Background
Early initiation of breastfeeding (EIBF) is the practice of introducing breast milk to newborns in which baby is placed skin-to-skin with the mother within the first hour of delivery, as recommended by the World Health Organization (WHO) [
1]. Being the first and the most important step to optimal breastfeeding (early initiation, exclusive for the first six months and then complementary breastfeeding for the first two years of life), EIBF remains one effective means of promoting the health and survival status of infants and mothers [
2]. Timely initiation of breastfeeding within the first hour of birth means neonates are introduced to colostrum (‘first milk’) which confers numerous benefits including active and passive immunity against a wide range of pathogenic diseases [
1,
2]. It also reduces postpartum bleeding in mothers, as well as protects against the leading causes of neonatal mortality such as respiratory tract infections (pneumonia, in particular), diarrhea, and neonatal sepsis [
2‐
5]. Maternal-child bonding, longer duration and greater breastfeeding success are some of the beneficial effects of EIBF [
6]. Moreover, a convincing body of evidence reveals that EIBF reduces neonatal mortality by approximately 22% in Ghana [
3] and 19% in Nepal [
7]. Despite its numerous benefits and the WHO recommendation, the rate of breastfeeding initiation within the first hour of delivery is poor in many countries around the world [
2].
In Nigeria, breastfeeding ('any breastfeeding') is universally practiced, however, the rate of EIBF is low and declining [
8,
9]. Evidence from the national households surveys in Nigeria indicates that the rate of EIBF increased from 31.9% in 2003 to 38.4% in 2008 but decreased sharply to 33.2% in 2013 [
9]. These rates are lower than those of similar developing countries like Ghana, the Gambia and Malawi at 46%, 48% and 56%, respectively [
10]. Studies have shown that a range of factors; socioeconomic, community, health, maternal and individual, may influence the rate of initiation of breastfeeding [
11,
12]. In view of this premise, it is imperative to understand factors associated with EIBF in Nigeria. Regrettably, nationally representative studies on the rates and factors associated with breastfeeding initiation are limited in Nigeria.
Two recent and nationally representative studies have investigated the determinants of EIBF in Nigeria. Using the pooled (for the whole Nigerian population) 2013 Nigeria Demographic and Health Survey (NDHS), a study found a significant association between EIBF and place of delivery, mode of delivery, parity, birth size, maternal occupation, wealth index, and rural-urban residence [
12]. Similarly, another study examined the trends and determinants of EIBF from 1990 to 2008 and reported maternal age at child’s birth, mother’s and father’s education level, parity, residence, region, antenatal visit, mode and place of delivery as being significantly associated with EIBF [
13]. However, all the studies to date only provided estimates based on the national average (overall Nigerian population) of EIBF and are limited, in that the within-population variations such as the rural-urban differences were not assessed. In other words, they were based only on the pooled datasets and not disaggregated by rural-urban residence. Using pooled datasets or national average of estimates may mask the within population differences [
14]. Thus, a gap in knowledge exists on how the rates and factors associated with EIBF differ between rural and urban residences in Nigeria. The present study aims to bridge this knowledge gap by disaggregating the most recent NDHS dataset along rural-urban residence thereby providing evidence-based, context-specific knowledge for addressing the challenge of low rates of EIBF in Nigeria.
The rural-urban stratification approach adopted in our study is in line with the growing consensus on using high quality disaggregated studies as an evidence-based method to bridge access/survival/equity gaps across socioeconomic and/or geographic divides [
15,
16]. Furthermore, the method agrees with the recent WHO’s framework for monitoring progress towards Universal Health Coverage (UHC) which states: ‘all measures should be disaggregated by socioeconomic and demographic strata’ for a better assessment of equity in intervention coverage among other factors [
14]. The approach may help capture context-specific factors which might not be possible with the use of ‘one-size-fits-all’ method of pooled datasets [
16‐
18]. Given the beneficial effects of EIBF and the critical need for accelerated reduction in neonatal mortality, especially, in light of the ambitious targets for UHC (inscribed in the 2030 agenda for sustainable development) [
16,
17], this study provides further evidence for target-specific interventions aimed at improving EIBF rates in Nigeria.
Discussion
We assessed the rates and factors associated with early breastfeeding initiation in rural and urban Nigeria. Previous Nigerian studies [
12,
13] have focused on the whole nation using pooled datasets (for the whole population). We have gone a step further to focus on the rural and urban residences in the country by analyzing disaggregated datasets. Our findings indicate that the rates of timely initiation of breastfeeding and the associated factors differ between rural and urban residences in Nigeria. For instance, a study has investigated the determinants of EIBF for the overall Nigerian population using the pooled 2013 NDHS [
12]. The factors reported to be associated with EIBF by these authors; place of delivery, mode of delivery, parity, birth size, maternal occupation, and wealth index were mainly relevant in rural residence when we disaggregated the data by rural-urban residence. This highlights the importance of data disaggregation method in identifying population-specific factors for EIBF.
The finding that urban residence had significantly higher EIBF rates than rural residence is not surprising, and, several factors may have contributed to such difference. First, cultural practices/beliefs such as discarding colostrum because it ‘is dirty/rusty’ may contribute to lower rates of EIBF and this would expectedly be prevalent in rural than urban residence in Nigeria [
28]. Second, access to and utilization of healthcare facility may facilitate the practice of early breastfeeding initiation, and rural residents in Nigeria are disproportionately disadvantaged in these regards [
29,
30]. In the present study, for instance, mothers in urban residence had nearly two-fold greater antenatal attendance (of at least 4 times) and approximately three-fold higher prevalence of health facility delivery. Antenatal attendance and health facility delivery provide great avenues for information on the importance of EIBF. Hence urban women would more likely have acquired better breastfeeding knowledge, and, consequently, had higher EIBF rates than their counterparts in rural areas. Nevertheless, EIBF rates were generally low whether in rural or urban Nigeria (less than 50–89% deemed as good, and 90–100% considered as being very good by the WHO) [
6]. This finding suggests the need for improved EIBF rates in both rural and urban Nigeria. However, given that rural residence had comparatively lower rates, greater attention is unarguably needed in the residence.
Consistent with previous Nigerian studies (overall Nigerian population only) [
12,
13], our study found cesarean delivery to be significantly associated with decreased odds of EIBF both in rural and urban residence. This finding may be linked with the rigor, stress and exhaustion that often go with cesarean deliveries including the effects/complications of anesthesia [
31]. The time-lapse between delivery, the repair of surgical incisions and recovery/responsiveness following cesarean section may contribute to late breastfeeding initiation. Also, given that most women are averse to cesarean delivery in Nigeria [
32] and the fact that the obstetric intervention is usually performed as the last option in life-threatening conditions [
32], the occurrence of complications is likely and such may further contribute to the risk of late breastfeeding initiation. Mothers who had undergone cesarean section may be less likely to introduce their newborns (which may also have difficulty sucking) to breastfeeding within the recommended one hour after birth. However, it is noteworthy that with suitable guidance and appropriate support, early initiation of breastfeeding is possible even among mothers who had undergone cesarean section [
31].
Our study reveals that the rates and the odds of EIBF were significantly higher in the North-Central region whether in rural or urban residence. On the other hand, the North-West and the South-West regions had the lowest rates of EIBF in rural and urban residences, respectively. Following multivariable analysis, the odds of EIBF was significantly higher in the North-Central, North-East, and South-South regions relative to the South-West both in rural and urban residence. These findings agree to some extent with those of previous studies for the overall Nigerian population [
12,
13]. However, the reason for these regional variations in EIBF rates and odds is not clear. A likely explanation, nonetheless, would be the impact of sociocultural practices/beliefs. For instance, in a community in South-West region of the country, the acceptable breastfeeding norms were prelacteal feedings of water, herbal infusions and ritual fluids [
28]. Consequently, newborns in the said community were normally introduced to water and complementary feeding almost immediately after delivery [
28]. Similarly, a study in the North-West region reported that colostrum was considered unfit for consumption in neonates because it was ‘dirty’ and ‘rusty’ [
33]. These and similar sociocultural practices/beliefs may have contributed to the differences in rates and the odds of EIBF observed in the present study.
Notably, the association between EIBF and the region of residence was generally stronger in urban compared to rural residence. For instance, while mothers in both rural and urban North-Central region had greater odds of EIBF, the odds were over two-fold higher for urban mothers. This finding is similarly true for mothers in the North-East and the South-South regions indicating that urban mothers in the named regions had greater odds of initiating their newborns into breastfeeding within the recommended one hour after birth timeframe than their rural counterparts. The reason for this result may be linked with rural-urban disparities in breastfeeding knowledge, access to−/utilization of maternal cares services and socio-cultural practices in Nigeria [
28‐
30]. Context-specific interventions are, therefore, needed to bridge these rural-urban differences in the country.
Wealth index attained statistical significance in the multivariable analysis, albeit in rural residence only. This finding is consistent with our Chi-Square test results where wealth index categories exhibited a strong and significant association with EIBF rates in rural residence. Contrariwise, wealth index categories showed only a negligible and nonsignificant difference in EIBF rates in urban residence suggesting that the rates of EIBF were similar among the rich, the middle class as well as the poor in urban Nigeria. The finding in urban areas clearly recommends breastfeeding as a simple, cost-effective intervention suitable for- and practicable by all irrespective of socioeconomic status (wealth index category). Conversely, in rural residence, both the rates and the odds of EIBF were significantly higher in wealthy compared to poor households. A previous study using the pooled 2013 NDHS has reported a similar result for the whole Nigerian population [
12]. However, a rural-urban disaggregation (as carried out in our study) indicates that the result applies mainly to rural residence in Nigeria [
12]. Thus, poor households in rural Nigeria would require greater priority for improved EIBF rates.
A critical review of the literature, however, reveals mixed results in respect of the association between EIBF and wealth index. For instance, a study conducted in Indonesia found that mothers classed in the rich wealth index had increased odds of late initiation of breastfeeding compared to those in poor wealth category [
34]. Furthermore, wealthy mothers in Pacific, East Asia, Middle East, and North Africa regions have been reported to have greater chances of later breastfeeding initiation than their poor counterparts [
34,
35]. These mixed findings may be explained by factors ranging from differences in educational attainment, and thus the level of breastfeeding knowledge to the marketing of breast milk substitutes and the purchasing power of the rich or subsidy for the poor [
36]. Experience, attitudes, nature of work and the belief of mothers may equally contribute in some ways to the observed results.
Similar to the results for wealth index, health facility delivery was associated with increased odds and higher rates of EIBF than home delivery, but in rural residence only. This result may be credited to the effectiveness of Baby Friendly Hospital Initiative in rural Nigeria and our finding compares well with those of studies (pooled/national average only) in Nigeria [
12], Nepal [
11] and Indonesia [
34]. However, the EIBF rate of 42.4% found in health facility for rural residence falls below the 90–100% recommended by the WHO suggesting the need to step up this initiative for a greater improvement in breastfeeding initiation rates in the residence. Besides, with only 23.1% (as found in the present study), the prevalence of health facility delivery in rural Nigeria remains unacceptably low. Future interventions would need to take cognizance of these findings for a holistic program/intervention design. In urban Nigeria, the rates of EIBF were nearly same for both home and health facility deliveries, showing no statistical difference, hence the factor did not make a selection for multivariable modelling. These results coupled with those of wealth index support our earlier position that urban residents in Nigeria possibly had better knowledge on the benefits of EIBF, hence the likely support from health facility delivery and the effects of higher socioeconomic status did not confer any appreciable advantage. Intervention(s)/practice(s) which may be responsible for these findings in urban residence need(s) to be investigated and replicated in rural Nigeria.
Our finding reveals that mothers in rural residence whose husbands had at least a secondary school education were more likely to initiate their newborns into breastfeeding within one hour of birth. Consistently, studies have shown that husband’s support is the most important influence on breastfeeding initiation and continuation decisions [
37,
38]. Hence, it is logical to anticipate that husbands with at least a secondary school education would have better breastfeeding knowledge and, thus, are able to support their spouse/partners for early breastfeeding initiation decision.
Furthermore, in rural residence only, mothers who were not working or those who reported being engaged in domestic/household works had greater odds of EIBF compared to their counterparts engaged in paid employments (office, business, clerical, as well as both skilled and unskilled manual). A similar result has been reported for the overall Nepalese population [
11], and two reasons may explain the current finding. First, mothers in paid jobs are more likely to have better access to financial resources and thus more susceptible to the practice of formula feeding which in turn may contribute to the late initiation of breastfeeding. Second, cesarean delivery is known to contribute to late breastfeeding initiation and mothers in paid jobs may opt for the mode of delivery, given their financial capability to afford it [
9,
11]. However, there have been mixed reports in respect of the association between mothers’ occupation and EIBF. For example, a study in Bangladesh found no association [
39] while a prospective study in the United States found that mothers in professional jobs had higher odds of early breastfeeding initiation [
40]. Future studies would need to further investigate the relationship between maternal occupation and EIBF.
Our findings further indicate that in rural residence, babies perceived as being small in size at the time of delivery or belonging to the first birth order had decreased odds of EIBF. Small sized babies may require special care owing to premature delivery and immaturity, thus, chances of late breastfeeding initiation may be higher among them compared to their large-sized counterparts. In the same vein, studies have shown that both the intention to breastfeed and early breastfeeding initiation is associated with previous breastfeeding experience [
41]. Hence, findings in respect of the association of EIBF with birth size and parity in rural Nigeria agree with the literature [
12,
41]. In urban residence, birth order and birth size did not attain statistical significance following adjustment for other variables in the multivariable logistic regression analysis. The finding is not surprising for ‘birth order’ given the result of our Chi-Square test that showed no significant difference in the rates of EIBF for the variable. Interestingly, the position expressed here may not hold strictly true in rural residence as ‘birth order’ which lacked statistical significance in the Chi-Square test became significant in the multivariable analysis justifying the criterion set (
p ≤ 0.20) for model building in our study. The finding for ‘birth size’ in urban areas may be due to the masking effect of the ‘region of residence’ and ‘caesarean delivery’ which were overwhelmingly significant in the residence.
Strengths and limitations
Our study presents a snapshot of the rates and factors associated with early breastfeeding initiation in rural and urban Nigeria. National representativeness, high response rate, application of complex sample statistics in all analyses (to adjust for sample weights and cluster design of the survey) and low missing data are some of the strengths of this study. Others include large sample size and the use of rural-urban data disaggregation method. Nevertheless, this study is limited in that the cross-sectional design of the survey does not allow the causal relationship to be estimated. Also, data were self-reported, collected retrospectively and so prone to social desirability and recall biases. However, restricting our study to data in the two years preceding the 2013 NDHS reduces the chances of recall bias. To the best of our knowledge, this is the first study to investigate rural-urban differences in EIBF rates and associated factors using nationally representative data in Nigeria.