Predictors of Breastfeeding Initiation Among Postnatal Mothers at Tertiary Care Center of a Tribal Dominant State in India: A Regression Analysis

Background Early initiation of breastfeeding (EIBF) is one of the most important predictors for the survival of a child, spacing between two children, and prevention from childhood infections. Breastfeeding plays an important role in reducing child mortality and morbidity but the practice of EIBF globally is way behind the required time for initiation of breastfeeding after delivery. So, we planned to evaluate the early time of initiation of breastfeeding among the postnatal mothers and to determine the predictors of early initiation of breastfeeding in a tertiary hospital setting. Methodology A hospital-based cross-sectional study was conducted in the postnatal ward of Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand for a period of three months (March-May 2017). Our study included 200 postnatal mothers who delivered normal and healthy babies. Mother-infant dyads enrolled in our study were interviewed personally during six hours of the postpartum period. Irrespective of the mode of delivery, all babies born during the study period whose mothers consented to be a part of the study were included. Data collected were entered in MS Excel and analyzed using IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Results A total of 200 postnatal mothers fulfilling the study criteria were enrolled during the study. Of them, the majority 98 (49%) belonged to the age group 18-25 years. A hundred and twenty-six (63%) of them resided in rural areas, 182 (91%) were housewives, and only 86 (43%) of them had completed secondary education & above. Early initiation of breastfeeding was found to be only 43 (21.5%) among postnatal mothers. Predictors found to be statistically significant with EIBF were mother's residential status [odds ratio (OR): 2.98; 95% confidence interval (CI): 1.25-7.13], educational status of mother (OR: 3.18; 95% CI: 1.12-9.01) mode of delivery of the baby (OR: 8.93; 95% CI: 2.66-30.06) and ante-natal care (ANC) visits (OR: 0.441; 95% CI: 0.311-0.651). Women’s age, religion, ethnicity, occupation, type of family, and socioeconomic status displayed no statistically significant relationship with EIBF. Conclusions It is concluded that nearly one-fifth of mothers in the study initiated breastfeeding within one hour of post-delivery. Maternal education, frequent ANC visits, place of residence, and mode of delivery were also associated with EIBF in India. Nursing staff, as well as clinicians, should reinforce the importance of early initiation of breastfeeding by providing proper health education to post-natal beneficiaries.


Introduction
Breastfeeding has many health benefits and provides all nutrients to infants in the early months of their life. As per the recommendation of WHO, breastfeeding should be introduced within the first hour after birth [1]. Provision of mother's milk to infants within an hour of birth is referred to as early initiation of breastfeeding (EIBF). This ensures that the first milk from the mother's breast also known as colostrum (rich in protective factors) is given to the infants immediately after delivery.
The protective and beneficial effect of EIBF is completely based on the immunological properties present in the mother's milk. Exclusive breastfeeding during the first six months and avoidance of pre-lacteal foods during the same period ensures proper nutrients and immunoglobulin to babies and helps them to fight against various diseases [2][3][4]. Although there is evidence supporting the beneficial effect of EIBF, the proportion of EIBF remains low (nearly 50%) in many developing countries including India against the worldwide recommendation of 90% [5][6][7]. India has made steady progress in raising EIBF rates in the last few decades, but evidence from the regional areas indicate that the percentage of mothers who put their newborn babies on breast milk within the first hour of birth remains abysmally low from the average expected level, which ranges from 36% to 42% [8]. The Lancet report showed that the optimal breastfeeding has a major role in averting 13% of all deaths under the age of two years worldwide [9].
EIBF has many other benefits such as promoting bonding with the mother, maintaining optimal body temperature, and maintaining respiration and blood sugar levels of the newborns. In addition, it is also vital for providing optimal nutrition and development of infants [10]. As per Global Breastfeeding Collective 2017 notes mentioned in WBTi report 2018, despite the exclusive breastfeeding rate being 55%, there have been high mortality in India due to diarrhea and pneumonia in under five children which may be prevented through early initiation of breast feeding, exclusive breast feeding and continued breast feeding up-to 2 years . Inadequate knowledge regarding breastfeeding and frequent use of commercially prepared top feeds were found to be the leading reasons for low breastfeeding rates in the country [11]. Over the years, evidence accumulated reveals the role of multiple socio-cultural, economic, and demographic factors in the promotion of EIBF. Some of these factors which affect EIBF include the gender of the baby, birth order, place of birth, type of delivery and birth, maternal age, maternal education, and religious affiliation. Certain household factors, including the wealth index, rural-urban locality, and region of residence, have also been cited as possible determinants of EIBF [12]. In Jharkhand, there are scanty studies on EIBF, and evidence from tertiary care settings is even less than the community settings. Therefore, the present study was conducted to evaluate the practice of breastfeeding in a tertiary hospital setting, with a focus on the time of initiation of breastfeeding and its determinants among postnatal mothers.

Materials And Methods
The present study was a hospital-based cross-sectional study done at the postnatal ward of the obstetrics department at Rajendra Institute of Medical Sciences (RIMS), Ranchi. Our institute caters to the medical needs of patients coming for medical care irrespective of age, gender, ethnicity, religion, residence, etc. Being a government setup where most of the medical services are free, this hospital is thronged by the population belonging below the poverty line. Approximately 12,000 babies are delivered every year in our hospital. The study was conducted for three months from March 2017 to May 2017 to understand the breastfeeding practices in the hospital settings. Considering the prevalence of initiation of breastfeeding within an hour to be 33% (NFHS 4) [13], power of the study 80%, with 95% confidence interval (CI), precision 7% and 10% additive to total sample size, a total sample size came out to be 198 and rounding it to 200 for our study. A total of 200 mother-baby dyads were randomly selected using the random table method and interviewed in the post-natal ward of the Department of Obstetrics, RIMS, Ranchi. All the pregnant women were enrolled on a structured protocol that contained details of the date of admission, date of discharge, details of vitals, investigation reports, etc. The semi-structured questionnaire which was pretested before the conduction of the study was used for the collection of data which includes parts covering the socio-demographic profile of the mothers and breastfeeding habits. The study was initiated after the prior approval of the Institutional Ethics committee, RIMS, Ranchi. Data was entered in the template created in MS Excel 2017 and all the statistical analysis was done on IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Frequencies and proportions of the study variables were calculated in our primary analysis for the whole sample. All the factors were cross-tabulated with the prevalence of EIBF to estimate any association. Binary logistic regression was used to evaluate the predictors or drivers associated with EIBF. A p-value of < 0.05 was set to be statistically significant and also their 95% confidence interval was reported in our present study.

Results
A total of 200 participants were included in our study. The majority of mothers, 98 (49%) were between the age group 18-25 years. Among the newborns, 103 (51.5%) were male and 97 (48.5%) were females. A majority of the mothers were Hindu 122 (61%), 135 (67.5) were of non-tribal ethnicity, 126 (63%) were from rural areas, and 78 (39%) belonged to B.G Prasad class 4 socioeconomic status. About 86 (43%) of the mothers had completed secondary and above education. In our study, most 175 (87.5%) of the babies born were mature, 166 (83%) had normal birth weight, 139 (69.5%) were of either first or second order birth, and 166 (83%) were delivered by caesarian section. According to our study, most of the mothers started breastfeeding within two to four hours but early initiation of breastfeeding was found to be only 43 (21.5%). Among 200 postnatal mothers, the median time of initiation of breastfeeding was three hours, inter-quartile range (IQR) two to five hrs ( Table 1).

S. No
Characteristics Category Frequency n (%)

TABLE 2: Association between early initiation of breastfeeding with socio-demographic variables (n=200)
Multivariate logistic regression analysis was done to find out the various predictors of EIBF. The relationships showing adjusted odds ratios (Adj OR) which are statistically significant with p < 0.05 are described in Table 3. In our study, the women residing in rural areas were three times more likely to have EIBF compared to women residing in urban areas. Children of mothers educated up to middle school were found to have three times more EIBF when compared to the children of illiterate mothers, showing direct association with EIBF and mothers' education status. Baby delivered by normal vaginal delivery were nine times more likely to have EIBF when compared to a baby delivered by caesarian section. Mothers who did not visit a health center for antenatal check-up were 56% less likely to have EIBF when compared to mothers who frequently visited health centers ( Table 3).

Discussion
Our study done in the Indian tertiary care setup showed that 21.5% of Indian post-natal mothers initiated breastfeeding within an hour of delivery. The proportion and chances of EIBF were found to be highest among Indian mothers who had regular health services visits and those with higher levels of educational status, with major differences in populations residing in rural areas in comparison to the urban population.
Early breastfeeding rates in the state of Jharkhand and the national averages are 32.7% and 50.2%, respectively [13]. Data from the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, suggest that the percentage of EIBF was found to be 64% and cesarean sections attributed to the late initiation of breastfeeding [14]. Report from the tertiary care center of Gujarat reported 32.4%, with maternal fatigue and cesarean section are common predictors for late initiation of breastfeeding [15]. However, in the present study, rates were much lower and the common reasons associated were lower cesarean section and urban population.
Our study indicated that the better academic background of mothers in the total population was associated with EIBF compared to those with poor educational attainment, which was in agreement with the findings from a systematic review conducted for South Asia [16]. Evidence has shown that higher maternal educational levels had a better impact on childhood nutrition and well-being also [17,18]. This may be due to the increased receptivity of a mother with formal education to health promotion campaigns and their empowerment status within the household to make informed health-related decisions [19]. The association between higher maternal educational attainment and EIBF highlights the wide-ranging importance of improving women's access to quality education, in line with the sustainable development goal-4 (SDG-4), which aims to ensure that all girls and boys complete free, equitable, and quality primary and secondary education by the year 2030 [20].
Difficulties in accessing health care services such as ANC have been found to be significant barriers in initiating breastfeeding within the first hour of birth [21]. Our study indicated that receiving four or more ANC sessions was associated with an increased likelihood of EIBF in the total population. This finding is congruous with previous studies conducted in Sri Lanka, and Bangladesh which showed that no or less than four ANC visits were associated with delayed initiation of breastfeeding [22,23]. These findings suggest that the health messages provided during ANC sessions could improve mothers' adherence to the WHO breastfeeding recommendations [24]. For example, step 3 of the revised baby-friendly hospital initiative (BFHI) indicates that all pregnant women and their families should be informed of the importance and management of breastfeeding in ANC sessions [25].
This study shows differences in rural and urban areas in relation to EIBF. Better maternal educational background and frequent ANC (≥ 4) visits were associated with EIBF. Mothers in rural areas are more inclined to timely initiate breastfeeding; this is mainly due to government-funded rural specific maternal and child health (MCH) interventions which aimed to address the health needs of under-served rural areas [26].
Furthermore, the mode of delivery also has a great role in determining EIBF, with cesarean sections potentially negating some of the positive effects of vaginal delivery. Consistent with previous Indian studies, as well as the broader literature, we found that cesarean section was associated with delayed EIBF compared to vaginal birth [5]. A recent systematic review suggests that the negative impact of cesarean section on EIBF may be due to the post-operative care that hampers the early skin-to-skin contact of mother and baby which supports EIBF [27]. Despite this challenge, evidence suggests that EIBF is feasible even after cesarean delivery if health professionals are well-trained to provide the necessary support and guidance to the mother [28]. It is, therefore, essential that initiatives aimed at increasing breastfeeding should include the training of health professionals and the establishment of 'baby friendly' health facilities to appropriately support mothers to breastfeed within the first hour of birth [29].
The study has methodological limitations that should be considered. We have conducted a cross-sectional study for data collection, so a clear temporal association between the study factors and EIBF cannot be established.

Conclusions
Our study concluded that nearly one-fifth of mothers in the study initiated breastfeeding within one hour of post-delivery. Maternal education, frequent ANC visits, place of residence, and mode of delivery were also associated with EIBF in India. The abysmally low prevalence of EIBF in tertiary care settings is a major concern and needs to be addressed at the hospital level as it shows a major gap in practices and a lack of health education. The health personnel should be motivated to counsel about the importance of early initiation of breastfeeding to all mothers with special attention to the predictors highlighted in the study. Continuous re-enforcement of the importance of EIBF by senior consultants and obstetricians to nursing staff will also help in increasing the prevalence of EIBF. The steps of the BFHI should be internally assessed and monitored to reap its benefits. More evidence is needed from major tertiary care settings in this regard to get a more clear picture of the present situation.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Rajendra Institute of Medical Sciences, Institutional Ethics Committee issued approval 113, Dated 15.02.2017. This is to certify that Institutional Ethics Committee, Rajendra Institute of Medical Sciences, Ranchi approves and grants permission for academic and scientific work on the project entitled: "A hospital based cross-sectional study to assess breastfeeding and its co-relates amongst post natal care women in a teaching hospital of Jharkhand" to be done by Aishwarya Dandapat, VII semester MBBS student under the guidance of Dr. Dewesh Kumar, Assistant Professor, PSM Department, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand (India). Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.