Bruno Tongun et al.

International Breastfeeding Journal (2018) 13:28

https://doi.org/10.1186/s13006-018-0170-0

RESEARCH Open Access

Factors associated with delayed initiation of

breastfeeding: a cross-sectional study in
South Sudan
Justin Bruno Tongun1,2*, Mohammed Boy Sebit3, David Mukunya1, Grace Ndeezi4, Victoria Nankabirwa1,5,
Thorkild Tylleskar1 and James K. Tumwine4

Abstract
Background: The global breastfeeding recommendation states that all infants should be put to the breast within
one hour of birth, which is defined as timely initiation or early initiation of breastfeeding. Early initiation of breastfeeding is
associated with reduced risk in infant illness and death. Understanding the determinants of delay in initiation
of breastfeeding might spur health staff and policy makers to foster timely breastfeeding. We assessed the
prevalence and determinants of delay in initiation of breastfeeding among mothers in Juba Teaching Hospital.
Methods: The present study enrolled 806 mother-infant pairs within 24 hrs of birth in Juba Teaching Hospital
in 2017. The mothers were interviewed about the time of initiation of breastfeeding, sociodemographic and
birth characteristics. The independent variables associated with delay in initiation of breastfeeding were identified using
multivariable logistic regression analysis.
Results: In the current study, 52% (418/806) of the mothers initiated breastfeeding later than one hour after birth. Birth
by Caesarean section (Adjusted Odds Ratio [AOR] 41; 95% Confidence Interval [CI] 12.21, 138), discarding of colostrum
(AOR 9.89; 95% CI 4.14, 23.62), unmarried mothers (AOR 3.76; 95% CI 1.53, 9.24), exposure to infant formula advertisement
(AOR 1.82; 95% CI 1.09, 3.02) and no house ownership (AOR 1.52; 95% CI 1.11, 2.09) were independent factors associated
with delay in initiation of breastfeeding.
Conclusion: We found that more than half of the mothers delayed the initiation of breastfeeding. Therefore, we
recommend training on best breastfeeding practices and counselling skills for health staff in Juba Teaching Hospital.
Policy dialogue, with the relevant ministries and departments on the promotion and protection of early initiation of
breastfeeding is crucial.
Keywords: Breastfeeding, Early initiation, Infant, Associated factors, South Sudan

Background appropriate complementary foods while continuing

The universally accepted breastfeeding recommenda- breastfeeding up to two years or beyond [2, 3].
tions state that all newborn babies should be placed in In a recent study, 58% of infants were put to the breast
skin-to-skin contact with their mothers immediately within one hour of birth [4]. Early initiation of breastfeed-
after birth and initiate breastfeeding within one hour of ing (EIBF) promotes the release of oxytocin that enables
birth [1]. It also states that all infants should be exclu- contraction of the uterus and decreases postpartum haem-
sively breastfed (EBF) for six months. From six months orrhage [5]. Early breast suckling facilitates production of
of age introduce the child to timely, adequate, safe and the first breastmilk, called colostrum which has nutrients
and immunity substances that protect infants from infec-
tions [5]. Evidence from studies found that EIBF was asso-
* Correspondence: tongunmafi@gmail.com
1
Centre for International Health, University of Bergen, Bergen, Norway
ciated with a lower risk of diarrhoea in infants in Nigeria
2
Department of Paediatrics and Child Health, College of Medicine, University [6], reduced infant morbidity in Nepal, Vietnam and India
of Juba, Juba, South Sudan [7–9] and reduced infant mortality in Ghana [10, 11].
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Bruno Tongun et al. International Breastfeeding Journal (2018) 13:28 Page 2 of 7

However, suboptimal breastfeeding was one of the three size of 461 participants. This sample size was deter-
leading causes of infant diseases in sub-Saharan Africa mined using Open Epi [22].
[12]. Delay in the initiation of breastfeeding was respon- We also calculated a sample size for factors associated
sible for increased risk in infant morbidity and mortality with delay in initiation of breastfeeding. Initially, the
in Ghana, India and Tanzania [13]. This practice was asso- sample sizes of various exposures were computed using
ciated with antenatal care visits [14], birth place [15], Open-Epi [22] epidemiological calculator for detecting
home area, household income [16, 17], prelacteal feeding differences between proportions of two groups (Kelsey
[18], birth by Caesarian section (CS) and colostrum dis- formula). Finally, discarding of colostrum was used to
carding [19]. calculate the sample size needed for detecting variations
The present study was carried out in South Sudan, a between proportions of delay in initiation of breastfeed-
country plagued by wars since the 1950s and only punc- ing between mothers who discarded colostrum and
tuated by peace, in 2005 to 2013. These conflicts trau- those who did not. Using a study from the Somali region
matized women and children, consequently influencing of Ethiopia where 46.3% of the mothers discarded colos-
health seeking behaviour and infant feeding. In 2016, the trum, while 53.7% did not [23], we assumed the propor-
United Nations Children’s Fund (UNICEF) estimated tion of delay in initiation of breastfeeding of 59% for
that 48% of infants were breastfed early; while 45% were mothers who discarded colostrum and 49% for those
exclusively breastfed for six months [20]. There is little who have not discarded. This gave a sample size of 806;
known about the determinants of early breastfeeding which was enough to detect differences in the propor-
practices in South Sudan. This, Africa’s youngest nation tions of the exposures of interest with 80% power.
is fast introducing a number of WHO/UNICEF pro-
moted policies and practices. However, it is not clear to Sampling procedure
what extent these policies have been implemented. For A total of 1723 mothers gave birth in JTH, of these 13
example, there is a draft policy on infant and young had stillbirths; and 94 mothers were enrolled in another
child feeding which apparently, incorporated the Baby study. The study objectives and procedures were ex-
Friendly Hospital Initiative (BFHI). To date, however no plained to the 1616 mothers eligible to participate in the
hospital in the country has yet started implementing the study. In the design of the study, we planned to recruit
BFHI policy. Therefore, identifying predictors of delay in 10 of the 20 mothers who gave birth daily. However,
initiation of breastfeeding is critical in designing strat- consecutive sampling would have favored those mothers
egies to improve early initiation of breastfeeding. This who gave birth in the day and left out those who gave
study sought to establish factors associated with delay in birth at night; who may have different characteristics. It
initiation of breastfeeding in South Sudan. was also not practical to randomly sample 10 mothers
after all births had occurred in a day, because most
Methods mothers leave the hospital few hours after birth. There-
Study setting fore, we decided to randomly sample one of every two
This study was conducted at the maternity ward in Juba mothers who gave birth. This process spread the data
Teaching Hospital (JTH) in South Sudan. This is a na- collection throughout the day. So, for every two births,
tional referral and teaching hospital for the College of the mothers were requested to pick a concealed piece of
Medicine, University of Juba. The hospital has a capacity paper from a box. Those who picked a “yes” were
of 500 beds and conducts, on average, 20 births daily. assigned to “participate” and those picking the “no” op-
tion to “not to participate” in the study (Fig. 1). Of the
Study design and sample 808 mothers who picked to participate in the study, 806
This was a cross-sectional study among 806 mother-infant consented to participate in the study; while two mothers
pairs conducted from October 2016 to January 2017. with ill infants declined consent.
Mothers who gave informed written consent, had a term
birth and live infant were included. We excluded mothers Data collection and instruments
who had ill infants; and those unable to communicate We used a questionnaire generated from the World
independently. Health Organization (WHO) indicators for assessing in-
fant and young child feeding practices [24] and a study
Sample size estimation in Uganda [25]. The questionnaire was translated to Bari
This study considered a 50% prevalence of early initi- (the local language) and back translated into English by
ation of breastfeeding in sub-Saharan Africa from a re- a different translator for validation. Next, it was piloted
cent descriptive analysis in 57 low-and middle-income and pretested in Al Sabbah Children Hospital in Juba.
counties [21], with a precision of 5%, 95% confidence in- After the pilot test, irrelevant questions were removed,
tervals and non-response of 20%. This gave us sample vague questions made clearer and errors corrected. The
Bruno Tongun et al. International Breastfeeding Journal (2018) 13:28 Page 3 of 7

infant formula advertisement through radio, TV or

newspapers one month before birth.
3: Breastfeeding practices including prelacteal feeding
and colostrum discarding.

Data processing and analysis

In the present study, we reported the descriptive vari-
ables as means and standard deviations. The categorical
variables were reported as proportions. Chi square tests
were performed to identify the independent variables
that were associated with outcome variable of interest
and recorded their p - values. Factors from the literature
known to predict our outcome variable and those with a
p - value ≤0.25 at binary analysis, not in the causal path-
way and not strongly collinear with other independent
variables were entered into the initial multivariable logis-
tic regression model. We evaluated for collinearity and
any factor with variance inflation factor (VIF) > 10 was
regarded as strongly collinear. In instances where there
was collinearity, the factor with a stronger measure of
association with the outcome variable was retained in
the model and the other dropped. The variables with
Fig. 1 Flowchart of mother-infant pairs in Juba Teaching Hospital,
a p - value ≤0.25 from bivariate analysis were then
South Sudan entered into a backward stepwise multivariate model.
Next interaction terms were formed between the variables
retained in the multivariate model. The reduced model
was then compared with the model with the interaction
questionnaire had three sections: sociodemographic terms using chunk test to assess for interaction. We evalu-
characteristics, birth characteristics, and breastfeeding ated the confounding effect for the variables dropped from
practices. The data were collected by a pair of trained the model on the variables that remained in the multivari-
research assistants in a face to face interview. The col- ate model. Any variable that caused a variation ≥10% be-
lected data were checked daily for completeness, tween the crude and adjusted degrees of association of
consistency and errors by the principal investigator (PI). any of the variables that remained in the multivariate
The data were cleaned, coded, double entered into Epi model was kept in the model as a confounder. In the final
Info version 6 and stored safely in a password-protected model, independent variables with a p - value < 0.05 were
computer to which the PI had sole access. regarded key associated factors. Finally, we carried out
the multivariable logistic regression analysis without
Study variables discarding of colostrum. Since this variable could be a
The outcome variable was timely or early initiation of consequence and not a cause of the delay in initiation
breastfeeding. The mothers were asked how long after of breastfeeding. For example, discarding of colostrum
birth their babies were first put to the breast. Initiating could result from delay in initiation of breastfeeding
breastfeeding within one hour was categorized as “early”, due to mother’s engorged breast or infant illness. To
whereas later than one hour was categorized as “late /de- control for this situation, we repeated the analysis with-
layed”. The independent variables have three sections: out this variable. Data analysis for the current study
was conducted using STATA version 14 (Stata Corp
1: Sociodemographic characteristics including maternal LLC, Texas, USA).
age, marital status, parity, place of residence,
educational status, employment status, religion, Results
household assets, house ownership, age of infant, Baseline and birth characteristics
and infant sex. The mean age of the mothers was 24.9 years (SD 5.3)
2: Maternal health services including antenatal care, (Tables 1 and 2). Of all the mothers, more than half 51%
place of birth, assistance during birth, mode of lived in urban area, 46% owned houses, 96% were mar-
delivery, type of birth, birth order, breastfeeding ried, 17% were uneducated, and 76% were unemployed.
counseling, breastfeeding support; and exposure to The majority, 91% of the mothers attended antenatal
Bruno Tongun et al. International Breastfeeding Journal (2018) 13:28 Page 4 of 7

Table 1 Baseline characteristics of mother-infant pairs and Table 2 Birth characteristics of mother-infant pairs and delayed
delayed initiation of breastfeeding in Juba Teaching Hospital, initiation of breastfeeding in Juba Teaching Hospital, South Sudan
South Sudan All participants Delayed initiationa of
All participants Delayed initiation of a n = 806 breastfeeding n = 418
n = 806 breastfeeding n = 418 Variables n (%) n (%)
Variables n (%) n (%) Antenatal care visit
Infant sex 2 or more 731 (90.7) 368 (88.0)
Male 386 (47.9) 209 (50.0) 0–1 75 (9.3) 50 (12.0)
Female 420 (52.1) 209 (50.0) Skilled birth attendant
Mother age Yes 788 (97.8) 406 (97.1)
≤ 19 139 (17.2) 73 (17.5) No 18 (2.2) 12 (2.9)
20–24 252 (31.3) 126 (30.1) Mode of birth
25–29 246 (30.5) 135 (32.3) Normal vaginal 709 (88.0) 324 (77.5)
30–34 123 (15.3) 57 (13.6) Caesarean section 97 (12.0) 94 (22.5)
≥ 35 46 (5.7) 27 (6.5) Birth type
Place of residence Single 790 (98.0) 407 (97.4)
Urban 410 (50.9) 204 (48.8) Multiple 16 (2.0) 11 (2.6)
Rural 396 (49.1) 214 (51.2) Birth order
House ownership Primipara 523 (64.9) 263 (62.9)
Yes 373 (46.3) 167 (40.0) Multipara 283 (35.1) 155 (37.1)
No 433 (53.7) 251 (60.0) Exposure to infant formula advertisement one month before birth
Mother marital status No 711 (88.2) 354 (84.7)
Married 775 (96.2) 394 (94.3) Yes 95 (11.8) 64 (15.3)
Single 31 (3.8) 24 (5.7) Breastfeeding counseling
Mother education status Yes 445 (55.2) 241 (57.7)
None 136 (16.9) 65 (15.6) No 361 (44.8) 177 (42.3)
Primary 377 (46.8) 194 (46.4) Breastfeeding support
Secondary 239 (29.7) 128 (30.6) Yes 459 (56.9) 232 (55.5)
Tertiary 54 (6.7) 31 (7.4) No 347 (43.1) 186 (44.5)
Mother employment status Discarding of colostrum
Employed 197 (24.4) 101 (24.2) No 739 (91.7) 357 (85.4)
Not employed 609 (75.6) 317 (75.8) Yes 67 (8.3) 61 (14.6)
a
Delayed initiation refers to putting an infant to the breast later than 1 hr a
Delayed initiation refers to putting an infant to the breast later than 1 h
after birth after birth

Multivariable analysis
care (ANC), 88% gave birth normally, 55% received In this analysis, birth by Caesarean section (Adjusted
breastfeeding counseling, and 88% were not exposed to odd ratio [AOR] 41; 95% confidence interval [CI] 12.21,
infant formula advertisement a month before birth. 138), discarding of colostrum (AOR 9.89; 95% CI 4.14,
23.62), unmarried mothers (AOR 3.76; 95% CI 1.53,
9.24), exposure to infant formula advertisement (AOR
Bivariate analysis 1.82; 95% CI 1.09, 3.02), and no house ownership (AOR
More than half 52% (418/806) of the mothers delayed 1.52; 95% CI 1.11, 2.09) were associated with delay in
initiation of breastfeeding. Place of residence, marital initiation of breastfeeding (Table 3). The repeated model
status, no house ownership, ANC, mode of birth, birth without discarding of colostrum found the same results
order, type of birth, discarding of colostrum, and expos- with similar measure of association.
ure to infant formula advertisement were associated with
delay in initiation of breastfeeding (Table 3). The vari- Discussion
ables which were not associated at this level were ex- In this study, more than half of the mothers initiated
cluded in final multivariable analysis. breastfeeding later than one hour after birth. Factors
Bruno Tongun et al. International Breastfeeding Journal (2018) 13:28 Page 5 of 7

Table 3 Bivariate and multivariable analysis for delayed in Table 3 Bivariate and multivariable analysis for delayed in
initiation of breastfeeding in Juba Teaching Hospital, South Sudan initiation of breastfeeding in Juba Teaching Hospital, South Sudan
Bivariate n = 806 Multivariable n = 806 (Continued)
Variables OR (95% CI) AORa (95% CI) Bivariate n = 806 Multivariable n = 806

Infant’s sex Exposure to infant formula advertisement one month before birth

Male 1 No 1 1

Female 0.84 (0.64, 1.11) – Yes 2.08 (1.32, 3.28) 1.82 (1.09, 3.02)

Mother’s age Breastfeeding counseling

≤ 19 1 Yes 1

20–24 0.90 (0.60, 1.37) – No 0.81(0.62, 1.08) –

25–29 1.10 (0.72, 1.67) – Breastfeeding support

30–34 0.78 (0.48, 1.27) – Yes 1

≥ 35 1.28 (0.65, 2.52) – No 1.13 (0.85, 1.49) –

Place of residence Discarding of colostrum

Urban 1 No

Rural 1.19 (0.90, 1.57) – Yes 10.88(4.65, 25.47) 9.89 (4.14, 23.62)
a
AOR adjusted odds ratio
House ownership
Yes 1 1
associated with this practice were birth by Caesarean sec-
No 1.70 (1.29, 2.45) 1.52 (1.11, 2.09)
tion, discarding of colostrum, unmarried mothers, no house
Mother marital status ownership and exposure to infant formula advertisement.
Married 1 1 According to the WHO rating on early initiation of
Unmarried 3.32 (1.41, 7.79) 3.76 (1.53, 9.24) breastfeeding; 0–29% is considered poor, 30–49% as fair,
Mother education status 50–89% as good and 90–100% as very good [26]. The
prevalence of early initiation of breastfeeding in the
None 1
present study is fair. This was similar to that of a study
Primary 1.56 (0.78, 1.71) –
in Ethiopia [27]. This was however, lower than that of
Secondary 1.26 (0.83, 1.92) – other studies in Mulago hospital (69%) [16], rural
Tertiary 1.47 (0.36, 1.28) – Uganda (57%) [28], and Ethiopia (84%) [29].
Mother employment status There was strong evidence that birth by Caesarean
Employed 1 section (CS) was associated with delay in initiation of
breastfeeding. This was similar to findings from Uganda
Not employed 1.03 (0.75, 1.42) –
[30], Tanzania [31], Ethiopia [27], and Nigeria [32]. This
Antenatal care visits
could be explained by the hospital practice of separating
2 or more 1 infants from their mothers after CS as reported in stud-
0–1 1.97 (1.19, 3.26) 1.53(0.87, 2.71) ies in Nigeria [33] and Vietnam [34]. This also could be
Skilled birth attendant due to fatigue and pain experienced by the mother after
Yes 1 birth [16].
Mothers who were exposed to infant formula adver-
No 1.88 (0.70, 5.06) –
tisement were two times more likely to delay initiation
Mode of birth
of breastfeeding. This was similar to that of a study in
Normal vaginal 1 Cambodia [35]. A recent systematic review found that
Caesarean section 37.23 (11.68, 119) 41 (12.21, 138) infant formula promotion undermined breastfeeding,
Birth type urged mothers to stop breastfeeding and gave prelacteal
Single 1 feeding [36]. A study in Nepal found that promotion of
infant formula by health staff contributed to suboptimal
Multiple 2.07 (0.71, 6.01) –
breastfeeding [37].
Birth order
Discarding of colostrum was strongly associated with
Multipara 1 delay in initiation of breastfeeding. However, discarding
Primipara 1.20 (0.90, 1.60) 1.22 (0.88, 1.68) colostrum could be a consequence and not a cause of
delay in initiation of breastfeeding. To counter this situ-
ation, the multivariable analysis was repeated without
Bruno Tongun et al. International Breastfeeding Journal (2018) 13:28 Page 6 of 7

discarding of colostrum, but the findings were similar. In breastfeeding in the hospital. Lastly, a qualitative study
this study, mothers thought colostrum was dirty and is recommended to investigate the rational for delay in
bad. This finding was similar to studies in Guinea-Bissau initiation of breastfeeding among unmarried mothers.
[38], Ethiopia [39] and Guatemala [40]. Negative cultural
Abbreviations
beliefs were responsible for discarding of colostrum. ANC: Antenatal care; CS: Caesarean section; EBF: Exclusive breastfeeding;
However, our study did not explore the effect of cultural JTH: Juba Teaching Hospital; VIF: Variance inflation factor; WHO: World Health
beliefs on discarding of colostrum. Organization
Unmarried mothers were four times more likely to prac-
Acknowledgements
tice delay in initiation of breastfeeding compared to mar- We are highly indebted to the NORHED program for financial assistance
ried mothers. This was similar to recent findings in the through the Survival PLUSS project. We thank the research assistants for the
Democratic Republic of Congo [41] and Tanzania [31]. data collection. We owe this study to the mothers and infants who
participated in this study.
Another study in the USA reported delayed initiation of
breastfeeding among unmarried mothers who gave birth Funding
to preterm infants [42]. The present study however, did This study received funding from the Survival PLUSS project under the
Norwegian program for capacity building in higher education and research
not investigate the reasons underlying delay in initiation for development (NORHED).
of breastfeeding among the unmarried mothers.
Lastly, mothers who did not own houses were two Availability of data and materials
The dataset for this study is available from the corresponding author on request.
times more likely to breastfeed later than one hour after
birth compared to those who own houses. This was Authors’ contributions
similar to that of a study in Ethiopia [29]. The mothers JBT conceptualized, designed, and supervised the study, analyzed the data,
who breastfed later than one hour after birth may most wrote the first draft of the manuscript. JKT, TT, GN, VN and DM conceptualized,
designed the study and writing of the manuscript. JKT, TT, GN, VN, MBS and
likely be women living in poverty and were given less DM participated in the data analysis and interpretation of results. All authors
opportunity to initiate breastfeeding early. have read and approved the final version of the manuscript.

Ethics approval and consent to participate

Strengths and limitations Ethical approval was obtained from the Directorate of Planning, Budgeting
This study was the first to assess early initiation of and Research in the Ministry of Health and the Jubek State Ministry of
breastfeeding in a unique conflict setting in South Health, South Sudan – reference number SMOH/E/JS/44.K.1. To participate in
the study, participants gave written informed consent or a thumbprint for
Sudan. The data were gathered within 24 hrs after birth those who were unable to write.
which minimized recall bias. This study had several limi-
tations; the result of this study cannot be generalized Consent for publication
since one hospital was studied. This study omitted other Not applicable. Our manuscript does not contain individual person’s data in
any form such as individual details, images or videos.
methods of infant formula advertisement such as points
of sale, social media promotion, internet, health staff role Competing interests
and public display. In addition, the information on infant The authors declare that they have no competing interests.
formula advertisement could be subject to recall bias. Fi-
nally, the mothers’ ability to estimate exact time on initi- Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
ation of breastfeeding was not assessed. published maps and institutional affiliations.

Conclusion Author details

1
Centre for International Health, University of Bergen, Bergen, Norway.
In this study, delay in initiation of breastfeeding was 2
Department of Paediatrics and Child Health, College of Medicine, University
prevalent in Juba Teaching Hospital. Birth by Caesarean of Juba, Juba, South Sudan. 3Department of Internal Medicine, College of
section, discarding of colostrum, exposure to infant for- Medicine, University of Juba, Juba, South Sudan. 4Department of Paediatrics
and Child Health, School of Medicine, College of Health Sciences, Makerere
mula advertisement, unmarried mothers and no house University, Kampala, Uganda. 5School of Public Health, College of Health
ownership were associated with delay in initiation of Sciences, Makerere University, Kampala, Uganda.
breastfeeding. We recommend health staff training on
Received: 26 October 2017 Accepted: 11 June 2018
best breastfeeding practices and counselling skills, espe-
cially the staff responsible for birth by Caesarean section.
In-depth study on cultural beliefs and socioeconomic de- References
terminants with special focus on discarding of colostrum 1. World Health Organization. Guideline: protecting, promoting and
supporting breastfeeding in facilities providing maternity and newborn
and house ownership is urgent. Policy dialogue is crucial services. Geneva: World Health Organization; 2017. Available from: http://
with the Ministry of Health to review compliance with apps.who.int/iris/handle/10665/259386. Accessed 18 May 2018.
WHO policies, especially the Code of Marketing Breast 2. World Health Organization. Global strategy for infant and young child
feeding. Geneva: World Health Organization; 2003. Available from: http://
Milk Substitutes. Initiation of the BFHI might go a long www.who.int/nutrition/publications/infantfeeding/9241562218/en/.
way in mitigating the challenge of delay in initiation of Accessed 18 May 2018.
Bruno Tongun et al. International Breastfeeding Journal (2018) 13:28 Page 7 of 7

3. Victora CG, Bahl R, Barros AJ, Franca GV, Horton S, Krasevec J, et al. 24. World Health Organization. Indicators for assessing infant and young
Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong child feeding practices. Geneva: World Health Organization; 2010.
effect. Lancet. 2016;387(10017):475–90. Available from: http://www.who.int/nutrition/publications/infantfeeding/
4. Takahashi K, Ganchimeg T, Ota E, Vogel JP, Souza JP, Laopaiboon M, et al. 9789241599290/en/. Accessed 19 May 2018.
Prevalence of early initiation of breastfeeding and determinants of delayed 25. Tylleskar T, Jackson D, Meda N, Engebretsen IM, Chopra M, Diallo AH, et al.
initiation of breastfeeding: secondary analysis of the WHO global survey. Sci Exclusive breastfeeding promotion by peer counsellors in sub-Saharan Africa
Rep. 2017;7:44868. (PROMISE-EBF): a cluster-randomised trial. Lancet. 2011;378(9789):420–7.
5. Palmeira P, Carneiro-Sampaio M. Immunology of breast milk. Rev Assoc 26. World Health Organization. Infant and young child feeding: a tool for
Med Bras. 2016;62(6):584–93. assessing national practices, policies and programmes. Geneva: World
6. Ogbo FA, Page A, Idoko J, Claudio F, Agho KE. Diarrhoea and suboptimal Health Organization; 2003. Available from: http://www.who.int/iris/handle/
feeding practices in Nigeria: evidence from the national household surveys. 10665/42794. Accessed 10 May 2018.
Paediatr Perinat Epidemiol. 2016;30(4):346–55. 27. Liben ML, Yesuf EM. Determinants of early initiation of breastfeeding in
7. Mullany LC, Katz J, Li YM, Khatry SK, LeClerq SC, Tielsch JM, et al. Breast- Amibara district, northeastern Ethiopia: a community based cross-sectional
feeding patterns, time to initiation, and mortality risk among newborns in study. Int Breastfeed J. 2016;11:7.
southern Nepal. J Nutr. 2008;138(3):599–603. 28. Waiswa P, Peterson S, Tomson G, Pariyo GW. Poor newborn care practices -
8. Hajeebhoy N, Nguyen PH, Mannava P, Nguyen TT, Mai LT. Suboptimal a population based survey in eastern Uganda. BMC Pregnancy and Childbirth.
breastfeeding practices are associated with infant illness in Vietnam. Int 2010;10:9.
Breastfeed J. 2014;9:12. 29. Beyene MG, Geda NR, Habtewold TD, Assen ZM. Early initiation of
9. Garcia CR, Mullany LC, Rahmathullah L, Katz J, Thulasiraj RD, Tielsch JM, et al. breastfeeding among mothers of children under the age of 24 months in
Breastfeeding initiation time and neonatal mortality risk among newborns southern Ethiopia. Int Breastfeed J. 2017;12:1.
in South India. J Perinatol. 2011;31(6):397–403. 30. Mukunya D, Tumwine JK, Nankabirwa V, Ndeezi G, Odongo I, Tylleskar T,
10. Edmond KM, Kirkwood BR, Amenga-Etego S, Owusu-Agyei S, Hurt LS. Effect et al. Factors associated with delayed initiation of breastfeeding: a survey in
of early infant feeding practices on infection-specific neonatal mortality: an northern Uganda. Glob Health Action. 2017;10(1):1410975.
investigation of the causal links with observational data from rural Ghana. 31. Exavery A, Kante AM, Hingora A, Phillips JF. Determinants of early initiation
Am J Clin Nutr. 2007;86(4):1126–31. of breastfeeding in rural Tanzania. Int Breastfeed J. 2015;10:27.
11. Edmond KM, Kirkwood BR, Tawiah CA, Owusu-Agyei S. Impact of early 32. Berde AS, Yalcin SS. Determinants of early initiation of breastfeeding in
infant feeding practices on mortality in low birth weight infants from rural Nigeria: a population-based study using the 2013 demographic and health
Ghana. J Perinatol. 2008;28(6):438–44. survey data. BMC Pregnancy Childbirth. 2016;16:32.
12. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Memish ZA, et al. A 33. Awi DD, Alikor EA. Barriers to timely initiation of breastfeeding among
comparative risk assessment of burden of disease and injury attributable to mothers of healthy full-term babies who deliver at the University of Port
67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic Harcourt Teaching Hospital. Niger J Clin Pract. 2006;9(1):57–64.
analysis for the global burden of disease study 2010. The Lancet. 2012; 34. Bui QT, Lee HY, Le AT, Van Dung D, Vu LT. Trends and determinants for
380(9859):2224–60. early initiation of and exclusive breastfeeding under six months in Vietnam:
13. Edmon K, Newton S, Hurt L, Shannon SG, Mazumder S, Taneja S, et al. results from the multiple indicator cluster surveys, 2000-2011. Glob Health
Timing of initiation, patterns of breastfeeding, and infant survival: Action. 2016;9:29433.
prospective analysis of pooled data from three randomised trials. Lancet. 35. Pries AM, Huffman SL, Mengkheang K, Kroeun H, Champeny M, Roberts M,
2016;4(4):e266–75. et al. Pervasive promotion of breastmilk substitutes in Phnom Penh,
14. Ekubay M, Berhe A, Yisma E. Initiation of breastfeeding within one hour of Cambodia, and high usage by mothers for infant and young child feeding.
birth among mothers with infants younger than or equal to 6 months of Maternal & Child Nutrition. 2016;12(Suppl 2):38–51.
age attending public health institutions in Addis Ababa, Ethiopia. Int 36. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al.
Breastfeed J. 2018;13:4. Why invest, and what it will take to improve breastfeeding practices?
15. Yimer NB, Liben ML. Effects of home delivery on colostrum avoidance Lancet. 2016;387(10017):491–504.
practices in north Wollo zone, an urban setting, Ethiopia: a cross sectional 37. Pries AM, Huffman SL, Adhikary I, Upreti SR, Dhungel S, Champeny M, et al.
study. Matern Child Nutr. 2018;37(1):4. Promotion and prelacteal feeding of breastmilk substitutes among mothers
in Kathmandu valley. Nepal Maternal & Child Nutrition. 2016;12(Suppl 2):8–21.
16. Kalisa R, Malande O, Nankunda J, Tumwine JK. Magnitude and factors
38. Gunnlaugsson G, da Silva MC, Smedman L. Determinants of delayed
associated with delayed initiation of breastfeeding among mothers who
initiation of breastfeeding: a community and hospital study from Guinea-
deliver in Mulago hospital. Uganda African Health Sciences. 2015;15(4):
Bissau. Int J Epidemiol. 1992;21(5):935–40.
1130–5.
39. Hailemariam TW, Adeba E, Sufa A. Predictors of early breastfeeding initiation
17. Engebretsen IM, Nankabirwa V, Doherty T, Diallo AH, Nankunda J, Fadnes
among mothers of children under 24 months of age in rural part of West
LT, et al. Early infant feeding practices in three African countries: the
Ethiopia. BMC Public Health. 2015;15:1076.
PROMISE-EBF trial promoting exclusive breastfeeding by peer counsellors.
40. Atyeo NN, Frank TD, Vail EF, Sperduto WAL, Boyd DL. Early initiation of
Int Breastfeed J. 2014;9:19.
breastfeeding among maya mothers in the western highlands of
18. Legesse M, Demena M, Mesfin F, Haile D. Prelacteal feeding practices and
Guatemala: practices and beliefs. J Hum Lact. 2017;33(4):781–9.
associated factors among mothers of children aged less than 24 months in
41. Kambale RM, Buliga JB, Isia NF, Muhimuzi AN, Battisti O, Mungo BM.
Raya kobo district, north eastern Ethiopia: a cross-sectional study. Int
Delayed initiation of breastfeeding in Bukavu, south Kivu, eastern
Breastfeed J. 2014;9:189.
Democratic Republic of the Congo: a cross-sectional study. Int Breastfeed J.
19. Tilahun G, Degu G, Azale T, Tigabu A. Prevalence and associated factors of
2018;13:6.
timely initiation of breastfeeding among mothers at Debre Berhan town,
42. Kair LR, Colaizy TT. Breastfeeding continuation among late preterm infants:
Ethiopia: a cross-sectional study. Int Breastfeed J. 2016;11:27.
barriers, facilitators, and any association with neonatal intensive care unit
20. UNICEF. The state of the world's children. New York: UNICEF; 2016. Available
admission? Hospital Pediatrics. 2016;6(5):261–8.
from: http://www.unicef.org/sowc2014/numbers. Accessed 4 January 2018.
21. Oakley L, Benova L, Macleod D, Lynch CA, Campbell OMR. Early
breastfeeding practices: descriptive analysis of recent demographic and
health surveys. Maternal & Child Nutrition. 2018;14(2):e12535.
22. Dean AG, Sullivan KM, Soe MM. Open epi: open source epidemiologic
statistics for Public Health; 2013. Available from: www.OpenEpi.com.
Accessed 4 September 2017
23. Rogers NL, Abdi J, Moore D, Nd'iangui S, Smith LJ, Carlson D, et al.
Colostrum avoidance, prelacteal feeding and late breast-feeding initiation in
rural northern Ethiopia. Public Health Nutr. 2011;14(11):2029–36.