Early initiation of breast feeding and associated factors among mother-baby dyads with immediate skin-to-skin contact: cross-sectional study based on the 2016 Ethiopian Demographic and Health Survey data

Strengths and limitations of this study

The study was nationally representative since the data was derived from a national survey.

The data were collected at the community level from rural and urban areas.

This study exclusively used data from mother-child dyads with immediate skin-to-skin contact.

The study was based on the mothers’ responses which may be affected by recall bias.

We excluded some necessary variables from the analysis due to missing values or unrecorded data.

Introduction

Early initiation of breast feeding (EIBF) is putting the newborn at the mother’s breast within 1 hour after delivery.1 EIBF within 1 hour of delivery benefits both mothers and newborns.2 The benefits of EIBF are the protection of newborns from infections and increasing the successful continuation of breast feeding.3 Additionally, the EIBF decreases neonatal mortality.4 It also improves childhood nutrition.5 On the other hand, delaying the EIBF increases the risk of neonatal infection and death.6

Skin-to-skin contact between mother and newborn is putting the baby on bare skin immediately at birth until the initiation of first breast feeding.7 Immediate early skin-to-skin contact in the delivery room benefits both mother and the baby.8 It helps EIBF and first lactation.9 Immediate skin-to-skin contact in the first hour after delivery provides vital advantages to the bonding of mother and infant.10 Additionally, it enhances maternal breast feeding self-efficacy and exclusive breast feeding duration.11 During labour and delivery, the birth attendants should pay attention to skin-to-skin contact between the mother and newborn immediately after birth.12 Immediate skin-to-skin contact shortens the third stage of labour.13 When it lasts longer than 20 min, it increases the maximum duration of exclusive breast feeding.14

At the global level, breast feeding saves the lives of more than 820 000 children annually, whereas EIBF within 1 hour of birth reduces newborn mortality. The EIBF increases the chances of a successful continuation of breast feeding.15 The finding of prospective survival analysis indicated that early skin-to-skin contact facilitates the continuation of exclusive breast feeding.16 Globally, only two out of five newborns began breast feeding within the first hour of birth, as reported by UNICEF and WHO. The report was from a Demographic Health Survey (DHS) of 76 countries, where an estimated 78 million newborns were not breast fed within 1 hour after birth. According to the report, the initiation rate ranges from 32% in East Asia and the Pacific to 65% in Eastern and Southern Africa, where Ethiopia is part of Eastern Africa.6 In another report from DHS from 57 low/middle-income countries (LMICs), from the year 2010–2018, 51.9% of newborns breastfeed within the first hour of delivery.17 Similarly, the report from DHS data between 2012 and 2017 from 58 LMICs shows that 53.8% started breast feeding after 1 hour of delivery.18

The reports from African countries also indicated that EIBF varies from country to country. In 13 Economic Communities of West African States countries, EIBF was 43%.19 Additionally, in 35 sub-Saharan African countries, EIBF was lowest in Chad (23.0%) and highest in Burundi (85.0%).20 Another report from 29 sub-Saharan African Countries’ DHS data from 2010 to 2018 indicates that the EIBF was 55.81%.21 A meta-analysis report from DHS data between 2010 and 2015 from 29 sub-Saharan African countries shows that EIBF was lowest in Central Africa, 37.84%, and highest in Southern Africa, 69.31%.22

EIBF is a simple intervention that improves neonatal outcomes.23 In the Ethiopian context, EIBF was 61.4%, as reported by a meta-analysis.1 The reports from the analysis of Ethiopian Demographic and Health Survey (EDHS) data that covers the years 2000–2016 show that the trend of EIBF was improving. The early breast feeding initiation was 48.8% in 2000 and 75.7% in 2016.24 Studies conducted on EDHS 2016 data reported EIBF differently in Ethiopia, 81.8%25 and 74.3%.26 Ethiopia is working to improve the EIBF by setting a target. Ethiopian Ministry of Health’s Health Sector Development Programme Four sets this target to increase the EIBF proportion from 69% to 92%.27 The report of EDHS data shows that the trend of EIBF in Ethiopia was improving with the proportion of the EDHS 2016 report of 73%.28

Even though the EIBF is improving in Ethiopia, the proportion is less than that of the target set by the Ethiopian Ministry of Health’s Health Sector Development Programme Four to reach 92%.27 The factors that determine EIBF are delivery assistance by health professionals, giving birth by caesarean section, wealth index, age, gender and birth order.26 Studies support that immediate skin-to-skin contact of mother-baby dyads positively affects the EIBF.29–35

We studied the EIBF among mother-baby dyads with immediate skin-to-skin contact. There are lists of studies regarding the EIBF in Ethiopia. But, there is no reported study regarding the EIBF among mothers with immediate skin-to-skin contact practice. Therefore, the current study assessed the proportion of EIBF and associated factors among mother-baby dyads who practiced skin-to-skin contact immediately.

MethodsData source, sampling and collection

EDHS is the fourth DHS implemented by the Central Statistical Agency at the request of the Federal Ministry of Health. Data used in the survey was collected from 18 January to 27 June 2016, using a cross-sectional study design. The data collection was conducted using Ethiopia Population and Housing Census sampling frame. Ethiopia had nine regional states and two city administrations during the survey. The survey divided each region into strata of urban and rural areas, and samples of enumeration areas (EAs) were selected independently in each stratum in two stages. In the first stage, a total of 645 EAs were selected. The samples included 202 EAs in urban and 443 EAs in rural and were selected with probability sampling. In each sampling stratum, the selection was proportional to the EA size with independent selection. During the first stage of choice, there was household identification. Then in the second stage of EAs selection, a fixed number of 28 households were selected per cluster with an equal probability of systematic selection. Finally, data were collected from women of reproductive age, men and children. During the survey, women’s sociodemographic and economic characteristics, obstetrics history and household characteristics were collected.28

During the survey, 15 683 mothers in the age group of 15–49 years old were interviewed.28 Among the women interviewed, we extracted the sample needed for the study based on our inclusion criteria. The last-born children (born in the 2 years preceding the survey and children less than 24 months old) and children put on their mother’s bare skin after birth were included in the study (figure 1).

Figure 1Figure 1Figure 1

Flow chart showing data extraction process from Ethiopian Demographic and Health Survey 2016 data for early initiation of breast feeding, Ethiopia.

VariablesDependent variable

The outcome variable of the study was the EIBF. It was categorised as mothers were early initiated breast feeding within 1 hour of birth or after an hour after birth.26 Mothers were interviewed about their breast feeding initiation, and the outcome variable was based on their responses.

Independent variables

The independent variables included in the study were sociodemographic and economic characteristics, including age, educational status, maternal working status, residence, frequency of reading newspaper, listening radio, and watching television, marital status, wealth index and region of the respondent. The variables included under obstetrics characteristics are antenatal care (ANC), age at first birth, place of delivery, mode of delivery, delivery by nurse assistance, delivery by midwifery assistance, size of the baby, child sex, child age and birth order.

Analysis of the data

After data extraction, we cleaned the data for analysis. We excluded babies’ birth weights due to missing value since 44.7% of babies’ weights were not recorded at birth. These babies were not weighed during delivery, or mothers did remember. Then the checked data were analysed using statistical software, SPSS V.23. The analysis of the data included both descriptive and inferential analysis. The descriptive analysis was used to present the frequency table distribution of variables with their descriptions. We used logistic regression analysis to test the statistical association of independent variables with the EIBF. First, we conducted a bivariate logistic regression analysis to check the relation of an individual variable with EIBF at 95% CI. We used variables with p<0.2 in the multivariable logistic regression analysis.

Multivariable logistic regression analysis was done using backward logistic regression at 95% CI and p<5%. We checked for the goodness of model fit using the likelihood ratio test. Then the relation of the independent variables with EIBF was expressed using the adjusted OR (AOR) at a 95% CI and p value <5%.

Participant and public involvement

Participants or the public were not involved in the design, conduct or reporting, or dissemination plans of our research.

ResultsSociodemographic and economic characteristics

The study included 1420 eligible study participants. According to the finding of our study, 49.9% of the respondents were in the age category of 25–34 years old. Nearly 60% (59.0%) of the respondents were from rural areas. More than a quarter (28.9%) of the respondents were from poor households. More than 90% (91.9%) of the respondents were married (table 1).

Table 1

Sociodemographic and economic characteristics of mother-baby dyads, early initiation of breast feeding, Ethiopian Demographic and Health Survey 2016

Obstetrics characteristics

The finding of our study indicated that nearly one-third (32.8%) of the study participants had less than four ANC visits. Regarding the place of delivery, 1208 (85.1%) of the respondents delivered at health institutions. And almost all (97.3%) of the respondents gave birth without a caesarean section (table 2). The proportion of EIBF among study participants was 88.8% (table 2).

Table 2

Obstetric characteristics of mother-baby dyads, early initiation of breast feeding, Ethiopian Demographic and Health Survey 2016

Factors associated with EIBF

We conducted both bivariate and multivariable logistic regression analyses. In bivariate logistic regression analysis, place of residence, frequency of listening to the radio, frequency of watching television, educational status, region of respondents, wealth index, mode of delivery, place of delivery, size of a baby at birth, delivery assisted by midwifery and nurse were statistically significantly associated with EIBF at 95% CI.

After conducting a multivariable logistic regression analysis, educational status, wealth index, region, place of delivery, mode of delivery and delivery assisted by midwifery were statistically significantly associated with EIBF at p<5% and 95% CI. Mothers from wealthier families were 2.37 (AOR=2.37; 95% CI 1.38 to 4.08) times more likely early initiate breast feeding than mothers from poorer families. Study participants with secondary and above educational status were 1.67 (AOR=1.67; 95% CI 1.12 to 2.57) times more likely early initiate breast feeding than study participants with primary education. Regarding respondents’ region, mothers from the Oromia region were 2.87 (AOR=2.87; 95% CI 1.11 to 7.46) times more likely early initiate breast feeding than mothers from Addis Ababa city. Similarly, mothers from Harari and Dire Dawa regions were 11.60 (AOR=11.60; 95% CI 2.48 to 24.34) and 2.93 (AOR=2.93; 95% CI 1.04 to 8.23) times more likely early initiate breast feeding than mothers from Addis Ababa city, respectively. Mothers who gave birth through vaginal delivery were 3.34 (AOR=3.34; 95% CI 1.33 to 8.39) times more likely early initiate breast feeding than mothers who gave birth by caesarean section. Regarding the place of delivery, study participants who gave birth at a hospital and health centre were 2.02 (AOR=2.02; 95% CI 1.02 to 4.00) and 2.19 (AOR=2.19; 95% CI 1.21 to 3.98) times more likely early initiate breast feeding than study participants who gave birth at home. Finally, mothers who gave birth with the assistance of midwifery were 1.62 (AOR=1.62; 95% CI 1.06 to 2.49) times more likely early initiate breast feeding than mothers who gave birth without the assistance of midwifery (table 3).

Table 3

Factors associated with EIBF among mother-baby dyads, Ethiopian Demographic and Health Survey 2016

Discussion

The Ethiopian National Strategy for Infant and Young Child Feeding recommends the EIBF and exclusive breast feeding for the first 6 months.36 In line with this recommendation, the Ethiopian Ministry of Health Sector Development Programme Four had set a target to increase the proportion of EIBF from 69% to 92%.27 Skin-to-skin contact between mothers and their newborns immediately after delivery facilitates the EIBF within the first hour of delivery.29–35

The finding of the current study shows that the proportion of EIBF was 88.8% (95% CI 87.2 to 90.4) in Ethiopia. This is higher than the findings of studies conducted in Romania,31 Asian countries,29 30 32 37 38 African countries33 39–41 and Ethiopia.24 25 35 42–50

In contrast to other studies, our study was based on immediate skin-to-skin contact, which could increase the EIBF. We noticed that the proportion of EIBF was high among mother-baby dyads with early skin-to-skin touch.

The EIBF was affected by educational status, region, wealth index, place of delivery, mode of delivery and delivery assisted by midwifery. Respondents from wealthier families were 2.37 times more likely early initiate breast feeding than respondents from poorer families. It may be due to access to advanced health services. Different studies supported this finding, where respondents from wealthier families were more likely early initiate breast feeding than respondents from poorer families.26 42 51 Conversely, other studies reported that mothers from lower socioeconomic families initiate breast feeding early.52 53

Mothers who attended secondary and above education were 1.67 times more likely early initiate breast feeding than mothers who attended primary education. Similarly, other studies support this finding where the educational status of mothers was positively associated with EIBF.43 45 But one study reported that mothers with no education or primary education initiate breast feeding early.41 This may be resulted from the ability of their understanding what they have told by health professionals, and what they have read and heard.

Mothers living in the Oromia, Harari and Dire Dawa regions were 2.87, 11.60 and 2.93 times more likely early initiate breast feeding than mothers living in Addis Ababa city, respectively. Mothers in Addis Ababa has access to health facilities and exposure to information than mothers from other parts of the country. But they less likely initiate breast feeding early than the above listed regions. This may be due to overcrowding of cases as the city is more populated, and care providers are unable to facilitate EIBF. Previous studies also identified that the region of the respondents was significantly associated with EIBF.24–26 54

Mothers who gave birth by non-caesarean section were 3.34 times more likely to initiate breast feeding early than mothers who gave birth by caesarean section. Mothers who gave birth by vaginal delivery early initiate breast feeding than mothers who gave birth by caesarean section.33 43 49 The reason may be due to the surgical procedure’s effect that may affect the EIBF. Additionally, mothers who gave birth at a hospital and health centre were 2.02 and 2.19 times more likely early initiate breast feeding than mothers who gave birth at home, respectively. Mothers who gave birth at health institutions early initiate breast feeding than mothers who gave birth at home.45 49 Institutional delivery facilitates skin-to-skin contact and then EIBF. Finally, mothers assisted by midwifery were 1.62 times more likely early initiate breast feeding than mothers who were not assisted by midwifery. Midwifery support during delivery helps to facilitate the EIBF.

On the other hand, variables like birth order and ANC were not significantly associated. But these variables were determining factors in other studies.25,54 In contrast to the current study, the variables were used differently.

The current study used data extracted from EDHS 2016, which is nationally representative. This study exclusively used data from mother-child dyads with immediate skin-to-skin contact. In this study, we used data from both rural and urban residents. There are some limitations in using the finding of the study. We excluded fetal birth weight from the analysis due to missing values. The data of fetal birth weight was not recorded for 44.7% (not weighted or mothers did not remember) babies. Additionally, we excluded the health condition of mothers and newborns during delivery from the analysis, where the variables could have a significant association with EIBF. Despite the limitations, the current study added its contribution.

Conclusion

Nine in ten mother-baby dyads with immediate skin-to-skin contact early initiate breast feeding. The EIBF was affected by educational status, wealth index, region, mode of delivery, place of delivery and delivery assisted by midwifery. Improving healthcare service, institutional delivery and the competency of maternal care providers may aid the EIBF in Ethiopia.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. The survey datasets used in this study were based on a publicly available dataset that is freely available online with no participant’s identity from http://www.dhsprogram.com/data/available-datasets.cfm. Approval was sought from MEASURE DHS/ICF International, and permission was granted for this use.

Ethics statementsPatient consent for publicationEthics approval

The study was based on a secondary data analysis of the EDHS data, and it is publicly available. We obtained permission from MEASURE DHS/ICF International and used the data. During the original data collection of DHS data, international and national ethical guidelines were applied. Additionally, the study participants gave written consent during data collection.

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