Determinant of Early Initiation of Breastfeeding in a Tertiary Neonatal Unit Nepal

Introduction: Initiation of breastfeeding within one hour of birth is an important determinant of successful breastfeeding. National Family and Health Survey -3(NFHS-3) reported that only 23.4% of children <3 years were breastfed within one hour of birth. Objectives: the purpose of this study is to study the determinant of initiation of breastfeeding within one hour of birth. Setting: Tertiary –level neonatal unit. Material and Methods: All mothers admitted in in the postnatal ward were eligible for inclusion; mothers of sick and /or preterm infants were excluded. Enrolled mothers were interviewed between 24 and 72 hours after delivery. Results: The proportion of mothers who initiated breast feeding within one hour of delivery was 32%, between 1-6 hrs were 47% and between 6 to 48 hrs were 21%. Maternal age, education, socioeconomic status, occupation and antenatal or labor room counseling did not influence the initiation of breast feeding within one hour of delivery in univariate analysis. On multivariate analysis, admission in the general ward and delivery by caesarean section were found to be significantly associated with not initiating breastfeeding within one hour (adjusted ORs: 8.79, 2.48 to 31.08, p=0.001 and 6.79, 4.07 to 22.02 p=0.001 respectively). Only about 13% of the infants received prelacteal feeds. Conclusion: Mothers delivering by caesarean section or admitted in the general ward were at high risk of not initiating breastfeeding within one hour. Innovative strategies are required to ensure timely ignition of breastfeeding.


Introduction
B reast feeding is the best way of providing ideal food for the optimal growth & development of an infant.It also protects babies from common diseases like ARI &diarrhoeal diseases.It is not only benefi cial to the baby but also benefi cial to the mother, family, society and a nation as a whole.
Early initiation of breastfeeding has been shown to be associated with a higher prevalence of subsequent breastfeeding 1 .Initiation of breastfeeding within 1 st hour of birth is the fi rst and most vital steps towards reducing infant and under fi ve mortality and foremost unacceptably high neonatal mortality rate in developing countries like India and Nepal.According to global data out of all 10.9 million under fi ve deaths 4 million deaths occur Neonatal period.One third of which is due to infection, we can prevent this mortality by one of the cheapest and safest method i.e. by exclusive breastfeeding.According to National family & health Survey-3(NHFs-3) only 23.4%neonates were breastfed early in India like wise according to NDHS survey 2006 only 35.4% of newborn were initiate breastfeeding early in Nepal.
To enable mothers to establish and sustain exclusive breast feeding for 6 months WHO and UNICEF recommend: a. Initiation of breast feeding within 1 st hr.b.Exclusive breast feeding.c.Breast feeding on demand.d.No use of artifi cial nipples, pacifi er or teats.
While breast feeding is a natural act, it is also a learned behaviour.Extensive research has demonstrated that mothers and other caregivers require active support for establishing and sustaining appropriate breast feeding practices.The decision to breast feeding is infl uenced by diverse factors including demographic variables, attitude and knowledge, physician endorsement support from the family members 2 to ensure that expectant mothers make a truly informed decision about infant feeding; prenatal breast feeding education, breast feeding counselling in labour room, postnatal ward and maternity ward should be practised in each step.Extensive researches document the impact of specifi c health care practices and hospital routines on breast feeding outcomes.Practices that promote successful breast feeding includes early initiation of breast feeding 3 , continuous rooming in 4 , demand feeding 5 , avoidance of unnecessary formula supplementation 6 , avoidance of artifi cial nipples 7 , availability of knowledgeable staff 8 , correct breast feeding technique 9 and appropriate support in the post discharge period.
Despite the documented rational for breast feeding by BFHI, the hospital itself as a barrier for breast feeding remains widespread.Common practices that interfere with successful lactation include delayed initiation of breast feeding, separation of mother and baby, restricted feeding, use of formula feeding, routeings use of pacifi ers, insuffi cient guidance in correct breast feeding techniques and exclusive alliance between hospitals and formula companies.Any maternal or infant factor that limit exclusive breastfeeding should be identifi ed early and solve the problems immediately offer the best chance of successful lactation.

Objective
To study the determinants of initiation of breastfeeding within one hour of birth.

Material and methods
This was the Hospital based cross sectional study conducted at Tertiary level neonatal unit of All India Institute of Medical Sciences (AIIMS), New Delhi; in maternity wards including postnatal ward and private wards.A total of 100 mothers who had delivered at AIIMS over a period of two months (May-June 2007) were taken for the study.Informed verbal consent was taken from all mothers.They were interviewed by using standard questionnaire which was pretested.The time of interview ranged from 24-72 hrs of delivery.Data were analysed by using EPI-INFO software.Inclusion criteria: Mothers who gave birth to singleton baby at term gestation.Exclusion criteria: Preterm babies, sick term babies who required NICU admission, severe congenital anomalies and multiple births

Results
A total of 100 mothers delivering at AIIMS were enrolled in the study.More than half (56%) of mothers were of 25-29 yrs of age group.Only 2% of mothers were >35 years and none of them were below 20 years.More than one third (34%) had secondary school education.Almost two thirds (67%) of mothers were from lower middle class family.Almost half (49%) of mothers delivered vaginally.Eighty percent of mothers were house wives.
Thirty two percent (32%) of mothers initiated early breast feeding (within 1 st hr. of delivery),88% of mothers initiate breast feeding within fi rst 12 hrs.75% of mothers were counselled for the early initiation of breast feeding, where as 7% of mothers never received breast feeding counselling till the time of interview.
Only one third of mothers initiated breast feeding within one hour of birth but more than ninty fi ve percent of mothers start breastfeeding within twenty four hours of delivery.Almost 30% had given prelacteal feeding.Among these more than half (56.6%) received formula feeding in the form of prelacteal feeding indicating wide use of formula feeding in the hospital.About seventy six (76.6%) of infants received prelacteal feeding at 1-6 hrs of life, whereas only 16.7% of neonates received prelacteal feeding within 1 st hr of birth, indicating that there is large scope of avoiding prelacteal feeding by avoidance of giving formula feeding and early initiation of breast feeding by giving early breast feeding counselling and supporting the mother for breast feeding.
Results were analysed and on multivariate analysis: Delivery by caesarean section was found to be signifi cantly associated with not initiating breastfeeding within one hour of birth.(OR 6.79, 4.07 to 22.07 p=0.001).Like wise on multivariate analysis; admission in general ward was also found to be signifi cantly associated with not initiating breastfeeding within one hour of birth (OR: 8.79, 2.48 to 31.08, p=0.001).All others variables i.e. mother's age, maternal education, maternal occupation and socioeconomic status was insignifi cantly associated with early initiation of breast feeding.Similarly mothers who underwent caesarean section were giving signifi cantly more prelacteal feeding to their babies (p=0.0001).Other factors i.e. maternal age group, maternal education, maternal occupation and socioeconomic condition were not signifi cantly associated for prelacteal feeding.Only two thirds (66.7%) of mothers received breastfeeding counselling from doctors during ANC period.
Table1: Showing Demographic Variables of Mothers.

Discussion
In India steps taken for the protection and promotion of the practice of breast feeding have been effective and breast feeding is almost universal.However the message that early initiation of breast feeding, avoidance of prelacteal feeding and exclusive breast feeding up to six months and gradual introduction of semisolid feeds has not been as effectively communicated.Data from literature shows a signifi cant level of exclusive breast feeding only till three months i.e. 55.2%, by six months exclusive breast feeding drop to 19%.goveernment of India is making an extensive effort to promote and support breast feeding.Breast feeding component is incorporated in the national nutrition goals for the 10 th 5 year plan.The goal for the 10 th plan is to: 1. Enhanced early initiation of breast feeding from the current level of 15.8% (as per NFHS-II) to 50%.
2. Enhanced the exclusive breast feeding rate for children up to the age of 6 months from the current rate of 55% at 3 months (as per NHFS-II) to 80 %.
In our study 32% of mothers initiated early breast feeding within 1 st hr of delivery, and 95% of mothers had initiated breast feeding within 1 st 24 hrs of delivery.Study by Ajay Vatsayan et.al. 10 in Simla found only 10.3%, but almost similar percentage of mothers (92.21%) started breast feeding within 1 st 24 hrs of delivery.Kameshwara rao et.al. 11 in their study which was found to be similar to our study showed 39.5% of mothers practiced exclusive breast feeding practices.Similar fi nding have also been observed by Ram et al. 12 i.e. 85.5% of infants were put on breast milk within fi rst 24 hours after their birth.Similarly K.S.Negi 13 observed 80.3% of the mothers initiated breastfeeding within 7-18 hours after delivery.Taneja 14 found that exclusive breast feeding was not so common (26.4%) as water was started to be given in most infants in the fi rst month itself.So much of a difference in studies regarding early initiation of breast feeding could be due to difference in hospital and community setup.This study we observed that, caesarean section was found to be a signifi cant cause of delayed initiation of breast feeding (19.9% vs. 44.9%,p=0.00030).A similar type of fi nding was observed by Vatsayan et.al 10 also observed similar correlation between caesarean section and a decreased rate of initiation of early breast feeding (only 8% of mothers undergoing caesarean section initiated breast feeding within 1 st 8 hrs of delivery, p=0.000).Similar type of fi ndings was also observed by Pandit N.Yeswant 15 .These fi ndings suggest that more and more support should be given for mothers who underwent caesarean section for early initiation of breast feeding.
No others factors in this study like; maternal age, maternal education, maternal occupation and socioeconomic status were correlated signifi cantly with early initiation of breast feeding.similar fi nding was observed by Ajaya Vatsayan 10.The fi nding that education and breastfeeding counselling of mothers is not conclusively linked to the initiation of breastfeeding may be due to other confounding factors as mother-in -law preferences, delayed rooming in of the child or simply personal attitude despite education.
In our study we found that only 13 % of mothers gave prelacteal feeding.Chhabra et al 16 also demonstrated from their study that in an urban resettlement colony of Delhi, 76.9% infants received prelacteal feeding.Devdas et al 17 also noted 87.9% nursing mothers gave sugar water, honey mixed with water, milk or jaggary as prelacteal feeding.A study conducted by Anuradha Goyle 18 also found 96.6% of mothers used prelacteal feeds.Such differences could be due to difference in study location (This study being hospital based and others being community based) and the presence of more dedicated hospital staff in this hospital.Among 13% of the prelacteal feeding group, 70%of mothers gave animal milk, 23% of mothers gave honey, 7 % of mothers gave ghutti as 1 st feeding.Anuradha et.el 18 found that plain water (48.3%) and jaggary with ghee 46.2% as a form of prelacteal feeding.This shows that there is further scope of increasing early initiation of breastfeeding by further counselling of mothers and their caregivers.

Conclusion
Despite antenatal and labour room counselling only about one thirds of mothers initiated breastfeeding within 1 st hour of delivery.Mothers delivering by caesarean section and admitted in general wards were at high risk of not initiating breastfeeding within the 1 st hour.Innovative strategies like provision of breastfeeding counsellors in the hospital setup, constant counselling to mothers and their immediate relatives who take care of baby and mothers; by doctors and nurses are essential for increasing early breastfeeding.As physicians and other medical personnel play an important role in the initiation of early breast feeding and prolongation of exclusive breast, their skill about breast feeding should be upgraded by giving periodic trainings and conducting workshops.Cent percent of pregnant ladies should get antenatal breast feeding counselling in the ANC period itself, similarly they should be counselled and supported in each and every step regarding breast feeding.As most of the mothers are giving formula feeding as a prelacteal feedings, it should be discouraged.