Initiation of breastfeeding within one hour of birth among mothers with infants younger than or equal to 6 months of age attending public health institutions in Addis Ababa, Ethiopia

More than four million neonatal deaths occur every year, and most of these deaths are from low- and middle-income countries [1]. Breastfeeding within the first hour of life provides protection against infection and has been shown to prevent neonatal death due to sepsis, pneumonia, diarrhea and hypothermia [2‐4]. Conversely, it was found that delayed initiation of breastfeeding after the first hour of birth doubled the risk of neonatal mortality [5].

The World Health Organization (WHO) recommends initiation of breastfeeding within one hour of birth [6]. However, the proportion of early initiation of breastfeeding among mothers varies widely across countries and regions worldwide. Factors that are often associated with timely initiation of breastfeeding include mother’s education [7‐9], place of residence [10, 11], household income [12, 13], Place of birth [14], mother’s occupation [12, 15], cultural beliefs and/or traditional feeding practices [4, 16‐18], counselling services provided during antenatal and postnatal visits [10, 13], and parity [9, 12], although these factors may differ according regions and states.

Previous studies revealed that cultural beliefs and traditional feeding practices may prevent mothers initiating breastfeeding immediately postbirth in developing settings. For example, in one systematic review involving 25 observational studies, it was found that women initiated breastfeeding in the evening after seeing stars if the child was born in morning due to cultural beliefs, and women discarded colostrum because of the negative perception that it may harm the newborn [4]. Furthermore, Legesse and colleagues in their cross-sectional study conducted in North-eastern Ethiopia demonstrated that late initiation of breastfeeding was associated with prelacteal feeding practice such as raw butter feeding [18], which is typically administered via a finger and perceived to be good for the health of newborns instead of colostrum.

In Addis Ababa, Ethiopia about 62.3% of births were born in public health institutions [19]. In 2004, the Family Health Department of Federal Ministry of Health of Ethiopia developed a national strategy for infant and young child feeding which states breastfeeding should begin within one hour after birth [20]. However, in Addis Ababa, there is limited insight regarding the prevalence and factors associated with timely initiation of breastfeeding among urban mothers. The purpose of this study was to estimate the prevalence and examine factors associated with initiation of breastfeeding within one hour of birth among urban mothers with infants younger than or equal to 6 months of age attending public health institutions in Addis Ababa, Ethiopia.

Of 597 mother–infant dyads approached, 583 mothers participated in the study (response rate 97.7%). The average age of participants was 25.7 years (± standard deviation =4.4 years). By ethnicity, the majority (47.86%) of the participants are Amhara and the majority of mothers (89.71%) were married. Initiation of breastfeeding within one of birth was highest among mothers in the age category of 30–34 years, mothers with secondary or more education, mothers who had two or more children, and women who started their first antenatal care visit at their fourth months of pregnancy or later. Compared with mothers who initiated breastfeeding after one hour of birth, more mothers who initiated breastfeeding within the first hour of birth gave birth at public hospitals and health centers. Details regarding characteristics of the study participants according to initiation of breastfeeding are given in Table 1.

This study assessed the prevalence and factors associated with initiation of breastfeeding within one hour of birth among mothers of infants younger than or equal to 6 months age. We found that 58.3% of mothers of infants initiated breastfeeding within one hour of birth, suggesting poor practice of timely initiation of breastfeeding among mothers. This figure was, however, somewhat higher than the findings reported in previous studies completed in Arba Minch (57.0%) [23] and Goba (52.0%) [10] towns in Ethiopia. Nonetheless, the finding of the present study is far from the WHO recommendation that states all mothers should initiate breastfeeding within the first hour of birth [6]. As our study focused on urban mothers living in Addis Ababa (the capital of Ethiopia), the prevalence should have been much higher than the prevalence that reported in other parts of Ethiopia. It is quite clear that urban mothers have increased access to health care and health literacy compared with those who live in small towns or rural areas. Thus, interventions such as health education to urban mothers are required to promote initiation of breastfeeding within one hour of birth.

The finding of this study showed that mothers who had three or more infants have about twice higher odds of initiation of breastfeeding within one hour of birth relative to mothers who had one infant. This is consistent with previous studies conducted in Nigeria [12] and Saudi Arabia [24], indicating that multiparty is associated with timely initiation of breastfeeding. Similarly, a study completed in Amibara district, Northeastern Ethiopia showed that mothers who have 2–3 children were less likely to initiate timely breastfeeding compared to those who had four or more children [9]. These findings may suggest that if a mother had more childbirth experience, the next infant is more likely to be put to the breast within one hour life.

Mothers who started antenatal care at their fourth month of pregnancy or later had a 49.0% higher odds of initiating breastfeeding within one hour of birth relative to mothers who started antenatal care before their fourth month of pregnancy. This may imply that health education/advice provided during antenatal visits at later months of pregnancy appear to be important. Likewise, the present study revealed that initiation of breastfeeding within one hour of birth was associated with mother’s attendance of health education/counselling, which is consistent with a study conducted in Goba town in Ethiopia [10], demonstrating that postnatal care advice/counseling about breastfeeding was associated with early initiation of breastfeeding. These findings suggest that health education/counseling is an important intervention for promoting early initiation of breastfeeding.

The study has notable limitations. First, the study was conducted five years ago and the prevalence of initiation of breastfeeding with one hour of birth reported in the current study might have changed in recent years. However, we believe that the findings are still relevant as the study was designed to include only urban mothers of infants presented to public health facilities, and examined factors associated with initiation of breastfeeding within one hour of birth. Besides, unlike few previous studies conducted in different parts of Ethiopia, the current study included urban mothers with infants younger than or equal to six months age, leaving little room for the possibility of recall/information bias. Secondly, as this study is confined to mothers of infants who attended public health facilities in Addis Ababa, the findings may not be generalizable to mothers who presented to private health facilities as well as to those who did not visit any other health institutions in Addis Ababa. Thirdly, as we did not collect information regarding expressed breast milk feeding, babies may be fed expressed breast milk and reported that they were breastfed by mothers, which technically may not be breastfeeding. Finally, this study did not collect data on history of method of birth, and as caesarean section may be associated with lack of early initiation of breastfeeding [4], this would have relevant to collect.

Initiation of breastfeeding within one hour of birth was low among mothers with infants younger than or equal to 6 months of age attending public health institutions in Addis Ababa. However, as the data for this study was collected several years ago, the current prevalence of timely initiation of breastfeeding might have changed. Early initiation of breastfeeding was highest among mothers aged 30–34 years and multiparous mothers. Public health officials and health care providers should consider interventions to promote and support timely initiation of breastfeeding.