The present findings show that after controlling for sociodemographic and delivery-related factors, the women who had undergone C/S had a 1.428-fold higher risk of non-EIBF and a 1.468-fold higher risk of non-EBF than those who had undergone VD (Table 5). In response to a growing body of evidence, scientists have stated, ‘Never before in the history of science has so much been known about the complex importance of breastfeeding for both mothers and children’ [17]. Mode of delivery is among the factors that play an important role in breastfeeding practices. C/S can negatively affect the physiology of lactation and cause adverse events that hinder maternal contact with the neonate, resulting in intolerable post-surgical maternal pain and an increase in the level of need for intensive care required by neonates, both of which can negatively affect breastfeeding [10,14,18-20]. The present study’s multivariate analysis indicates that maternal educational level, residential region, and mode of delivery are significantly related to non-EIBF and that mode of delivery has a significant relationship with non-EBF. The literature shows that maternal educational level is among the most significant determinants of breastfeeding behaviour [21]; however, findings related to the effect of maternal educational level on breastfeeding behaviour are inconsistent. Studies from Iran [22] and Bahrain [23] reported that as maternal educational level increases, the likelihood of breastfeeding decreases, whereas studies from Argentina [24] and Italy [25] show that there is a positive association between maternal educational level and the likelihood of breastfeeding. Based on the present findings, we think that, owing to their use of modern information resources (communication with healthcare professionals and access to scientific books and the internet), mothers with a high educational level were well aware of its benefits and, therefore, highly motivated to feed their newborns with colostrum. Further, they fully cooperated with healthcare personnel during hospitalisation, even though their intention toward EBF in the days following delivery did not continue in all cases. These results indicate that maternal educational level might be a potential confounder for non EIBF and non-EBF.
As per the results of the bivariate analysis, there existed a significant relationship between place of residence and non-EBF (43.0% of the women with non-EBF status lived in urban areas, versus 33.9% in rural areas [P = 0.033]). However, the relationship between place of residence and non-EIBF failed to achieve significance (Table 2). Based on DHSs, Adewuyi et al. [19] and Pandey et al. [26] reported that non-EIBF rates are lower in women from rural areas. 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 in women who delivered in hospitals. The non-EIBF rate (51.2%) was highest in women from Eastern Anatolia, which is the least developed region of Turkey, whereas it (37.9%) was lowest in women from Western Anatolia (the most developed region) (Table 2). The difference in odds ratios (ORs) between these two regions was significant according to regression analysis (Table 4), indicating that residential region could be another confounder for non-EIBF and non-EBF.
In the present study, the risk of non-EIBF and non-EBF was observed to be related to C/S. The relative risk of non-EIBF was 1.341 (95% CI: 1.132-1.589) when the C/S and VD groups were compared without adjustments. After controlling for maternal educational level and residential region, the SIR was 1.428 based on the adjusted incidence rates for non-EIBF, which indicates that the risk of non-EIBF in women who had C/S was 1.428-fold higher (95% CI, 1.212-1.683) than in those with VD. In women who had C/S, the risk of non-EBF three days following birth was 1.468-fold higher (95% CI, 1.233-1.748) after adjusting for maternal educational level and residential region.
According to secondary analysis of the WHO Global Survey [27] using data from several countries, the adjusted OR for EIBF was 0.28 (95% CI: 0.22-0.37; P < 0.001) for women who had C/S, indicating an evidently high risk of non-EIBF in cases of C/S. Prior et al. [9] also observed that the EIBF rate in cases of C/S was low; their calculated pooled OR was 0.57 (95% CI: 0.50-0.64; P < 0.00001). Regan et al. [28] reported that women with successful VD were 1.42-fold more likely to have EIBF than women who had a planned C/S after a previous C/S (95% CI: 1.30-1.56) and that those who had C/S after an unsuccessful VD attempt were 1.15-fold more likely to have EIBF than women who had a planned C/S after a previous C/S (95% CI: 1.01-1.31).
The results of the present study should be considered in the context of some limitations. As the data were obtained solely from the 2013 TDHS, factors associated with breastfeeding not included in the survey were not analysed. As such, it is possible that mode of delivery and breastfeeding are associated with the characteristics of the hospitals (such as type, region, and size) where women give birth; however, the 2013 TDHS data were not sufficient to evaluate this possibility. In addition, 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, before delivery, some of the women had decided not to breastfeed or to engage in less than ideal breastfeeding practices, but such data were not included in the 2013 TDHS. The number of deliveries that could be considered unnecessary C/S was not known and it could not be determined if any of the women had valid barriers to breastfeeding. The survey also did not include any data concerning the number of women who had instrumental or anaesthetic VD, which can cause a delay in mother-baby contact.
Despite these limitations, the present study has some strengths that should be acknowledged. The study was based on a subsample of a nationally representative survey that gathered high-quality data. The retrospective cohort design facilitated a thorough examination of the relationship between C/S and breastfeeding practices. Several potential influences were excluded in the process of selecting the study sample and some other confounders were controlled for via standardisation; thus, the measurement of the effect of C/S on breastfeeding practices was refined.