In this study, the prevalence of non-EBF among women after an elective caesarean delivery increased as the child's age increased: 19.9%, 40.4% and 57.9% at one month, three months and six months, respectively. The prevalence of non-EBF at one month and three months among women in this study is lower than that reported in the latest National Health Morbidity Survey NHMS, which showed 47.1% and 52.6% at 0 – 2 and 0 – 4 months, respectively, while the prevalence of non-EBF at six months in this study was comparable to the national rate of 52.9% among infants below six months old . In Italy, a study among 398 women who delivered by elective caesarean also showed comparable findings, indicating that 25.5%, 44.9% and 53.4% of the women discontinued EBF at seven days, three months and six months, respectively . A six -month cohort study in Hunan, China reported higher non-EBF rates for woman after a caesarean delivery, with 28.7% and 79.8% of the mothers discontinuing EBF at one month and six months, respectively. However, at three months after a caesarean delivery, a finding similar to the current study was reported, with 40% of the mothers in Hunan discontinuing EBF .
In our study, women who already had at least one child, regardless of the age of the last child, were more likely to continue EBF for one month after a caesarean delivery than those who did not have any children. This finding may be due to first-time mothers having less awareness of the advantages of breastfeeding as compared to multigravida women . It has been reported that early breastfeeding problems and mixed feeding practices at the time of hospital discharge are more common among primiparous women than multiparous women. Multiparous mothers have also shown significantly longer breastfeeding duration than primiparous mothers .
A positive attitude to EBF is more prevalent among multiparous mothers, most probably due to their higher maternal breastfeeding self-efficacy, in which the mother feels confident in her ability to breastfeed. The self-efficacy also increases with the past successful experience and performance . Besides previous positive breastfeeding experience, women can also develop their self-efficacy through the exposure to vicarious experiences (such as observing other mothers who breastfeed), watching videos related to breastfeeding, receiving verbal persuasion and encouragement from their friends and family, and the generation of pleasant and positive feelings towards breastfeeding . Therefore, strategies to increase the EBF rate among primiparous women should focus on improving self-efficacy for continuing EBF and, subsequently, help them deal with any breastfeeding challenge .
The women who did not practise EBF for their last child were more likely to discontinue EBF at one month and three months after a caesarean delivery. Our findings are in agreement with a study in Hong Kong which showed that the participants who did not breastfeed exclusively or who practised EBF for up to only two months were more likely to stop EBF earlier than those who breastfed exclusively for more than two months . A systematic review on breastfeeding experiences concluded that previous breastfeeding experience consistently correlates with subsequent breastfeeding initiation and duration. Previous short breastfeeding duration and unsatisfactory experience can negatively affect subsequent breastfeeding practices . A qualitative study in the United States found that women who had successfully breastfed in the past were intrinsically motivated from their own emotional attachment to the practice. Besides, they were also extrinsically motivated from their family who encouraged them to breastfeed . Therefore, it is recommended for midwives and lactation consultants to provide individualised interventions to the mothers based on their previous breastfeeding experience to improve breastfeeding initiation and duration .
In our study, the women who had never felt confident that their breast milk was adequate or who had at any point perceived that they had no breast milk were more likely to discontinue EBF within the first six months after a caesarean delivery. A perception of insufficient milk is defined as the mother's perception that she is not producing an adequate supply of breast milk to meet her infant's needs . Other studies in Vietnam, Taiwan and Australia have noted the same perception which is the most common reason the mothers discontinued EBF [29,30,31]. It could be related to the low level of maternal self-confidence in the ability to breastfeed. This fact is further supported by a study by Blyth et al. which revealed that the mothers with a high breastfeeding self-efficacy were significantly more likely to practise EBF at one week and four months postpartum than the mothers with low breastfeeding self-efficacy . Support and reassurance from hospital staff are very crucial at this stage. Mothers should also be educated on how to assess their breastmilk adequacy so that they will be able to distinguish between a perceived breastmilk insufficiency and a true breastmilk insufficiency. The best way to assess breastmilk supply is by monitoring infant weight gain and measuring stool output, and this can be managed with patient education, support and reassurance .
Breastfeeding difficulties due to breast conditions such as sore or cracked nipples or breast engorgement commonly occur during the first few days of breastfeeding. These conditions can arise due to improper latching or improper positioning of the baby during feeding . In our study, mothers who experienced breast pain as the baby suckled were more likely to discontinue EBF at six months after a caesarean delivery. A study in Kelantan, Malaysia showed that sore or cracked nipples, difficulty with latching and breast engorgement were associated with the discontinuation of EBF at one month . On the other hand, a study done among women in Argentina found that mothers who had no nipple problems and whose child had an appropriate suckling technique were more likely to practise EBF for a longer duration . Breastfeeding difficulties that persist beyond the first few days after birth can be discouraging and may lead to early discontinuation of EBF. With the right help, however, most of these difficulties can be overcome.
In this study, none of the mothers’ socio-demographic characteristics, including age, educational level or employment status, were significantly associated with their non-EBF during the first six months after an elective caesarean delivery. On the contrary, a multilevel analysis on the factors associated with non-EBF in five Asian countries found that first-born infants, working mothers and higher maternal age were the significant individual factors associated with non-EBF . Another study in Ethiopia reported that mothers who completed primary school were less likely to practise non-EBF as compared to mothers with no formal education, while governmental employees were more likely to practise non-EBF .
The strength of the current study was that we identified factors that contributed to the practice of non-EBF at one, three and six months after an elective caesarean delivery. This important information provides a basis on which strategic planning can be made. Early intervention such as exposure to breastfeeding educational modules to support post-caesarean women in the postnatal wards may help them overcome the factors contributing to non-EBF at one month and three months, such that the women would be able to sustain EBF for six months, as recommended.
In addition, the educational interventions should also be delivered to women during the antenatal period so that they are well-informed about the circumstances they may encounter during the initiation and maintenance of EBF, including perceived breast milk insufficiency and breast pain. As a result, they will be physically and mentally well-prepared to face the challenges. The interventions should include information on different types of breastfeeding positions that are convenient for the women after a caesarean delivery. They should also provide information on how to increase breast milk production since a perceived breast milk insufficiency is the only factor associated with non-EBF practice at all months.
Furthermore, mothers must be informed about where to seek help if they do face problems related to breastfeeding after being discharged from the hospital. This can be done by providing them the lactation helpline number, by which the necessary breastfeeding advice and guidance can be offered. Mothers should also be encouraged to join the lactation support group to discuss their breastfeeding problems with other women who have had an elective caesarean and share their solutions to those problems.
This study has several limitations. The findings of this study cannot be inferred to all women admitted for an elective caesarean delivery in Malaysia as the sample was restricted to only two tertiary hospitals in Kelantan, Malaysia and women were recruited using convenience sampling. Furthermore, this study was carried out at hospitals located in an area where Malays are the predominant ethnic group. The results are thus not generalisable to other racial groups or settings. Therefore, replicating this study in a larger, more racially or ethnically diverse sample should be considered.