The present study’s findings show that women that had CD had a 1.428-fold higher risk of non-EIBF and a 1.468-fold higher risk of non-EBF, as compared to those that had VD while controlling for the effects of socio-demographic and delivery-related characteristics (Table V).
According to growing body of evidence, scientists stated “Never before in the history of science has so much been known about the complex importance of breastfeeding for both mothers and children” (15). Mode of delivery is one of the factors that play an important role in breastfeeding practices. CD can negatively affect the physiology of lactation, cause adverse events that hinder maternal contact with the neonate, result in intolerable post-surgical maternal pain, and increase the level of need to intense care required by neonates, all of which can negatively affect breastfeeding (8,12,16-18). In this study, multivariate analysis showed that education, residential region, and mode of delivery were significantly related to non-EIBF and mode of delivery had significant relationship with non-EBF. In the literature, the education of the mother is evaluated in the most intimate level of determinants of breastfeeding behavior (19); however, findings related to the effect of maternal education on breastfeeding behavior are inconsistent. Findings from Iran (20) and Bahrain (21) show that as the maternal level of education increases the likelihood of breastfeeding decreases whereas in Argentina (22) and Italy (23) there was a positive association between the maternal level of education and the likelihood of breastfeeding. According to the present findings, we think that the benefits of colostrum were well known to the mothers with a high level of education due to their use of modern information resources (healthcare professionals, scientific books, and the Internet). Therefore, they highly cared to give the colostrum to their newborns and they cooperated well with health personnel when they were in-patient; however, their intention for exclusive breastfeeding in the following days might not continue. Results indicated that maternal level of education could be a potential confounder.
Bivariate analysis showed that there was a significant relationship between place of residence and non-EBF (43.0% with non-EBF lived in urban areas, versus 33.9% in rural areas [P = 0.033]) while there was no significant relationship between place of residence and non-EIBF (Table II). Adewuyi et al. (17) and Pandey et al. (24) reported that the non-EIBF rate was lower in rural settings based on DHSs. The significance of the relationship between place of residence and non-EBF in the present study disappeared in multivariate analysis. As such, we think that place of residence alone did not have a significant effect on breastfeeding practices of the women that delivered in hospitals. The non-EIBF rate (51.2%) was highest in those from Eastern Anatolia, which is the least developed region of Turkey, whereas the non-EIBF rate was highest (51.2%) in those from Western Anatolia (Table II). The difference in ORs between these two regions was significant based on regression analysis (Table IV), indicating that residential region could potentially be consider as another confounder.
In the present study the risk of non-EIBF and non-EBF was calculated, and was observed to be related to CD. The relative risk of non-EIBF was 1.341 (95% CI, 1.132-1.589); when the CD and VD groups were compared without adjustments. After controlling for maternal education and residential region, the SIR was 1.428 based on the adjusted incidence rates for non-EIBF. This meant that the risk of non-EIBF in the women that had CD was 1.428-fold higher (95% CI, 1.212-1.683) than in those that had VD. The risk of non-EBF in the women that had CD three days after delivery was 1.468-fold higher (95% CI, 1.233-1.748) after adjusting for maternal education and residential region.
According to secondary analysis of World Health Organization Global Survey (25) data from several countries, the adjusted odds ratio for EIBF was 0.28 (95% CI: 0.22-0.37; P <0.001) for CD, indicating an evidently high risk of non-EIBF risk in cases of CD. Prior et al. (7) also observed that the EIBF rate in cases of CD was low; their calculated pooled OR was 0.57 (95% CI: 0.50, 0.64; P < 0.00001). Regan et al. (26) reported that women that had successful VD were 1.42-fold more likely to EIBF than women that had a planned CD after a previous CD (95% CI: 1.30-1.56) and those that had CD after unsuccessful attempted VD were 1.15-fold more likely to EIBF than women that had a planned CD after a previous CD (95% CI: 1.01, 1.31).
It is possible that hospital policies that direct women to CD unnecessarily according to the interventionist approach to childbirth do not promote breastfeeding or the provision of sufficient breastfeeding counseling, and might even encourage mothers to feed their newborns nutritional sources other than breast milk. The present study was based solely on data obtained from the 2013 TDHS; therefore, factors associated with breastfeeding not included in the survey were not analyzed. As such, it is possible that mode of delivery and breastfeeding are correlated with the characteristics of hospitals (such as type, region, size etc.) in which the women had delivery; however, the TDHS data was not sufficient for evaluating this possibility. The data could not be used to determine if any of the women delivered babies in hospitals that were not baby-friendly. Moreover, the 2013 TDHS did not collect data about the women’s pre-delivery intentions to breastfeed. It is possible that some of the women intended not to breastfeed or not to use ideal breastfeeding practices before delivery; and TDHS data did not provide information on this issue. The number of deliveries that could be considered unnecessary CD was not known and it could not be determined if any of the women had real barriers to breastfeeding. The survey also did not include any data concerning the number of women that had instrumental or anesthetic VD, which can cause a delay in mother-baby contact, the findings clearly showed that the dataset was sufficient for determining the effects of CD on the breastfeeding practices of women in Turkey.