Breastfeeding has many benefits for infants' growth and development (United Nations Children's Fund and World Health Organization (WHO), 2019). It is widely established as a life-saving practice that reduces neonatal mortality by improving nutrition and immunity, and reducing infection (Victora et al, 2016). Early initiation of breastfeeding is defined as breastfeeding within 1 hour of birth, is especially important as it facilitates mother–child bonding, induces colostrum production, and positively affects the duration of exclusive breastfeeding (Khan et al, 2015). Consequently, the WHO (2012) and the American Academy of Pediatrics (Meek and Noble, 2022) endorse early initiation of breastfeeding and exclusive breastfeeding for 6 months (United Nations Children's Fund and WHO, 2019).
Globally, only 44% of infants under 6 months are exclusively breastfed, while the target is 70% (WHO, 2021). The last national data collected on breastfeeding in Jordan showed that only 18.6% of mothers had early initiation of breastfeeding in 2012 (WHO, 2022). A cohort study in Jordan in 2018 found that the rate of breastfeeding initiation within the first 4 hours after birth was only 13% (Dasoqi et al, 2018). This situation deprives populations of the potential improvements to population health that optimal breastfeeding can achieve.
Practically, breastfeeding initiation differs according to factors related to mothers, infants and birth circumstances. A mothers' age, income, education and previous experience with breastfeeding have been reported to impact breastfeeding practices (Abuidhail et al, 2014; Alshebly and Sobaih, 2016; Al Ketbi et al, 2018; Alnasser et al, 2018, Mohd Shukri et al, 2021; Temoirokomalani et al, 2021). Studies have also demonstrated a strong and direct negative influence of caesarean section birth on breastfeeding practices. Breastfeeding experiences of a woman who gives birth via caesarean section may be mediated by her physical and psychological health after surgery and may also be compounded by the effect of anesthesia (Taha et al, 2019; Sodeno et al, 2021). Consequently, mothers who give birth by caesarean section are less likely to initiate breastfeeding and successfully breastfeed, and are more likely to delay breastfeeding; caesarean section is documented as the strongest barrier to breastfeeding within the first hour of life (Esteves et al, 2014, Wu et al, 2018; Yisma et al, 2019). In addition, healthcare professionals' attitudes, the type of healthcare facility where a woman gives birth and admission to a neonatal intensive care unit can influence the breastfeeding process (Roostaee et al, 2015; Al Ketbi et al, 2018; Yang et al, 2018; Shobo et al, 2020).
In Jordan, research into early initiation of breastfeeding and factors that may influence this practice is scarce. The present study aimed to assess the rate of early initiation of breastfeeding after birth in a sample of mothers in Jordan, and to explore the factors that influence and predict early initiation of breastfeeding.
Methods
Study design and setting
An observational cross-sectional study design was implemented to explore the breastfeeding practices of mothers attending maternal and child health centers for routine childhood immunisation with their children in Amman in 2021. Maternal and child health centres in Jordan are public health facilities that provide all necessary services for mother and child care during pregnancy, the postnatal period and child growth. Three of the largest capacity health centers in Amman were purposively selected for this study.
Target population and sample
The target population was mothers with children less than 1 year old who attended one of the three selected centres for routine childhood immunisation. The sample size was determined using the formula outlined by Sullivan (no date), with a confidence interval of 95% and a 5% margin of error. A sample of at least 398 mothers was found to be required. Non-probability convenience sampling was used to select 400 mothers to participate in the study.
Data collection
Data were collected from the participants using an interviewer-administered questionnaire with three parts: sociodemographic characteristics, including age, education, working status and income; pregnancy and birth information, including mode of birth, complications during pregnancy or birth, admission to the neonatal intensive care unit, medical problems that prevented breastfeeding, antenatal counselling for breastfeeding and attendance at antenatal care; and breastfeeding practices. The final section asked 10 questions that were adapted from the Centers for Disease Control and Prevention (2021) questionnaires for breastfeeding and infant feeding practices. The questions included asking about planned type of feeding, first feeding, initiation and duration of breastfeeding, type of current feeding and time and cause of introducing formula milk.
Cronbach's alpha analysis found that the instrument had good reliability, with a coefficient of 0.75. The questionnaire was pre-tested with a sample of 30 participants, and no major changes were made according to the results.
Data were collected from the participants between July and September 2021. The researchers approached mothers in the centre waiting room and 431 mothers agreed to participate. The response rate was 93%, with 400 mothers completing the questionnaire. One member of the research team conducted interviews with the participants, to minimise potential interviewer bias.
Data analysis
Statistical analysis was conducted using the statistical package for social sciences (version 20). Descriptive statistics were calculated for socioeconomic and demographic personal characteristics and infant feeding practices. To determine the specific factors that influence early initiation of breastfeeding among the participants, a Chi-squared test was performed. The level of significance was set at P<0.05. Logistic regression was used to investigate the predictors of early initiation of breastfeeding, based on results from the Chi-squared test. Factors found to be significantly associated with early initiation were entered for logistic regression analysis.
Ethical considerations
The Institutional Review Board of the university approved this study (approval number: 19-2021-721), in addition to the ethics committee of the Jordan Ministry of Health. Participants were assured of the anonymous nature of the study, that participation was voluntary and of their right to refuse or withdraw without undue influence. The data obtained were confidential, used strictly for the purpose of this study and stored in password-protected files.
Results
Table 1 presents the sociodemographic, pregnancy- and birth-related characteristics of the participants. The mean age was 29.67 years (standard deviation: 5.21 years). More than half of the participants were educated to degree level or higher (68.0%), but less than a third were employed (28.0%). The majority visited private antenatal care clinics (75.5%), although almost one in 10 (9.0%) participants did not attend antenatal care visits. Approximately two-thirds of the participants received breastfeeding counselling during antenatal care or after birth (63.7%) and the majority gave birth in private hospitals (77.5%). Almost a third had given birth via medically indicated caesarean section (31.3%), with a further 13.8% having an elective caesarean section, a total caesarean rate of 45.1%.
Table 1. Participants' characteristics
| Characteristic | Frequency, n=400 (%) | |
|---|---|---|
| Age (years)Mean: 29.67Standard deviation: 5.21 | <25 | 63 (15.8) |
| 25–29 | 140 (35.0) | |
| 30–34 | 122 (30.5) | |
| ≥35 | 75 (18.8) | |
| ChildrenMean: 2.47Standard deviation: 0.45 | 1 | 120 (30.0) |
| 2–3 | 191 (47.8) | |
| ≥4 | 89 (22.2) | |
| Education | Primary or lower | 27 (6.8) |
| Secondary | 101 (25.3) | |
| University degree or higher | 272 (68.0) | |
| Smoking | Non-smoker | 277 (69.3) |
| Light smoker | 67 (16.7) | |
| Moderate/heavy smoker | 56 (14.0) | |
| Employment | Employed | 112 (28.0) |
| Unemployed | 288 (72.0) | |
| Monthly family income (JD) | <500 | 137 (34.3) |
| 500–1000 | 190 (47.5) | |
| >1000 | 73 (18.3) | |
| Pregnancy complications | Yes | 121 (30.3) |
| No | 279 (69.8) | |
| Antenatal care | Maternal/child health centre | 35 (8.8) |
| Government hospital | 27 (6.8) | |
| Private clinic | 302 (75.5) | |
| None | 36 (9.0) | |
| Place of birth | Private hospital | 310 (77.5) |
| Public hospital | 90 (22.5) | |
| Birth complications | Yes | 37 (9.3) |
| No | 363 (90.8) | |
| Mode of birth | Vaginal | 220 (55.0) |
| Elective caesarean section | 55 (13.8) | |
| Medically indicated caesarean section | 125 (31.3) | |
| Neonatal intensive care unit admission | Yes | 46 (11.5) |
| No | 354 (88.5) | |
| Breastfeeding counselling in antenatal care or postpartum | Yes | 255 (63.7) |
| No | 145 (36.3) |
Table 2 outlines participants' infant feeding practices. Over half (58.0%) of the participants had planned to breastfeed their infants exclusively, with approximately one-third planning for mixed feeding (31.0%). However, only 41.8% of participants reported that their infant's first feed was breast milk, and only 22.3% initiated breastfeeding within an hour of birth. A further 29.8% initiated breastfeeding within 6 hours, and 27.2% initiated more than 24 hours after birth. Over a quarter of the participants (26.3%) reported that they did not introduce formula milk to their infants' diet.
Table 2. Participants' infant feeding practices
| Characteristic | Frequency, n=400 (%) | |
|---|---|---|
| Intended feeding before birth | Breastfeeding | 232 (58.0) |
| Formula | 8 (2.0) | |
| Mixed feeding | 124 (31.0) | |
| No plan | 36 (9.0) | |
| Baby's first feed | Breastfeeding | 167 (41.8) |
| Formula | 233 (58.3) | |
| Time to initiating breastfeeding after birth (hours) | Within 1 | 89 (22.3) |
| 1–6 | 119 (29.8) | |
| 6–12 | 52 (13.0) | |
| 12–24 | 31 (7.7) | |
| Did not initiate | 109 (27.2) | |
| Time to introducing formula milk after birth (months) | 0–3 | 223 (55.8) |
| 4–6 | 42 (10.5) | |
| >6 | 30 (7.5) | |
| Did not introduce | 105 (26.3) |
A Chi-squared test was conducted to investigate the association between breastfeeding initiation and participants' characteristics (Table 3). Increased age was negatively associated with early initiation (P=0.038). Participants who had a vaginal birth were significantly more likely to initiate breastfeeding early compared to those who gave birth by caesarean section (P<0.001). Place of birth was also associated with early initiation (P=0.001), with those who gave birth in government hospitals initiating breastfeeding early more frequently than those who gave birth in private hospitals. Participants who received breastfeeding counselling during antenatal care or after birth were significantly more likely to initiate breastfeeding early (P=0.001), while infants who received formula milk for the first feed showed a significantly lower rate of early breastfeeding initiation (P<0.001). The incidence of medical complications that prevented breastfeeding had no significant correlations with initiation of breastfeeding practices.
Table 3. Factors associated with early initiation of breastfeeding
| Characteristic | Breastfeeding initiation, n=400 (%) | |||
|---|---|---|---|---|
| >1 hour after birth (n=311) | ≤1 hour after birth (n=89) | P value | ||
| Maternal age (years) | <25 | 20 (31.7) | 43 (68.3) | 0.038 |
| 25–29 | 31 (22.1) | 109 (77.9) | ||
| 30–34 | 24 (19.7) | 98 (80.3) | ||
| ≥35 | 14 (18.7) | 61 (81.3) | ||
| Education | Primary or lower | 5 (18.5) | 22 (81.5) | 0.070 |
| Secondary | 31 (30.7) | 70 (69.3) | ||
| University degree or higher | 53 (19.5) | 219 (80.3) | ||
| Employment | Employed | 28 (25.0) | 84 (75.0) | 0.424 |
| Unemployed | 61 (21.2) | 227 (78.8) | ||
| Complications during pregnancy | Yes | 10 (16.6) | 101 (83.5) | 0.064 |
| No | 69 (24.7) | 210 (75.3) | ||
| Complications during birth | Yes | 4 (10.8) | 33 (89.2) | 0.059 |
| No | 85 (23.4) | 278 (76.6) | ||
| Mode of birth | Vaginal | 77 (35.0) | 143 (65.0) | <0.001 |
| Elective caesarean section | 4 (7.3) | 51 (92.7) | ||
| Medically indicated caesarean section | 8 (6.4) | 117 (93.6) | ||
| Place of birth | Government hospital | 32 (35.5) | 58 (64.5) | 0.001 |
| Private hospital | 57 (18.4) | 253 (81.8) | ||
| Breastfeeding counselling in antenatal care | Yes | 70 (27.5) | 185 (72.5) | 0.001 |
| No | 19 (13.1) | 126 (86.9) | ||
| Planned feeding before birth | Breastfeeding | 60 (34.5) | 172 (65.5) | 0.156 |
| Formula | 2 (25.0) | 6 (75.0) | ||
| Mixed feeding | 19 (20.9) | 105 (79.1) | ||
| No plan | 8 (38.1) | 28 (61.9) | ||
| Medical problems prevented breastfeeding | Yes | 7 (15.8) | 39 (84.2) | 0.091 |
| No | 82 (31.6) | 272 (68.4) | ||
| Neonatal intensive care unit admission | Yes | 7 (15.8) | 39 (84.2) | 0.200 |
| No | 82 (31.6) | 272 (68.4) | ||
| First feed | Breastfeeding | 82 (49.1) | 85 (50.9) | <0.001 |
| Formula | 7 (3.0) | 226 (97.0) | ||
Table 4 presents the results of a logistic regression carried out to assess the independent effect of age, income, employment, mode of birth, place of birth, breastfeeding counselling and first feed on the likelihood of early breastfeeding initiation. The overall model was statistically significant when compared to the null model, (χ2(7)=109, P<0.001). The model explained 44.1% (Nagelkerke R2) of the variance in early initiation of breastfeeding and correctly classified 78.4% of cases.
Table 4. Predictors of early initiation of breastfeeding
| Variable | Odds ratio | 95% confidence interval | P value | |
|---|---|---|---|---|
| Mother's age | 0.779 | 0.44–1.37 | 0.384 | |
| Monthly family income (JD) | <500 | 1 | - | - |
| 500–1000 | 0.88 | 0.32–2.45 | 0.810 | |
| >1000 | 1.09 | 0.45–2.67 | 0.840 | |
| Employment | Unemployed | 1 | - | - |
| Employed | 1.26 | 0.65–2.47 | 0.491 | |
| Mode of birth | Vaginal | 4.02 | 1.77–9.14 | 0.024 |
| Caesarean section | 1 | - | - | |
| Place of birth | Private hospital | 1 | - | - |
| Government hospital | 3.29 | 1.74–6.12 | 0.004 | |
| Breastfeeding counselling | Yes | 2.75 | 1.35–4.87 | 0.007 |
| No | 1 | - | - | |
| First feed | Formula | 1 | - | - |
| Breastfeeding | 13.69 | 5.79–32.34 | 0.000 |
Participants who had a vaginal birth (P=0.024), gave birth in government hospitals (P=0.004), received breastfeeding counselling (P=0.007) and whose infants received breast milk as the first feed (P<0.001) were all independently and significantly more likely to initiate breastfeeding early (Table 4).
Discussion
Given the decline in breastfeeding rates in Jordan and worldwide (WHO, 2022), this study was conducted to investigate infant feeding practices among mothers in Jordan, and assess factors that predict early breastfeeding initiation. The findings found the rate of early initiation was 22.3%, and over a quarter of participants did not breastfeed their infants. This is a notable proportion of infants who are not being breastfed as recommended, despite the fact that over half of participants intended to breastfeed before birth.
Literature regarding breastfeeding in Jordan shows varying rates. Khasawneh and Khasawneh (2017) reported that 87% of mothers initiated breastfeeding within 3 hours of birth, whereas Dasoqi et al (2018) reported that only 13% initiated within 4 hours. Studies from similar settings show that rates can vary widely. The rate of early initiation of breastfeeding in Abu Dhabi was reported to be as high as 79.2% (Taha et al, 2019), 75% was reported in Ethiopia (Gedefaw et al, 2020) and 72.8% was reported in Lebanon and Qatar (Naja et al, 2022). However, rates as low as 36% have been found in Saudi Arabia (Raheel and Tharkar, 2018), and 51% in Bangladesh (Islam et al, 2019).
Considering mode of birth, caesarean section negatively influenced early initiation of breastfeeding compared to vaginal birth, which was a significant predictor of early breastfeeding initiation. After a caesarean section, attention is often focused on recovery and wound healing, increasing the likelihood that skin-to-skin contact and breastfeeding during the first hour after birth are not prioritised, both of which are essential for enhancing and sustaining breastfeeding (Taha et al, 2019; Sodeno et al, 2021).
Caesarean section has been consistently and significantly associated with late initiation of breastfeeding in Jordan (Khasawneh and Khasawneh, 2017; Dasoqi et al, 2018), as well as in Nigeria (Shobo et al, 2020), the Middle East (Sodeno et al, 2021), China (Wu et al, 2018), Abu Dhabi, the United Arab Emirates (Taha et al, 2019), Ethiopia (Gedefaw et al, 2020) and Egypt (Kandeel et al, 2018). Studies have shown that a high prevalence of caesarean section is associated with reduced early initiation of breastfeeding in many countries, including Palestine, Egypt and Iraq (Sodeno et al, 2021). A systematic review reported that a caesarean section was the most consistent risk factor for not breastfeeding within the first hour of life in Asia, Africa and South America (Esteves et al, 2014). Several studies have reported that having a caesarean section encourages the decision to mixed feed after birth (Kandeel et al, 2018).
A randomised controlled trial examining an intervention to increase breastfeeding knowledge among women who underwent caesarean section found the intervention to be highly effective in improving breastfeeding, compared to women who received conventional breastfeeding guidance (Hu et al, 2020). The early provision of breast milk to an infant ensures that they receive highly nutritious and protective colostrum, and assists with more rapid uterus contraction (Moberg et al, 2020). Therefore, it is essential that mothers receive help and support after a caesarean section to initiate breastfeeding in a timely and successful manner.
The present study's results found that 58.3% of infants received formula milk as the first feed in the hospital after birth, which was the strongest predictor of late breastfeeding initiation. Given the high rate of formula feeding for first feed, many infants likely received formula milk even if there were no health problems or complications. In the authors' experience, this may indicate that nursing staff in hospitals are feeding infants before a mother has the chance to initiate breastfeeding. This practice may cause parents to mistakenly believe that formula milk is an appropriate substitute for breast milk, or that it is recommended by health professionals. Mothers may feel encouraged to use milk substitutes to feed their infants and this can limit initiation, exclusivity and continuity of breastfeeding. Research has demonstrated that early initiation of breastfeeding protects against the use of breast milk substitutes (Champeny and Pries, 2019).
Antenatal and postnatal counselling about breastfeeding is critical to early initiation of breastfeeding. In the present study, only 63.7% of mothers received counselling about breastfeeding from a healthcare professional, but those who did were significantly more likely to initiate breastfeeding early. This rate of counselling is higher than findings in Saudi Arabia (55%), India (30%) and a previous study in Jordan (20%) (Mosher et al, 2016; Khasawneh et al, 2020; Namasivayam et al, 2021). This may be because the participants in the present study were attending a mother and child health centre, and likely used the prenatal services available at the centre; these services follow specific guidance regarding breastfeeding.
Esteves et al (2014) concluded that ‘no prenatal guidance on breastfeeding’ was a major barrier to early initiation, while receiving both prenatal and postnatal care has been found to predict the highest levels of early initiation in India (Namasivayam et al, 2021) and in Jordan (Dasoqi et al, 2018). In Cambodia, breastfeeding support from health providers was negatively associated with formula milk use among newborns (Champeny and Pries, 2019).
The results show a considerable deficiency in counselling about breastfeeding for pregnant women during antenatal care in Jordan generally, as over a third of participants received no counselling either antenatally or postpartum. Giving birth in a government hospital independently predicted early initiation of breastfeeding, even after controlling for income, suggesting that government hospitals encourage breastfeeding immediately after childbirth. Over three-quarters of the mothers in this study gave birth in private hospitals, which may factor into the low rate of early breastfeeding initiation.
Recommendations and implications
There is a pressing need for interventions to improve breastfeeding rates in Jordan. As many women in Jordan give birth in private hospitals, these institutions should be encouraged to join the baby-friendly hospitals initiative, which ensures hospitals comply with quality standards and become more breastfeeding-oriented. Policies and legislation in Jordan are needed to implement maternity care standard practices in all hospitals, based on the WHO (2018) 10 steps to successful breastfeeding.
The findings of this study can be used as feedback for the healthcare system, with the potential to inform improvement initiatives to ensure effective initiation and practice of breastfeeding. Hospital policies surrounding training for healthcare professionals play an important role in ensuring the availability of counselling, and that mothers are encouraged and supported to initiate and practice breastfeeding effectively. Counselling about breastfeeding should be an essential element of antenatal and postnatal service protocols in clinics and hospitals in both public and private hospitals.
Escalating rates of caesarean section in Jordan (Al-Rawashdeh et al, 2022) are a cause of concern, particularly for elective caesarean section. It is important to educate women on different modes of birth, their indications, advantages and disadvantages, so that these women can make educated decisions. This must be accompanied by breastfeeding counselling and special support for mothers after a caesarean section, as well as for mothers whose infants are admitted to the neonatal intensive care unit, to facilitate early initiation and continuity of breastfeeding.
Many pregnant women in Jordan attend private prenatal care, and it is vital that healthcare professionals take responsibility for counselling mothers on breastfeeding during antenatal care and paediatric appointments. Future research should focus women's and healthcare professionals' attitudes to breastfeeding in Jordan, and both qualitative and quantitative research are needed to investigate attitudes as a factor that may influence breastfeeding practices.
Limitations
Recall bias may have affected the present study's results because of the retrospective nature of data collection. Social desirability bias may also have affected the data, as they were collected from mothers visiting health centers for immunisation in a health-oriented environment and questionnaires were interviewer-administered. Additionally, the results have limited generalisability to mothers in Jordan as the researchers used a convenience sample.
Conclusions
The results of this study show a suboptimal rate of early breastfeeding initiation in Jordan. It is essential that breastfeeding rates are increased, which may require the adoption of multi-level strategies to encourage more favorable breastfeeding practices in Jordan.
Key points
- Only 22.3% of mothers in Jordan initiated breastfeeding early, which is a low rate compared to the global target of 70%.
- A caesarean section birth was associated with significant delays to the initiation of breastfeeding.
- Women who give birth in public hospitals initiated breastfeeding significantly earlier than those in private hospitals.
- Receiving counselling about breastfeeding had a significant positive influence on early initiation of breastfeeding.
- Providing formula milk as the first feed for an infant significantly delayed initiation of breastfeeding.