Magnitude and determinants of early initiation and exclusive breastfeeding at six weeks postpartum: evidence from the PMA Ethiopia longitudinal survey

This analysis used data from PMA Ethiopia, a cohort study conducted from October 2019 to August 2021. PMA Ethiopia survey is a national study being implemented in collaboration between Addis Ababa University (AAU), the Ethiopia Federal Ministry of Health (FMOH), and Johns Hopkins Bloomberg School of Public Health (JHSPH). PMA Ethiopia generates timely cross-sectional and longitudinal data on reproductive, maternal, and newborn health indicators to inform national and regional government priorities and policies [19].

PMA Ethiopia conducted a full census in 217 enumeration areas (EA) across six regions and listed 36,614 households between October and November 2019. All women aged 15–49 in these households were screened (32,792) and, if they reported being currently pregnant or having delivered within the past six weeks, were eligible for the panel study; 2,889 women were identified as eligible and 2,855 enrolled with a response rate of 98.4% and 93.6% for the baseline and 6-week surveys, respectively. The panel was conducted in six regions that collectively represent 90% of the population in Ethiopia; Addis Ababa, Afar, Amhara, Oromia, SNNP and Tigray [19].

The baseline interview collected information about women’s sociodemographic characteristics. Information about initiation of breastfeeding, exclusive breastfeeding and maternal health service-related variables was collected at the six-week postpartum follow-up interview. Women who were already 5–9 weeks postpartum at enrollment were asked all the sociodemographic, breastfeeding and maternal health service-related questions during the baseline interview. Informed consent to participate was obtained at the screening and prior to enrollment by all participants and was provided verbally [19].

Among the 2855 enrolled pregnant or recently postpartum women in our survey, 2,664 completed six-week postpartum interviews (conducted at baseline and six weeks postpartum), 2564 women with live births used for the analysis (100 women with miscarriage or abortion excluded) (Fig. 1).

Estimated or actual delivery dates of women were used to schedule the six-week postpartum interview, which was conducted when respondents were about six weeks postpartum. *Women who were pregnant or 0–4 weeks postpartum at the time of the first panel interview received the sociodemographic characteristics related survey questions at baseline and questions related to their breastfeeding behavior and maternal care services at 6-week postpartum interview. **Women who were 5–9 weeks postpartum at the time of the first panel interview received a combined set of survey questions that included the six-week survey, that other women received during two separate interviews.

We used the baseline and six-week postpartum interview data that are collected at that particular period in order to assess the magnitude of early initiation of breastfeeding and exclusive breastfeeding and its relationship with the sociodemographic, maternal and child health related factors.

Early initiation of breastfeeding and exclusive breastfeeding (EBF) are the main outcomes (variables of interest) of this study.

Early initiation of breastfeeding was assessed by asking women “How long after birth did you first put the baby to the breast”, responses were recorded in minutes, hours, or days when baby was first put to breast. A binary variable was then created and categorized as: (1) early initiation of breastfeeding if a newborn was breastfed within 1 h after birth, or (2) delayed initiation of breastfeeding if a child was breastfed after 1 h [20]. This indicator was self-reported by mothers who were approximately six-weeks postpartum at time of interview.

Exclusive breastfeeding was calculated as the proportion of infants, who received only breast milk and no other liquids or solids based on a 24-h recall (exclusive of medication, immunizations, ORS drops, or vitamin supplements) at the 6-week follow-up visit. Similarly, exclusive breastfeeding was expressed as a dichotomous variable with category 1 for EBF and category 0 for non-EBF [19].

Table 1 shows the operational definition/ description for all the variables included in this study.

We used descriptive statistics to examine the distribution of women’s sociodemographic and reproductive characteristics (Table 2, pattern of initiation of breastfeeding and exclusive breastfeeding). We assessed the bivariate distributions of early initiation of breastfeeding and exclusive breastfeeding with each covariate. Maternal and infant characteristics of early initiation of breastfeeding and EBF were compared to those of breastfeeding initiation > 1 h after birth, and non EBF respectively.

We conducted a series of bivariate and multivariate analyses by using a multilevel binary logistic regression model to examine the association between explanatory variables with the outcome variables while controlling for confounding factors. Those explanatory variables that showed significance (p < 0.25) in the bivariate analysis were included for multivariate analysis. Let \({y}_{ij}\) denote the binary outcome for subject i in cluster j, and assume \({y}_{ij}\) follows a Bernoulli distribution with probability of success, \({p}_{ij}\). Then, using the usual logit link function, a binary outcome can be associated with a linear predictor as follows:where \({\beta }_{0}\) is an intercept, \(\beta\) is an unknown parameter for individual level predictors, and \({u}_{j}\) are mutually independent Gaussian random effects used to capture within-cluster correlation. In standard multilevel models, \({u}_{j}\) is usually assumed to be a normally distributed random intercept with mean 0 and variance \({\sigma }_{u}^{2}\). The multilevel approach produces reliable standard errors and parameter estimates when outcomes for individuals within clusters are correlated [21, 22].

Breastfeeding initiation at > 1 h after birth, and non-exclusive breastfeeding respectively and multiple logistic regression analysis was performed to determine the adjusted odds ratio (AOR). We used multivariate, multilevel models to estimate differences in women’s odds of timely initiation of breastfeeding and exclusive breastfeeding by individual characteristics, adjusting for clustering of women within the enumeration area. We examined model fit by analyzing model fit statistics (i.e., Aikake’s Information Criterion (AIC) values) and assessed collinearity at 0.6 using a correlation matrix for all analytic variables. Statistical significance for the adjusted multivariate analysis was set to p < 0.05. All analyses were weighted to reflect the national population of pregnant and postpartum women in Ethiopia and to account for the complex survey design. All analyses were conducted in Stata/SE, Version 17 [23].

The PMA Ethiopia survey received ethical approval from Addis Ababa University, College of Health Sciences (AAU/CHS) (Ref: AAUMF 03–008) and the Johns Hopkins University Bloomberg School of Public Health (JHSPH) Institutional Review Board (FWA00000287). Additional information on the PMA Ethiopia survey design, including weighting and informed consent procedures, is described elsewhere [19].

Tables 2 and 3 presents the sociodemographic characteristics of the mothers/infants and the distribution of breastfeeding practices by background characteristics. A total of 2564 mothers who are at six weeks postpartum were included in the study, and 48.8% of the women were between 25–34 years old. Four in every ten mothers (41.0%) had never attended school. A predominant percentage of mothers lived in rural area (77.2%) and in Oromia region (43.7%).

More than half (54.4%) of women delivered at a health facility with regional variation (Fig. 2) The majority (94.5%) of the women had vaginal delivery for their most recent birth and approximately six in ten (58.6%) women’s deliveries were assisted by a skilled birth attendant, and 37.3% of the respondents reported having had some complications during or within 24 h of delivery.

Most of the women (95.4%) reported that their baby cried/breathed normally immediately after birth without need of any resuscitation. Less than half of newborns (44.9%) were placed on their mother’s chest immediately after birth. More than three fifth (65.8%) of the mothers reported not having any postnatal care (PNC) after delivery and only 14.5% of women reported that the health provider discusses about exclusive breastfeeding during their PNC visit. Four in ten (40.8%) infants had experienced some illness since delivery.

The majority of the respondents (93.3%) reported that they were breastfeeding during the six-week postpartum interview. Of the total 2564 enrolled six-week postpartum women, 77.8% of mothers reported breastfeeding their infants within first hour of birth. The percentage of timely initiation of breastfeeding is higher in Oromia followed by Addis Ababa and lowest in Afar region (Fig. 3).

About a quarter of the surveyed women-initiated breastfeeding between one and 24 h of birth and 7% started breastfeeding after 24 h of delivery (Table 4).

Nearly seven in ten (68.4%) women practiced EBF at six weeks postpartum with significant variation across regions, ranging from the lowest in Afar to the highest in Tigray region (Fig. 4).

The mode of delivery had significant association with timely initiation of breastfeeding with mothers delivering by caesarean section having 73% reduced odds of early breastfeeding initiation (AOR 0.27; 95% CI 0.17, 0.41) compared to mothers who had a vaginal delivery. In addition, mothers who have two or more children had a higher chance of initiating breastfeeding timely (AOR 1.54; 95% CI 1.13, 2.09) than primiparous women. The likelihood of early breastfeeding initiation were more than two times higher for mothers who were delivered by a skilled birth attendant (SBA) (AOR 2.13; 95% CI 1.01, 4.48) compared to mothers who did not have SBA assistance.

Mothers whose baby cried immediately after birth without a need of resuscitation were three times more likely to initiate breastfeeding timely (AOR 3.31; 95% CI 1.95, 5.62). Again, immediate skin-to-skin contact; putting the infant on the mother's chest right after delivery increased the likelihood to early initiation of breastfeeding (AOR 1.58; 95% CI 1.14, 2.20). In addition, timely breastfeeding initiation was also significantly associated with immediate PNC (PNC with in 1 h of delivery) where breastfeeding is more likely to start right after delivery for women who received immediate postnatal care than for mothers who didn't (AOR 1.54; 95% CI 1.07, 2.22).

Mothers who had obstetric complications during birth or within 24 h of birth have a lesser chance for early initiation of breastfeeding (AOR 0.74; 95% CI 0.58, 0.95). Women from the Afar region were less likely to adhere to the suggested breastfeeding initiation time compared to women from other regions (AOR 0.36; 95% CI: 0.14, 0.95).

Table 5 shows crude and adjusted odds ratios (AOR) that were calculated to determine the strength of association between the co-variates and early initiation of breastfeeding.

The chance of exclusive breastfeeding were more than two times higher for mothers between the ages of 20 and 24 (AOR 1.48; 95% CI 1.01, 2.16) compared to the older age groups. In addition, mothers who had two or more children had a higher odd of exclusive breastfeeding compared to primiparous women (AOR 1.41; 95% CI 1.08, 1.82). Mothers whose baby cried immediately after birth without the need for resuscitation were more likely to exclusively breastfeed (AOR 1.81; 95% CI 1.09, 2.99). The baby’s sex had significant association, with female babies having an increased odds of exclusive breastfeeding (AOR 1.38; 95% CI 1.14, 1.67). Mothers whose child had some illness between delivery and six weeks postpartum have a reduced chance for early initiation of breastfeeding (AOR 0.57; 95% CI 0.47, 0.69). Women from Amhara (AOR 3.29; 95% CI 1.86, 5.84) and Tigray region (AOR 4.64; 95% CI 2.59, 8.31) was more likely to exclusively breastfed compared to women from other regions.

Table 6 shows crude and adjusted odds ratios (AOR) that were calculated to determine the strength of association between the co-variates and exclusive breastfeeding.