Determinants of early initiation of breastfeeding in rural Tanzania

To ensure the health of newborns, the World Health Organization (WHO) recommends placing newborn babies in direct contact with their mothers immediately after birth for at least 1 h, and encouraging initiation of breastfeeding as soon as possible [1]. Evidence shows that if newborns are exposed to breastfeeding at this early stage, they are much more likely to adhere to exclusive breastfeeding and ultimately have better health outcomes [2, 3]. Exclusive breastfeeding contributes to a 22 % reduction in neonatal mortality [4], suggesting that the earlier breastfeeding initiation takes place, the lower the chances of neonatal mortality, mostly due to reduction in infection [5]. A recent systematic review regarding timing of breastfeeding initiation shows that initiating breastfeeding within 1 h of birth results in significant reduction of the risk of neonatal mortality [6]. One ecological study that uses demographic and health survey (DHS) data from 67 countries shows a protective effect of breastfeeding within the first hour of birth on neonatal survival [7]. Several other studies indicate similar results regarding the importance of early initiation of breastfeeding [4, 8].

The benefits of early initiation of breastfeeding extend to both the mother and the newborn. Consistent production and ejection of breast milk is facilitated by secretion of prolactin and oxytocin which are stimulated by suction of the nipple by the newborn, thus indicating that early initiation of breastfeeding aids in consistent breastfeeding. The first breast milk to be secreted for the first few days after birth, known as colostrum, provides the newborn with natural immunity from the mother to avert infections. Therefore, it is particularly important to the health of newborns that they are breastfed immediately after birth [9]. Breast milk has immunological properties which protect newborn babies against common illnesses and infectious diseases such as diarrhea [10, 11], respiratory infections especially pneumonia [12], meningitis [10, 11] and neonatal sepsis [13–16], all of which are important causes of infant morbidity and mortality.

In addition to these benefits, early suckling stimulates the contraction of the uterus after childbirth which reduces risk of postpartum hemorrhage [9]. Furthermore, breastfeeding lengthens the postpartum infertility period, helps the mother return to her pregestational weight, and reduces the risk of breast cancer [17] as well as ovarian cancer [18–20].

While the benefits of early initiation of breastfeeding are well recognized, a significant proportion of newborn babies in many countries are still not breastfed within 1 h of birth as the WHO recommends. This implies that barriers still exist, thus necessitating further investigations. In Tanzania, the recent DHS report shows that less than a half (49 %) of newborn babies are breastfed within 1 h of birth, and ranges from 18 % in Rukwa region to 93 % in Manyara region [9]. However, 94 % of the Tanzanian newborns are breastfed within 1 day after birth [9]. In the Sub-Saharan African region, prevalence of early initiation of breastfeeding varies widely, with less than 60 % of mothers in Kenya [21], Ethiopia [22] and Lesotho [23] initiating breastfeeding within the first hour; and as many as 95 % of women in Malawi adhering to this recommendation [24]. Elsewhere, early initiation of breastfeeding has been estimated at 11 % in one province in Saudi Arabia [25], 31 % in India [26] and 83 % in Sri Lanka [27].

Several factors associated with early initiation of breastfeeding have been identified. This includes absence of prelacteal feeding, rural residence, absence of breast problems, and multi-parity [25]. One recent systematic review found that childbirth by caesarean section is the most consistent risk factor for delayed breastfeeding initiation [8]. Other factors identified by this review were low family income, maternal age under 25 years, low maternal education, absence of prenatal health visits, home birth, absence of prenatal guidance on breastfeeding, and preterm birth. In Sri Lanka, delayed initiation of breastfeeding was associated with low birth weight and childbirth by caesarean section, but less likely among female infants and mothers within higher wealth quintiles [27]. Furthermore, one study in India found that the practice is influenced by educational level, economic status, mother’s tribe, place of birth, prenatal visits to health care facilities, assistance during childbirth, and partner’s violent behavior [26]. Unfortunately, Tanzania-specific literature on timing of initial breastfeeding is scarce. One large cross-sectional survey was conducted in Southern Tanzania regarding newborn care practices that reported prevalence of breastfeeding initiation within 1 h, yet this study did not assess factors associated with the behavior [28]. Only the recent DHS report for Tanzania points out that early initiation of breastfeeding increases with maternal educational status, wealth quintile, urban residence, and professional or skilled birth attendance [9]. Given that the proportion of women who breastfeed their newborns within 1 h of birth varies widely across Tanzania [9], and the lack of district level data on this behavior, it is possible that factors underlying the behaviour differ by geographical locations due to differences in context specific conditions. Therefore the current analysis assesses the levels and factors associated with early initiation of breastfeeding among women who have recently given birth in Rufiji, Kilombero, and Ulanga districts of Tanzania.

This study assessed prevalence and determinants of early initiation of breastfeeding among 889 women who had recently given birth in Kilombero, Rufiji and Ulanga districts of Tanzania, using cross–sectional household survey data collected in 2011. As highlighted previously, early initiation of breastfeeding is an essential component of maternal and newborn health. Early suckling stimulates the production of breast milk as well as oxytocin which helps the uterus to contract and reduces postpartum blood loss. Colostrum, which is contained in the first breast milk is highly nutritious and has antibodies which protect the newborn baby from acquiring diseases. Moreover, early initiation of breastfeeding enhances bonding between the mother and the child. Therefore early breastfeeding initiation is very crucial for the health of the newborn baby as well as the mother.

Findings from this study reveal that slightly more than one half (51 %) of the women who had given birth within 2 years preceding the survey in the study area initiated breastfeeding within 1 h of birth. This shows presence of a significant proportion of newborn babies in the study area who are not breastfed within 1 h of birth as recommended, and could partly be linked with misconceptions about early breastfeeding as similarly noted in southern Tanzania, that colostrum is dirty and should thus not be given to newborn babies [36]. The observed proportion of early initiation of breastfeeding by this study is comparable to that found in a rural area of Morogoro region in Tanzania [37] as well as the national estimate of 49 % [9], but significantly higher than 18 % reported in southern Tanzania [28]. Early initiation of breastfeeding within Tanzania has been reported to vary between rural and urban areas (45 and 62 % respectively), and ranges from 18 % in Rukwa to 93 % in Manyara region [9]. Outside Tanzania, our observation is comparable to 52 and 53 % observed in Ethiopia [22] and Lesotho [23] respectively, but lower than 58 % observed in Kenya [21] and even lower compared to 95 % recorded in Malawi in 2010 [24].

In the multivariate analysis, childbirth by caesarean section emerged as the strongest factor with negative association with early initiation of breastfeeding. It has been pointed out that postoperative care sometimes takes longer, preventing the mother from achieving contacting her baby during the postpartum period, thus delaying breastfeeding initiation [38]. This association between childbirth by caesarean section and delayed breastfeeding initiation is consistent with a recent systematic review [8] as well as other studies [39–42]. In many low and middle income countries, rates of childbirth by caesarean section are rapidly growing [43]. In Tanzania for example, the current rate of childbirth by caesarean section stands at 5 % [9] and it is 13 % in the current study area from these data. While caesarean section is considered a valuable lifesaving tool for both the mother and newborn in an obstetric emergency [44], interventions that can enhance early initiation of breastfeeding following caesarean section are greatly needed, as well as reducing or if possible stopping caesarean sections that have no medical indication [43]. This is because a caesarean section in one pregnancy suggests the same or at least specialized medical care in subsequent childbirth in order to minimize the risk of complications such as uterus rupture due to the scar from previous caesarean (s). Unfortunately, the fragile health system in the country as the case in many less developed countries may not adequately support this when it is massively needed.

With respect to place of childbirth, women who gave birth in health facilities were more likely than those who gave birth at home to initiate breastfeeding within 1 h of birth. This may be because health workers at health facilities facilitate timely initiation of breastfeeding. This implies that efforts to discourage nonuse of health facilities for childbirth should continue given the detrimental health outcomes associated with the practice, including delayed breastfeeding initiation which consequently increases the risk of newborn morbidity and mortality [8, 26]. Timely initiation of breastfeeding should as well be encouraged for babies born at home. In communities with community health workers (CHWs), which is the case with CHAs in the study area [31], this may be addressed during regular household visits whereby pregnant women can be identified and provided with basic health care and promotion of maternal and newborn health practices.

Maternal knowledge of newborn danger signs was negatively associated with early initiation of breastfeeding, and this observation came up in a dose–response fashion. This was unexpected, as it was anticipated that higher knowledge would increase the likelihood that breastfeeding would be initiated within 1 h of birth. While previous scholars have found that higher educational attainment (not knowledge of newborn danger signs) was associated with higher likelihood of early initiation of breastfeeding [8, 9, 26], the effect of knowledge of newborn danger signs on early initiation of breastfeeding is missing in the previous literature. However, a somewhat similar study in Ghana found that maternal knowledge of at least four newborn danger signs is associated with good neonatal feeding [45]. Ultimately, this study was unable to ascertain the mechanisms fostering this observation, thus warranting further research, especially qualitative studies.

Variations in early initiation of breastfeeding existed between districts, with women in Rufiji district being less likely than those in Kilombero district to initiate breastfeeding early. Women in Ulanga district were similar to those in Kilombero district, possibly because these two districts are in the same geographical location and share a border, thus women therein share the same environment, a situation which may shape their behaviors and health practices alike. Rufiji district, however, is located far from Ulanga and Kilombero, suggesting that variations in environments, cultural values, beliefs, and practices may account for the differences in breastfeeding practice. Although specific explanations of the observed finding are lacking, it has been noted that early initiation of breastfeeding in Tanzania vary by geographical locations [9]. Differences in early initiation of breastfeeding also existed by marital status, with ever married women being less likely to initiate breastfeeding within 1 h than currently married women. Although this was independent of pregnancy wantedness, it remains unclear why this was the case. Further research, especially qualitative studies, are needed to further characterize differential breastfeeding practices and inform interventions to increase early initiation of breastfeeding.

Despite the known health benefits of early initiation of breastfeeding to the mother and the newborn, only about half of the mothers in Rufiji, Kilombero, and Ulanga districts of Tanzania succeed in starting breastfeeding within 1 h of birth. Efforts should be taken to ensure the universality of this practice. Promotion of health facility use for childbirth should be continued and facilitated to enhance timely initiation of breastfeeding along with promoting other positive health outcomes. On the other hand, timely initiation of breastfeeding should be encouraged for babies born at home. Specifically, developing and implementing interventions to improve timely breastfeeding initiation following childbirth by caesarean section is of utmost importance. Further assessments should occur to understand why higher maternal knowledge of newborn danger signs decreases the odds of early initiation of breastfeeding. Ultimately, early initiation of breastfeeding should be promoted among Tanzanian mothers to ensure healthy outcomes for both mothers and newborns.