To our knowledge, using data from the ENADID 2018 survey, this is the first study that demonstrated an association between skin-to-skin contact in the mother-baby pair immediately after birth with breastfeeding initiation in the first hour of life, a breastfeeding duration of ≥ 6 months and receiving an explanation about breastfeeding immediately after birth. These findings are supported by machine learning methods, offering visual models to facilitate the support and understanding of the phenomenon. Bayesian network analysis showed that in mother-baby pairs who had ever breastfed, there was a probabilistic dependence between skin-to-skin contact with the initiation of breastfeeding, the duration of breastfeeding and receiving an explanation about breastfeeding immediately after birth. Interestingly, the machine learning methods also showed a probabilistic dependence between the type of delivery with breastfeeding initiation and breastfeeding duration. Furthermore, infant formula, powdered milk or bovine milk supplementation was higher in the group without skin-to-skin contact than in the group with skin-to-skin contact. The results are difficult to compare because the previous survey, the ENADID 2014, did not include a question about skin-to-skin contact between newborns and mothers.
There is evidence in Mexico that the information about breastfeeding provided by health personnel to mothers is not enough to support them in initiating or continuing with any type of breastfeeding. Hernández-Cordero and colleagues reported that in a sample of 543 women, 34.7% supplemented with infant formula at the hospital . A rate of 44.8% of exclusive breastfeeding at 1 month postpartum was estimated, as well as a higher timely initiation of breastfeeding in mothers with vaginal delivery and those who received information during pregnancy . Although exclusive breastfeeding at 1 month postpartum was associated with mothers who received more information about breastfeeding during pregnancy, the perception of having an insufficient supply of breastmilk and the belief that infant formula is recommended persisted . Health personnel know about the benefits of breastfeeding but have not been adequately trained to solve practical problems associated with breastfeeding . In this context, a pioneering study carried out in a maternity service in Mexico showed that breastfeeding guidance during the hospital stay, including practical breastfeeding advice from a trained nurse, was associated with higher full breastfeeding rates in the group with breastfeeding guidance, compared to the group who had not received guidance .
Research has shown that the implementation of evidence-based guidelines that improve hospital practices favors breastfeeding rates. In a hospital on the Texas–Mexico border, a plan–do–study–act model carried out over a 2-year period successfully implemented the practice of skin-to-skin contact between newborns and mothers in the operating room, maintaining a 25% cesarean birth rate, substantial improvements in breastfeeding initiation and exclusive breastfeeding rates at hospital discharge .
In Mexico, it has been reported that study programs for health personnel do not provide training in counseling mothers to support breastfeeding . Health personnel in Mexico should be supported to increase breastfeeding knowledge, develop practical skills and change attitudes . Theoretical and practical training in breastfeeding should be a fundamental and indispensable component in all university degrees in health sciences . Although continuous education programs in breastfeeding have been proposed in Mexico, their impact is unknown, and the indicators are still below the minimum recommended by the WHO . Moreover, it has been reported that almost 60% of health personnel lack knowledge regarding the International Code of Marketing of Breastmilk Substitutes, subscribed by Mexico in 1981 as member states of the WHO, and that violations are common .
In Mexico, it is also necessary to promote breastfeeding in mass media and popular events, such as World Breastfeeding Week, including the participation of civil society and professional organizations free from commercial conflicts of interest [17, 18]. Operational research, monitoring, and evaluation are also essential to promote breastfeeding rates in Mexico .
Breastfeeding counseling is an important approach to improving global breastfeeding practices . The WHO and UNICEF guidelines, “Implementation guidance on counseling women to improve breastfeeding practices”, outline six key recommendations to ensure that breastfeeding counseling is provided as follows: 1) to all pregnant women and mothers with young children; 2) in both the antenatal period and the postnatal period and up to 24 months or longer; 3) at least six times, and additionally as needed; 4) through face-to-face counseling, or additionally, through telephone or other remote modes of counseling in certain contexts; 5) as a continuum of care, by appropriately trained health care professionals and community-based lay and peer breastfeeding counsellors; and 6) as anticipatory guidance to address important challenges and contexts for breastfeeding, in addition to promoting skills, competencies, and confidence among mothers .
In addition, the UNICEF UK Baby Friendly Initiative states that the conversations in the immediate postpartum period between health personnel and mothers who breastfeed should be focused on closeness, and the meaning of responsive feeding and how to make it work for them can be part of ongoing discussions . In addition, it should be explained to mothers that they cannot overfeed their baby and that maternal breastmilk can promote comfort and rest for the baby, as well as “food” . As a safety issue, upon release from the hospital, parents should understand the signals regarding whether their baby is getting enough breastmilk . Although antenatal breastfeeding education contributed to the substantial increase in the initiation of breastfeeding, at hospital discharge, new parents should be provided with resources that favor breastfeeding establishment, including support from breastfeeding consultants, inclusion in a support group and early follow-up with a health provider that is competent in breastfeeding .
Evidence has shown that in normal neonates, breastfeeding reflexes are strong at birth; indeed, preterm babies are capable of breastfeeding efficiently [22, 23]. Consequently, hospital practices, such as the separation of the mother-baby pair, can affect the establishment of breastfeeding . In Mexico, the social determinants of health require greater articulation and concerted actions in different sectors, such as education, labor, and the development of social and indigenous people . These articulations and actions should consider care of the mother-baby pair as a continuum, from the prenatal stage to natural weaning, with strict adherence to the International Code of Marketing of Breastmilk Substitutes.
Infant formula supplementation before hospital discharge is associated with a reduction in breastfeeding duration, undermining maternal confidence, affecting the natural microbiome and increasing the risk of early weaning [25, 26]. In addition to supplementation with infant formula, this study demonstrated that supplementation during the first day of life occurs with other breastmilk substitutes, such as water, tea, egg, atole, cereals, tortillas, bread, purees, juices and broths. Previous studies in Mexico have shown the introduction of breastmilk substitutes before the WHO recommendations, with a great variety of foods, such as coffee, pork, fish, and soft drinks [27, 28].
Hospital barriers to breastfeeding must be addressed to favor the maximum state of health of the mother-baby pair, and this is of particular importance during the COVID-19 pandemic. According to Lubbe and collaborators, “current evidence states that the coronavirus is not transmitted via breastmilk”, and therefore, to support breastfeeding during the current pandemic, it is crucial to understand the clinical characteristics of COVID-19 and the protective properties of breastfeeding, including practicing skin-to-skin contact between newborns and mothers . In the context of the COVID-19 pandemic, the separation of mothers with suspected or confirmed SARS-CoV-2 from their infants after birth can cause an excess of illnesses and preventable deaths , as well as costs that impact the health system and families alike.
Strengths and limitations
To our knowledge, this is the first report in Mexico that can be generalized at the national level about the association of skin-to-skin contact between mothers and the babies immediately after birth with breastfeeding initiation in the first hour of life; a breastfeeding duration of ≥ 6 months; and receiving an explanation about breastfeeding. The strength of this study is the sample design, which was probabilistic and included a considerable number of participants (N = 26,587). The results represent support for public health interventions in Mexico to promote breastfeeding.
The lack of a definition in time (minutes) of the concept "immediately after delivery" relating to the time elapsed between birth and the start of skin-to-skin contact between newborns and their mothers, as well the lack of data if this was uninterrupted, are a considerable limitation of this study, apart from possible memory bias. Other limitations of this study are the lack of specification about timing, personal responsibility for providing an explanation about how to give the baby breastmilk or the breast after delivery, explanation content and employed resources. We considered that the lack of specifications due to the instruments used to collect the information had an implication on the results.