International Journal of Community Medicine and Public Health

Bham AA et al. Int J Community Med Public Health. 2021 Aug;8(8):3766-3772

http://www.ijcmph.com

pISSN 2394-6032 | eISSN 2394-6040

Original Research Article

DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20213000

Frequency of primiparous mother initiated breastfeeding earlier after birth and factors associated with it in Sindh, Pakistan: a secondary analysis

Asma A. Bham1*, Sucheta Sharma2, Akash Sardool3, Umer F. Mujahid4, Amrat Ayaz5, Komal Valliani6, Nawaal Maredia7

1Indus Hospital Research center, Indus Hospital and Health Network, Karachi, Pakistan

2Department of Pharmacology, Punjab Institute of Medical Science, Houston, Jalandhar, India

3Medical College, Maulana Azad Medical College, New Delhi, India

4Medical College, ABWA Medical College, Faisalabad, Pakistan

5Medical College, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan

6Digital Health Resource Center, Aga Khan University, Karachi, Pakistan

7Department of Pediatrics, Aga Khan University, Karachi, Pakistan

Received: 04 May 2021

Accepted: 03 June 2021

*Correspondence:

Asma A. Bham,

E-mail: asma_bham@outlook.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Initiation of breastfeeding within one hour after delivery plays a vital role in a newborns life by not only increasing their survival rate but also reducing many life-threatening diseases in the newborn. The aim of the study was to determine frequency of early initiation of breastfeeding among primiparous mothers in a rural district of Thatta, Pakistan.

Methods: This study was conducted using survey data extracted from a cross-sectional study conducted in 2019 on prevalence of exclusive breastfeeding and factors associated with it among women in Thatta. The outcome was early initiation of breastfeeding. To determine factors associated with it, multi variable logistic regression was carried out.

Results: The study showed that 30.3% of primiparous mothers in Thatta initiated breastfeeding within one hour of birth and knowledge of mothers (OR=9.76, 95% CI: 1.99-17.59), place of birth (OR=3.51, 95% CI: 1.32-9.31) and support of health care professional at health facility (OR=2.93, 95% CI: 1.09-7.86) are the factors significantly associated with early initiation of breastfeeding among primiparous mothers.

Conclusions: In order to enhance the early initiation of breastfeeding, it is important for health care professionals to emphasize on the effect of pre-lacteal feeding during and support breastfeeding immediately after delivery, especially among women who had given birth for the first time.

Keywords: Breastfeeding, Primiparous, Early initiation, Factors

INTRODUCTION

Breast milk is more than just food for babies. Breast milk has widespread benefits for both the mother and the baby.1 From the development of a healthy brain in babies and protecting them from infectious diseases, boosting their immune system, lowering the risk of acquired and autoimmune diseases to protecting mothers against ovarian and breast cancers, breast milk has multiple advantages.2 It has been reported that when the mother holds their babies’ skin-to-skin immediately after their birth, this act provides warmth to the baby, regulating their heartbeat, respiratory, oxygen saturation rate. Hence, infants should be breastfed within one hour of their birth, breastfed exclusively for six months, and continue to be breastfed for up to 2 years.3 Globally, less than half of newborns are breastfed soon after their delivery. Out of the 140 million live births in 2015, only 45% of newborns were put to the breast within one-hour of life, while 7 million newborns had to wait to be breastfed.4 In 2018, the prevalence of exclusive breastfeeding had improved to only 7 percent from 35% to 42%; while this progress is good, there is a need to boost the prevalence of exclusive breastfeeding worldwide.5 In Pakistan, the number of newborns benefiting from breastfeeding is increasing, with every one out of two children being sufficiently breastfed.6 The number of newborns who breastfeed within one hour after delivery increased from 40% to 45.8% in 2018. The WHO and UNICEF also laid down the 2018 global breastfeeding scorecard, showing the progression of breastfeeding programs and encouraging countries to increase the ratio of breastfeeding within an hour of childbirth.7

Initiation of breastfeeding within one hour after delivery plays a vital role in a newborns life by not only increasing their survival rate but also reducing many life-threatening diseases in the newborn.8 According to a global UNICEF report, infants who do not receive breast milk before six months were 2.8 times more likely to die than the ones who were breastfeed solely due to their weak immune system.9 The first breast milk is known as ‘colostrum’ and it is a sticky yellow discharge that is produced by the mother’s breast soon after she gives birth. It contains specific antibodies, which protect newborns from various infectious diseases like sepsis, pneumonia, and diarrhea that can lead to death of newborns. Increasing the prevalence of breastfeeding within one hour of birth is one of the essential steps towards achieving the sustainable development goal of reducing mortality rate in infants.10

It has been observed that mothers of two or more children are more likely to initiate early breastfeeding when compared to primiparous mothers. Mothers with prior knowledge and experience of breastfeeding are more likely to incorporate what they know into current practice, which is why women who have had two or more children relay on their previous breastfeeding experience.11 Primi mothers lack this advantage and are thus less likely to have knowledge about breastfeeding they can implement. Close bonding with the mother after birth is also an influencing factor of early breastfeeding.

Delivery complications can cause separation of mother and baby leading to delayed initiation of breastfeeding, unfortunately, pregnancy complications are more likely to occur in first pregnancies leading to delayed initiation of breastfeeding in primiparous mothers.12 Experience of motherhood is not the sole factor influencing the early initiation of breastfeeding. Breastfeeding practices vary across countries and cultures, even within the same culture it is normal to observe differences based on the economic standing of families. Those with limited access to healthcare services attach less value to breastfeeding as compared to mothers who have been counselled by medical professionals about the importance of early initiation of breastfeeding.13 In order to improve prevalence of early breastfeeding among primiparous mothers, it is vital to first understand the hesitance towards it. Understanding these circumstances will help in the creation of effective and targeted interventions.

The aim of the study was to determine frequency of early initiation of breastfeeding among primiparous mothers in a rural district of Thatta, Pakistan. The researchers also wanted to determine if certain factors like demographics, utilization of health and reproductive services, and breastfeeding patters influence early initiation of breastfeeding.

METHODS

Study setting

This study was conducted using survey data extracted from a cross-sectional study conducted in 2019 on prevalence of exclusive breastfeeding and factors associated with it among women in Thatta. This survey collected information about various aspects of maternal demographics and reproductive details including exclusive breastfeeding, infant’s age at introduction of complementary food, the food category, the intent of starting a meal, and other related information.

A prospective population-based study was implemented in Thatta under the Maternal and Neonatal Health Registry (MNHR). It was aimed at low and middle-income countries (LMICs) under the ‘Global Network for Women and Children Health Research, USA’ to assess outcomes associated with pregnancy. The urban and rural areas of these two sub-districts were distributed into eight clusters, the study was conducted in all eight clusters. Mothers with children aged between 6 to 11 months, who were registered in the MNH Registry, were included in this study through a systematic sampling technique. A total of 405 mothers were interviewed in this survey. For the purpose of this current study and its data analysis, the only data used was of 99 primiparous mothers.

Study outcome

The study outcome was defined as early breastfeeding initiation status. It was a binary variable, indicating ‘0’ if the mother did not initiate breastfeeding within an hour of delivery and ‘1’ if the mother started breastfeeding her child within an hour of the birth. Determinants associated with the study outcomes were obtained from the data.

Independent variables

Covariates studied in the analysis were parental educational status, maternal age, family monthly earning, maternal occupation, baby’s gestational age, baby’s gender, birthplace, residential area, presence of a professional birth attendant, delivery approach, health care professional support, and maternal knowledge about breastfeeding.

Maternal knowledge was assessed using a seven-item questionnaire. A point was allocated in case of a correct answer, which was calculated towards the final score. Mothers scoring 70% or greater were categorized as having adequate knowledge, while mothers with a score below 70% were considered to have inadequate knowledge.14

Data analysis

All analysis was carried out using Stata software version 16.0. Frequencies were stated for breastfeeding initiation within an hour of delivery in Thatta, Sindh. Demographic details were presented in frequencies with percentages. Variables were regressed with the main outcome that is early breastfeeding initiation status using univariate chi square test of independence and multi variable logistic regression to compute Odds ratio and their 95% confidence interval to determine factors associated with early breastfeeding initiation among primiparous mothers. For univariate and multivariable analysis, a cut-off of P value was kept at 0.25 and 0.05 respectively.

RESULTS

The average age of participants was 23.43±3.46. Sixty-six percent (66%) of participants were illiterate while thirty-three percent (33%) of the females were literate. 26.3% of mothers were employed. Most of the infants were male (51.5%) and most infants delivered in the health care facilities under the supervision of a doctor (47%). Out of 99 primiparous mothers, only 30.3% of females gave breastfeed to their infants within one hour of birth while 69.7% of females-initiated breastfeeding after one hour.

Table 2 shows the questions that were used to assess the knowledge of mothers related to breastfeeding. More than half of mothers (51.5%) had adequate knowledge about breastfeeding.

Factors associated with early initiation of breastfeeding among primiparous women

To determine the factors associated with early initiation of breastfeeding among primiparous women, a multivariable logistic regression was used. Before running multivariable logistic regression, univariate analysis was done using Chi square test of independence. Factors that were significant in univariate analysis included knowledge of mothers related to breastfeeding, gestational age of baby, place of birth, mode of delivery and support of health care professional after birth as shown in Table 3. All variables significant in univariate analysis were used to form a final model for multivariable analysis.

Table 4 shows the variables that were significantly associated with early initiation of breastfeeding among primiparous mothers in multivariable analysis. The multivariable logistic regression shows that knowledge of mothers, place of birth and support of health care professional at health facility are the factors significantly associated with early initiation of breastfeeding among primiparous mothers.

The odds of early breastfeeding initiation in primiparous mothers with adequate knowledge about breastfeeding is 9.76 (95% CI= 1.99-17.59) times more than primiparous mothers with inadequate knowledge about EBF.

The odds of early breastfeeding initiation in primiparous mothers who delivered a baby at home is 3.51 times (95% CI=1.32-9.31) than primiparous mothers who delivered a baby at a health care facility. The odds of early breastfeeding initiation in primiparous mothers who got the support of health care professional at health facility is 2.93 times more (95% CI=1.09-7.86) than primiparous mothers who did not any support from the end of health care professional after delivery.

Table 1: Characteristics of mothers and infants.
Table reproduced from source PDF page 3, part 1 of 2
Table reproduced from source PDF page 4, part 2 of 2
Table 2: Items used to assess knowledge of mothers about breastfeeding.
Table reproduced from source PDF page 4
Table 3: Factors significantly associated with initiation of breastfeeding within one hour of birth in univariate analysis.
Table reproduced from source PDF page 4, part 1 of 2
Table reproduced from source PDF page 5, part 2 of 2
Table 4: Significant factors associated with initiation of breastfeeding within one hour (multivariable logistic regression).
Table reproduced from source PDF page 5

DISCUSSION

The current study examines the frequency of primiparous mothers in Thatta, Pakistan who started breastfeeding within the first hour of birth and factors associated with it. In the current study, only 30.3% of primiparous mothers-initiated breastfeeding within one hour of birth. The rates of breastfeeding have been categorized into four groups by the WHO, based on the frequency of the practice. When the frequency of breastfeeding is between 90 to 100% it is ‘very good’, between 50 to 89% is ‘good’, between 30 to 49% is ‘fair’ and 0 to 29% is ‘poor’.15 The frequency of initiating breastfeeding within first hour of birth among primiparous mothers in Thatta, Pakistan is categorized as ‘fair’ according to this WHO classification. In Pakistan, there is still a pressing need to encourage primiparous mothers to start breastfeeding soon after giving birth. Hospitals must play a key role in stressing the importance of initiating breastfeeding within an hour after birth.

Hospital procedures should be reformed in a way that allows infants to be placed in the same space as the mother for the duration of their hospital stay. This will help mothers’ bond with their babies after birth and encourage early breastfeeding. Knowledge about breastfeeding can play an important role in the early initiation of breastfeeding. The current study has shown that the frequency of early initiation of breastfeeding among primiparous women with adequate knowledge is high as compared to primiparous women with inadequate knowledge. Not knowing the importance of starting breastfeeding early and wrong perceptions about colostrum are some of the major reasons for the poor performance of this outcome.16 In a study conducted in Ethopia, 35% of mothers discarded the colostrum as they believed it would be hard to digest for the infant and may cause cramps.17 In our study, 26% of primiparous mothers discarded colostrum. Colostrum is considered an important meal for newborns as it contains vital nutrients that have protective characteristics and give protections to newborns.

Primiparous mothers who gave birth in the hospital were less likely to initiate breastfeeding when compared to mothers who gave birth at their home. A study in Tanzania was in opposition with these results, as mothers who gave birth in a hospital setting were more likely to initiate breastfeeding.18 These varying results can be attributed to the lack of support provided to mothers from health care professionals and poor baby-friendly practices in hospitals in Thatta. It is crucial for mothers to receive proper counselling and support from the hospital staff regarding the early initiation of breastfeeding, this can in turn motivate mothers to practice exclusive breastfeeding. Studies have found that older mothers from, lower and middle-income countries not only have increased odds of initiating early breastfeeding but are also more likely to start breastfeeding within an hour after birth, the current study supports this result.19 As established earlier, this may be due to their previous experiences and higher level of knowledge regarding the benefits of early initiation on breastfeeding, which is not found in inexperienced and insecure first-time mothers.20

Various studies have shown that trained and skilled health care workers can motivate mothers to initiate the breastfeeding earlier, explain the benefits of breastfeeding and create awareness on the disadvantages of pre-lacteal feeding during routine postnatal care immediately after delivery.21, 22 In our study, only 31.6% of 76 primiparous mothers who delivered in a health facility received breastfeeding support after birth from health care professionals. The health-care system expands to ensure that mothers receive breastfeeding assistance as soon as possible after giving birth. There is a need to look into the obstacles that prevent health professionals from offering breastfeeding assistance to women soon after birth at health facilities.23

Factors more commonly associated with infant mortality and morbidity in Pakistan include neonatal malnutrition and infections. This is why Pakistan must work to support its healthcare services, which would in turn promote campaigns about improving neonatal and maternal outcomes by encouraging breastfeeding.

The current study has certain limitations. Due to the small sample size, generalization of the study results across Pakistan is not possible. Not only was the survey was conducted in a small rural part of Sindh registered with MNHR, it also included a small number of women as its sample making it difficult to generalize the study results to primiparous mothers across Pakistan. In addition, the study was cross-sectional in nature due to which it was unable to calculate the existence of a causal associations with determinants.

CONCLUSION

The frequency of primiparous mothers who initiated breastfeeding within one hour of birth in Thatta, Pakistan was 30.3%. This estimate is far behind the frequency of breastfeeding recommended by the WHO. Knowledge of mothers, place of delivery and support provided by health care professionals were the main factors associated with early initiation of breastfeeding in this study. In order to enhance the early initiation of breastfeeding, it is important for health care professionals to emphasize on the effect of pre-lacteal feeding during and support breastfeeding immediately after delivery, especially among women who had given birth for the first time. Interventions need to be enhanced to promote early breastfeeding initiation-particularly in Thatta. Besides this, there is a need of qualitive studies to better understand the reasons that cause delay in early breastfeeding initiation, which is a contributing factor towards low prevalence of early breastfeeding initiation in the region.

ACKNOWLEDGEMENTS

We would like to specially thank Dr. Erum Choudry and Dr. Anum Rahim for their efforts in guiding us throughout this study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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