Empowering early breastfeeding: Determinants of timely initiation among the infants in a rural Indian medical centre

Abstract

BACKGROUND

Initiating breastfeeding within the first hour after birth is a proven intervention for improving newborn survival and long-term health outcomes. Despite its recognized advantages, early initiation of breastfeeding (EIBF) remains limited in India, and data from rural Maharashtra are scarce.

AIM

To determine the prevalence of EIBF and explore maternal and delivery-related factors influencing its practice among late preterm and term infants in a rural tertiary care hospital.

METHODS

This observational study was conducted over a period of 18 months, from May 2022 to October 2023 and included 380 neonates born at ≥ 34 weeks of gestation. Information on maternal sociodemographic profile, delivery characteristics, antenatal counselling, breastfeeding practices, and early maternal or neonatal health concerns was collected through a structured interview of the mothers and the accompanying attendants and hospital records at birth and within 6 hours of birth. Data were analysed using descriptive statistics. Appropriate association tests were applied.

RESULTS

EIBF was reported in 50.8% of newborns, higher than the National Family Health Survey-5 national estimate of 41.8%, but still below the desired levels. Mothers who received antenatal maternal counselling [P < 0.05, adjusted odds ratio (aOR) = 3.5], had prior breastfeeding experience (P < 0.05, aOR = 2.4), and had vaginal deliveries (P < 0.05, aOR = 2.4) were more likely to initiate breastfeeding within the first hour. Caesarean births (P < 0.05, aOR = 0.4), maternal illness (P < 0.05, aOR = 0.3), and lactation problems (P < 0.05, aOR = 0.2) were associated with delays. No significant relationships were observed between maternal age, residence, education, occupation, religion, parity, or birth spacing and the practice of giving prelacteal feeds. Among the modifiable influences, antenatal advice emerged as the strongest predictor of success.

CONCLUSION

Interventions focusing on antenatal counselling during pregnancy and providing enhanced lactation support for surgical deliveries, and addressing the lactational problems by appointing a dedicated nurse, may substantially improve EIBF. Strengthening these measures can improve neonatal outcomes and align with national and global child health targets.

Key Words: Early initiation of breastfeeding; Lactation problems; Antenatal counselling; Colostrum; Prelacteal feeding; First hour

Core Tip: This study reveals that while early initiation of breastfeeding in a rural area of Maharashtra (50.8%) exceeds national averages, it remains suboptimal. Antenatal counselling emerged as the most significant modifiable predictor of success, whereas caesarean sections and maternal illness were primary barriers. To meet global health targets, clinical interventions must prioritise standardised prenatal breastfeeding education and provide enhanced lactation support for surgical deliveries to ensure the vital “first-hour” window is utilised.

INTRODUCTION

Early initiation of breastfeeding (EIBF), defined as initiating breastfeeding within one hour of birth, protects the infants from infections and reduces neonatal mortality[1]. It strengthens maternal-infant bonding, promotes the duration of exclusive breastfeeding, and stimulates early milk production, including colostrum, which provides essential nutritional and immunological benefits to the newborns. Breastfeeding is consistently shown to improve infant health, growth, and development, offering protection against gastrointestinal and respiratory infections, otitis media, asthma, eczema, sudden infant death syndrome, childhood leukaemia, dental caries, and obesity[2-4]. It also enhances cognitive development and reduces long-term risks of cardiovascular and metabolic disorders[5-7]. Beyond health benefits, breastfeeding alleviates financial burden by reducing expenses on food substitutes and healthcare.

The World Health Organisation recommends initiating breastfeeding within the first hour of birth and continuing exclusive breastfeeding for six months, followed by adequate complementary feeding up to two years of age[8]. EIBF supports skin-to-skin contact, reduces neonatal hypothermia, promotes maternal-infant bonding, and decreases all causes of neonatal mortality[9]. A recent study from India demonstrates that neonates who are not breastfed within the first hour have nearly threefold higher odds of mortality[10]. For mothers, EIBF facilitates uterine involution, reduces postpartum bleeding and infections, supports lactational amenorrhea, and lowers stress and depression. Long-term maternal benefits include reduced risk of breast, ovarian, and endometrial cancers, endometriosis, diabetes, osteoporosis, and cardiovascular and metabolic diseases[11].

Despite these well-established advantages, global EIBF rates remain suboptimal. Only three out of five newborns worldwide receive breastfeeding within one hour, and in India, the National Family Health Survey-5 reports a rate of just 41.8%. Given the low rate of EIBF, it is essential to identify the factors that affect it. Numerous maternal, neonatal, and sociodemographic factors influence EIBF[12-15], including maternal education[12], occupation[12], residence[12], age[12], parity[13,14], mode of delivery[13-15], antenatal counselling[13-15], previous breastfeeding experience[14], prelacteal feeding[14,15], rooming-in, and maternal illness[12,14]. A South Asian review highlighted barriers, including traditional feeding practices, prelacteal feeds, discarding colostrum, lack of awareness, limited media exposure, and inadequate decision-making support[12]. Other determinants, including rural residence, home delivery, caesarean birth, low birth weight, and large family size, have been identified in earlier studies[13].

Despite hospital delivery, the rate of EIBF remains just around 41.8% (National Family Health Survey-5 data). Limited research exists on EIBF in rural Maharashtra, particularly the Marathwada region, with most data originating from national surveys or urban settings. This study addresses this gap by providing institution-based data from a rural tertiary care referral centre with a high caesarean section rate, where clinical barriers differ significantly. We aimed to identify the prevalence, barriers, and enablers of EIBF in this specific rural context. Notably, this is the first study of its kind in this region, including both term and late preterm (> 34 weeks) infants to reflect real-world postnatal practices. Furthermore, data collection within 6 hours of birth minimises recall bias.

MATERIALS AND METHODS

This observational study was carried out at Yeshwantrao Chavan Rural Hospital and Maharashtra Institute of Medical Sciences and Research Medical College, Latur, India, which is a Tertiary care referral centre in a rural area with a level 3 obstetric care unit for high-risk pregnancies and a level 3 neonatal intensive care unit. We conducted the present study over a period of 18 months, from May 2022 to October 2023, in the obstetric and paediatric departments. The mothers were identified by referring to their antenatal case sheets for the gestational age, and the mothers who had delivered beyond 34 completed weeks of gestation, and who had no complications mentioned in the exclusion criteria, were recruited into the study.

This study included all the healthy newborns born after 34 completed weeks of gestation, who were transferred to the mother's side. All the high-risk newborns were transferred to the neonatal intensive care unit immediately after birth, preterm neonates < 34 weeks, newborns with significant congenital anomalies, babies born to human immunodeficiency virus-positive mothers and babies whose mothers were shifted to the critical care setup for postpartum complications were excluded. The study was approved by the institutional ethical committee vide its letter dated 04/10/2022. Written informed consent was obtained from all the mothers, and those who did not give consent were excluded from the study.

Data collection

The sociodemographic variables[12-15] that may affect the early initiation of breast feeding included were maternal age, residence (rural or urban), religion, educational status of mother (up to high school and beyond high school), profession, gravidity status, birth spacing, antenatal maternal counselling, previous breast-feeding experience, maternal illness, gender of the newborn, mode of delivery, receipt of prelacteal feeds by newborn, lactational problems in mother (like flat nipples, inverted nipples, sore or cracked nipples, breast engorgement, baby not latching properly, not having milk). A study proforma was prepared from maternal and infant factors affecting EIBF from the existing literature and previous hospital records. It had separate sections on maternal and infant factors to be studied. The information was filled in by the paediatric resident doctors attending the birth either in the operating theatre or the delivery room. All the paediatric residents were trained in data collection before the beginning of the study by the department of paediatrics regarding the use of a structured questionnaire and timings of data collection. The sociodemographic factors information was collected at birth in most of the cases from the hospital records, and for a few emergency deliveries, the remaining information was completed and cross-checked within the first 6 hours as and when feasible. The data on the timing of initiation of breastfeeding and factors influencing it were collected within 6 hours of birth by interviewing the mothers and their accompanying attendants. Data collected at 24 hours or at the time of discharge focused on measuring exclusive breastfeeding success rates rather than determinants of early initiation. At our institute, the antenatal counselling for all the registered mothers was done by the obstetric department during pregnancy, but being a referral centre, antenatal counselling could not be done for the emergency referrals and unregistered pregnancies. We did not follow the protocol of delivering the baby on the mother’s abdomen, but all the babies were taken to a radiant warmer in the delivery room and shifted immediately to the mother’s side after the initial stabilisation and completing the head-to-toe examination of the babies. The pediatric residents and accompanying pediatric nurses were assigned the work of initiating skin-to-skin contact and help in breastfeeding. All the paediatric nurses were taught about skin-to-skin care and breastfeeding techniques by the paediatric department as and when required. There were no separate lactational counsellors in our institute at the time of study. The confidentiality, anonymity, and participants’ privacy were guaranteed throughout the study.

Data were analysed using R-4.5, and a P-value of < 0.05 was considered statistically significant. Qualitative data were expressed as percentages and proportions. Quantitative data were expressed in terms of mean ± SD. Association between two qualitative variables: χ²/Fisher’s exact test used. For comparing the mean ± SD between two groups, the unpaired t-test was used. Descriptive statistics of each variable were presented in terms of Mean and standard deviation. Logistic regression was used to estimate the contribution of various factors in the EIBF as a multivariate analysis. Diagnostic plots were not taken into account, as it was a non-linear model.

RESULTS

A total of 380 mother-infant pairs were studied, out of which around 50.8% (193) of mothers had initiated breastfeeding within 1 hour of the child’s birth, and 49.2 % (187) initiated breastfeeding after 1 hour of childbirth. Out of 380 mother-infant pairs studied, 261 (68.7%) mothers were residing in rural areas, while 119 (31.3%) mothers were from the urban areas. The mean age of the mothers was 24.34 ± 3.83 years, and the mean gestation was 38.42 ± 1.32 weeks. A total of 197 (51.9%) mothers had been educated up to high school level, and 183 (48.1%) mothers had been educated beyond high school level. A total of 341 (89.7%) mothers belonged to the Hindu religion. Mothers were divided as working 12 (3.2%) and non-working (Housewives) 368 (96.9%) depending on their professions. Of the total number of mothers, 116 (30.5%) were primigravidas, while the remaining 264 (69.5%) were multigravidas. Antenatal counselling about breastfeeding was provided to 317 (83.4%) mothers, while the remaining 63 (16.6%) could not be counselled due to emergency admissions. A total of 236 (62.1%) mothers had previous breastfeeding experience, while 144 (37.9%) mothers did not have previous breastfeeding experience in earlier childbirths, which includes both primigravidas and multigravidas with a previous history of abortions or neonatal deaths. Around 52 (13.7%) mothers had some of the medical illnesses like severe preeclampsia or eclampsia, chorioamnionitis, shock, sepsis, severe anaemia, perineal tear, postpartum haemorrhage, malaria, tuberculosis, urinary tract infection, hypertension, gestational diabetes, obesity, heart disease, bronchial asthma, epilepsy, etc. while 328 (86.3%) did not have any illness. Out of the 380 newborns, 212 (55.8%) were males. As it was a tertiary care centre, most of the patients were referred due to some pregnancy-related complications; therefore, the number of caesarean sections was higher, i.e., 285 (75%), compared to the normal deliveries, 95 (25%). We had five vaginally assisted deliveries during the study period; hence, we had made only two groups of mothers based on mode of delivery, i.e. caesarean section or vaginally delivered, for data evaluation. A total of 15 (3.9%) babies had received some prelacteal feeds in the form of water, honey, jaggery, sugar water, or other milk before the initiation of breastfeeding at birth, but 365 (96.1%) babies did not receive any prelacteal feeds at birth. Out of 380 mothers, 69 (18.2%) experienced lactation problems like flat nipples, inverted nipples, sore or cracked nipples, breast engorgement, improper baby latching, and inadequate milk flow, which affected the process of lactation. The remaining 311 (81.8%) mothers did not have any lactation problems (Table 1).

Table 1 Sociodemographic variables, n (%).

Variables
Place of residence
Rural	261 (68.7)
Urban	119 (31.3)
Mean age of mothers in years (mean ± SD)	24.34 ± 3.83
Average gestational age in weeks (mean ± SD)	38.42 ± 1.32
Education of mothers
Up to SSC (high school)	197 (51.9)
Beyond SSC (high school)	183 (48.1)
Religion
Hindu	341(89.7)
Others	39 (10.3)
Profession
Non-working (housewife)	368 (96.9)
Working	12 (3.1)
Gravidity
Primigravida	116 (30.5)
Multigravida	264 (69.5)
Maternal counselling
Done	317 (83.4)
Not done	63 (16.6)
Mothers with previous breastfeeding experience
Yes	236 (62.1)
No	144 (37.9)
Mothers having other medical illnesses
Yes	52 (13.7)
No	328 (86.3)
Gender of the newborn
Male	212 (55.8)
Female	168 (44.2)
Mode of delivery
Vaginal delivery	95 (25)
Caesarean section	285 (75)
Newborns receiving prelacteal feeds
Yes	15 (3.9)
No	365 (96.1)
Mothers having lactation problems
Yes	69 (18.2)
No	311 (81.8)

n: Number of mothers; SSC: Secondary school certificate examination.

After comparing the demographic characteristics between the mothers who had EIBF and those who had late initiation of breastfeeding (Table 2), it was observed that the factors, which had a positive impact on EIBF were maternal education beyond high school, antenatal maternal counseling, mothers with previous breastfeeding experience, mothers without any other medical illness, mothers who had normal vaginal delivery, not giving prelacteal feeds to the babies and mothers who did not have any lactation problems (P value < 0.05).

Table 2 Comparison of the factors influencing the early initiation of breastfeeding, n (%).

Factor	EIBF 193 (50.8)	Late initiation of breastfeeding, 187 (49.2)	P value
Residence
Rural residence	131 (67.9)	130 (69.5)	0.73
Urban residence	62 (32.1)	57 (30.5)
Maternal age
18-20 years	26 (13.5)	34 (18.2)
21-30 years	149 (77.2)	145 (77.5)	0.087
31-40 years education	18 (9.3)	8 (4.3)
Education up to high school	90 (46.6)	107 (57.2)	0.0389
Education beyond high school	103 (53.3)	80 (42.8)
Religion
Hindu	170 (88.1)	171 (91.4)	0.2805
Others (Muslim, Jain)	23 (11.5)	16 (8.6)
Profession
Not working (housewife)	186 (96.4)	182 (97.3)	0.53
Working	7 (3.6)	5 (2.7)
Maternal counselling
Done	178 (92.2)	140 (74.9)	0.0001
Not done brestfeeding experience	15 (7.8)	47 (25.1)
Mothers with previous breastfeeding experience	143 (74.1)	93 (49.7)	0.0001
Without previous BF experience	50 (25.9)	94 (50.3)
Mothers with other medical illnesses
Present	14 (7.3)	38 (20.3)	0.0001
Absent	179 (92.7)	149 (79.7)
Gender of the newborn
Male	105 (54.4)	107 (57.2)	0.58
Female	88 (45.6)	80 (42.8)
Mode of delivery
Vaginal delivery	66 (34.2)	29 (15.5)	0.0001
Caesarean section	127 (65.8)	158 (84.5)
Newborns receiving prelacteal feeds
Not received	191 (99)	174 (93.3)	0.031
Received	2 (1)	13 (6.7)
Mothers having lactational problems
Present	13 (6.7)	56 (29.9)	0.0001
Absent	180 (93.3)	131 (70.1)

EIBF: Early initiation of breastfeeding.

Multivariate logistic regression analysis was conducted on seven significant variables identified in the univariate analysis (as the collinearity of the factors could not be assessed). The results showed that antenatal counselling [adjusted odds ratio (aOR) = 1.28] and previous breastfeeding experience (aOR = 2.4) significantly improved EIBF rates. Conversely, delivery by Caesarean section (aOR = 0.4), maternal medical illness (aOR = 0.3), and lactational problems (aOR = 0.2) were significant factors leading to delayed initiation of breastfeeding (Table 3).

Table 3 Multivariate Logistic regression analysis.

Impact factor	Regression coefficient	2.5%	97.5%	Adjusted odds ratio	Conclusion
Maternal counselling	1.2588312	1.7751	6.9855	3.5	Significant
Previous breastfeeding experience	0.8624945	1.4606	3.8426	2.4	Significant
Maternal illness	-1.2394842	0.1419	0.5908	0.3	Significant
Mode of delivery LSCS	-0.8624333	0.2442	0.7299	0.4	Significant
Lactational problems	-1.6379762	0.0982	0.3847	0.2	Significant

LSCS: Lower segment cesarean section.

From the data recorded at 24 hours and at the time of discharge, it was observed that among the mothers following EIBF (n = 193), a total of 133 (69%) mothers were following exclusive breastfeeding, and the remaining mothers were giving mixed feeds (breastfeeding and formula feeds both). Amongst the mothers who did not initiate early breastfeeding, only 75 (40%) were following exclusive breastfeeding.

DISCUSSION

In our study, the proportion of women who initiated breastfeeding early was 50.8%, which was higher than the national average (41.8%) and almost equal to that of Maharashtra state (53.2%), as per National Family Health Survey-5 data, but still below the World Health Organisation-recommended levels. Many previous studies carried out across different states of India have shown different rates of EIBF ranging from 30% to 68.4%[14-18]. Our study revealed that antenatal maternal counselling had a significant positive impact on the EIBF, which is consistent with a recent study in India by Namasivayam et al[19], who observed that mothers receiving prenatal breastfeeding advice and immediate postnatal support were 2.7 times more likely to initiate early breastfeeding.

This study also showed that mothers with prior breastfeeding experience were more likely to initiate early breastfeeding (aOR = 2.4). This finding is consistent with two Indian studies[14,20]. The present study revealed that those who had a caesarean section had delayed initiation of breastfeeding. This finding fairly correlates with earlier studies from various parts of India[14,17,21,22]. This suggested that women who undergo caesarean delivery may need additional help to attain comfortable and correct positioning of their infant for breastfeeding. Despite the difficulty practising EIBF following caesarean delivery, it has been found that if dedicated support is provided, then even a caesarean section is not a barrier to EIBF[23].

It was found that maternal medical illness (aOR = 0.3) was associated with a negative impact on EIBF. This was consistent with the studies by Khan et al[14] and Hassan et al[24]. Mothers with lactation problems had initiated breastfeeding late (aOR = 0.2). Similar findings were noted in a study done in Turkey by Yılmaz et al[25]. The overall results of the present study show that mothers who had received antenatal counselling, had prior breastfeeding experience, and vaginal deliveries were significantly more likely to initiate breastfeeding within the first hour. Conversely, caesarean births, maternal illness, and lactation problems were associated with delays. No significant relationships were observed with maternal age, residence, occupation, education, religion, parity, birth spacing, or prelacteal feeding. Key modifiable predictors of successful breastfeeding included antenatal counselling, appointing specialised lactation support (counsellor/nurse) for addressing the lactational problems and targeted assistance following cesarean sections.

Strengths and limitations

This study provided clinically relevant evidence on EIBF from a rural tertiary care referral centre in Maharashtra, a setting that is under-represented in the existing literature. Key strengths include prospective data collection within the first six hours of birth, which minimised recall bias, and an adequate sample size accrued over 18 months. Inclusion of both late preterm and term neonates reflected routine postnatal ward practices. Evaluation of a broad range of maternal, obstetric, and health-system factors, combined with multivariate logistic regression analysis, enabled identification of independent and modifiable predictors of EIBF with direct clinical and programmatic implications.

The study had certain limitations. Being a single-centre, referral-based study with a high proportion of caesarean deliveries, the findings might not be generalizable to primary-level or non-referral settings. Exclusion of neonates requiring immediate neonatal intensive care unit admission might have influenced EIBF estimates. Residual confounding due to unmeasured sociocultural and provider-related factors (doctor beliefs and attitudes) could not be excluded, and long-term breastfeeding outcomes were not assessed. We had formulated a lactation policy for our institution based on these study results and planned a quality improvement initiative to improve breastfeeding usage in the golden hour after birth.

CONCLUSION

The rate of timely breastfeeding initiation in our setting remains suboptimal. Interventions focusing on antenatal counselling, formulating a lactation policy, targeted assistance following caesarean sections and appointing a specialized lactation counsellor or nurse to address the lactational problems may substantially improve EIBF. Strengthening these measures can improve neonatal outcomes and align with national and global child health targets.

ACKNOWLEDGEMENTS

The authors wish to thank Dr Arunkumar Rao for revising this article for syntax and scientific language style. The authors also wish to thank Mr Devendra Tandale for statistical analysis. Thanks are due to Mr Vinod Jogdand and Mr Deepak Badane for all the technical support in the preparation of this manuscript.