Overwhelming scientific evidence supports breastfeeding as the best food for newborn infants, with direct nutritional, immunological, and developmental benefits (Victora et al., 2016; Rollins et al., 2016). Early initiation of breastfeeding is defined by the World Health Organization (WHO) as “the proportion of children born in the past 24 months who were put to the breast within an hour of birth” (World Health Organization, 2008). The critical importance of early initiation of breastfeeding is highlighted in a recent meta-analysis, which reported a clear association with decreased neonatal mortality and morbidity (Smith et al., 2017). Despite this, early initiation of breastfeeding remains sub-optimal globally in low, lower-middle and upper-middle income countries (Victora et al., 2016) where infant mortality remains unacceptably high (GBD 2015 Child Mortality Collaborators, 2016). This describes the context of many Sub-Saharan African countries. At the same time, cesarean sections are increasing, especially as countries move from low to middle income countries. Cesarean births provide an additional challenge to early initiation of breastfeeding (Takahashi et al., 2017; Moore, Bergman, Anderson & Medley, 2016; Berde & Yalcin, 2016). Therefore, we sought to describe and understand the trends over 20 years in 27 Sub-Saharan Africa, low- and middle-income countries for early initiation of breastfeeding, cesarean births, and their association by wealth quintile within country. Globally, breastfeeding remains critical for achieving sustainable development goals #2 and #3 by decreasing malnutrition and mortality among children under 5 years of age (UN General Assembly, 2015). Rollins et al. (2016) call for interventions programs and policies to better support breastfeeding directly as well as through supportive environments such as breastfeeding friendly hospitals (World Health Organization & UNICEF, 2009). Nurses play a key role in both contexts.
Methods: Data from the Household and Women’s Demographic Health Surveys (DHS) from three time periods covering approximately 20 years were used for 27 Sub-Saharan countries including low, low-middle and upper-middle income countries. The DHS is a nationally representative cross-sectional household survey conducted about every 5 years by country that provides data in the areas of population, health and nutrition. In particular, the Women’s DHS includes topic areas of antenatal care, delivery, postnatal care, breastfeeding and nutrition. Nationally representative, randomized samples are drawn using a stratified two-stage cluster design, first selecting enumeration areas and second, selecting households within the enumeration areas. Sample sizes ranged from 730 to 7530 infant/mother pairs by country for each time point. Mode of delivery represented the main independent variable of interest (cesarean-section or not) and early breastfeeding initiation (yes or no), the outcome variable. Descriptive analyses examined frequency trends over time for cesarean deliveries and early breastfeeding initiation by country and by wealth status within country. For the most recent round of DHS data (most 2011-2015), unadjusted and adjusted logistic regression models estimated the association (odds ratios and 95% confidence intervals) between birthing practices and the outcome of early breastfeeding initiation. Adjusted models controlled for potential confounding variables and covariates, including maternal age, education, and employment, residence (urban or rural) wealth quintile, antenatal care, birth location, and parity. Sample weights were applied, and all analyses completed using STATA 14 (Stata Corp LP, College Station, TX).
Results: Country-level early breastfeeding initiation rates were variable by country, changing over time, and sub-optimal compared to WHO guidelines. The most recent data point by country revealed more countries (15) experienced a decrease in the percentage of mothers initiating early breastfeeding than increase (12). Among countries, early initiation of breastfeeding ranged from 17% to 82% with an interquartile range of 41-62%. Rates varied within country by wealth quintile. Cesarean-section rates increased over time in all but one country, yet the majority remained below 10%. Higher rates tended to occur as countries moved into middle-income economic status. Comparison of the highest and lowest wealth quintile within each country revealed significant disparities, with the wealthiest quintile often above the WHO recommended cesarean rate of 10-15% and lowest quintile well below this mark. In the majority of countries (15), after controlling for socio-demographic variables, antenatal care and birth location, mothers who underwent a cesarean delivery had significantly lower odds of early initiation of breastfeeding compared to those with vaginal delivery. The remaining 11 countries demonstrated lower odds but did not achieve statistical significance; most of these countries had wide confidence intervals.
Conclusions: Despite overwhelming evidence of the benefits of early initiation of breastfeeding, sub-optimal rates were found from our analysis of DHS data in 27 countries in Sub-Saharan Africa, where infant mortality remains unacceptably high. Cesarean rates demonstrated appropriate increases at the country level toward WHO recommended levels, but concerning disparities by wealth. The decreased odds for early initiation of breastfeeding after cesarean birth, and the rise in the percentage of cesarean births across countries, speaks to the need for policy implementation of WHOs breastfeeding friendly hospitals. Of critical importance are nurses, the front-line workers during deliveries to promote early initiation of breastfeeding. Continued study of the global trends in early initiation of breastfeeding and cesarean births remain critical as do intervention studies involving nurses and health system strengthening to best promote early initiation of breastfeeding. Early initiation of breastfeeding works toward achieving the sustainable development goals, and improving lives globally.