (Approval number – ERC/NWP/2021/11)

Availability of data and material: The dataset related to this study is available from the corresponding author and it is not deposited in any repository. The dataset generated and/or analysed during the current study are available upon request.

Authors’ contributions: Laavanya Lokeesan contributed to established research methods, collected, and analysed data collection, drafted manuscripts, critically reviewed, and revised the manuscript, and edited, read, and approved the final manuscript. Elizabeth Martin reviewed data coding and analysis, contributed to writing, critically reviewed, and revised the manuscript, and edited, read and approved the final manuscript. Yvette Miller conceived the research idea, reviewed data coding and analysis, contributed to writing, critically reviewed, and revised the manuscript, and edited, read and approved the final manuscript. The content is solely the responsibility of the authors.

Acknowledgements: We acknowledge the Director /Medical Superintendents of selected hospitals for giving permission to conduct the study; Chief Nursing Officers of selected hospitals, Consultant Obstetricians and Gynaecologists, Nurse in-charge, nursing officers, and doctors and midwives of the postnatal wards of selected hospitals for supporting data collection; and women who participated in this study. The Faculty of Health, Queensland University of Technology, Australia funded travel costs for the principal researcher to collect data.

Submission declaration: An abstract related to this research was presented at a local student research conference held on the 15^th of July 2022, organized by the School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Australia

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Predictors of early initiation of breastfeeding in women who birth in government hospitals in Sri Lanka: an assessment across socio-demographic and clinical measures

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Abstract

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