Factors Associated with Delayed Initiation of Breastfeeding among Newly Delivered Women in a Tertiary Care Hospital

Early initiation of breastfeeding (EIBF)—breastfeeding in the first hour after birth—is a critical determinant of neonatal survival and maternal–infant health. Yet, despite strong global guidance, including World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) recommendations to initiate breastfeeding in the first hour and exclusively breastfeed for the first six months, early initiation remains suboptimal in many low- and middle-income countries. Delayed initiation of breastfeeding increases the newborn’s risks of hypothermia, infection, pre-lacteal feeding, and neonatal death. Emerging data now confirms that initiating breastfeeding beyond the first hour of life independently increases the risk of neonatal death by up to 33% [1]. A recent global pooled analysis across 153 countries estimates only ~50–60% of all infants are breastfed within the first hour of life[2].

The parent article analyzed over 244 000 births in 24 countries to estimate the prevalence of EIBF and identify risk factors for delayed initiation. The analysis found an overall prevalence of EIBF of 57.6% (range 17.7–98.4%) and identified caesarean delivery and maternal complications as the main drivers of delayed breastfeeding initiation

Delayed initiation has been reported consistently in other recent settings. Similar studies in South Asia and Sub-Saharan Africa report that caesarean section halves the odds of initiating breastfeeding within one hour compared with vaginal delivery, with adjusted odds ratios (OR) of 0.3–0.6[3–5]. Early breastfeeding initiation has also been shown to be delayed by pre-lacteal feeding, inadequate antenatal counselling, and not practising skin-to-skin contact[6].

Breastfeeding early protects against neonatal sepsis, diarrhea, and respiratory tract infections in the newborn period, and is associated with long-term cognitive and metabolic health benefits for the child[7]. However, high rates of delayed initiation have also been reported in institutional births, where mothers should theoretically have more support to breastfeed early. A recent multicountry systematic review and meta-analysis showed that even in the hospital setting, only 58% of newborns were placed on the breast within the first hour. This delay was attributed to staff workload, postoperative pain, and a lack of breastfeeding assistance[8].

Large global and local inequities in the provision of care, as well as a growing body of evidence on the independent importance of early feeding practices on neonatal survival, means that understanding the patterns of and risk factors for delayed breastfeeding initiation at the local level is vital. Determining which risk factors are preventable, or can be modified with existing resources, will inform the design of novel and targeted intervention packages to promote early breastfeeding and reduce preventable neonatal morbidity and mortality.

A total of 264 postpartum women were included in the analysis. Their baseline characteristics are summarized in Table 1. The mean maternal age was 27.8 ± 5.4 years, and most participants were between 20–30 years (61.7%). Maternal age and parity did not show a statistically significant association with delayed initiation of breastfeeding (p = 0.214 and p = 0.087, respectively).

Obstetric characteristics are presented in Table 2. More than half of the participants delivered by caesarean section (53.0%, n = 140). Mode of delivery showed a strong and significant association with breastfeeding delay, with 82.1% of women undergoing caesarean section reporting delayed initiation compared to 34.6% of those delivering vaginally (p < 0.001). Term infants constituted 88.6% of the sample, and preterm birth showed a mild but significant association with delay (p = 0.041).

Neonatal characteristics are shown in Table 3. Most newborns had a birth weight ≥2500 g (80.3%), and birth weight did not significantly affect the timing of breastfeeding (p = 0.067). Neonatal suckling difficulty was noted in 19.3% of infants and was significantly associated with delayed initiation (p = 0.032).

Reasons for delayed initiation of breastfeeding are displayed in Table 4 and illustrated visually in Figure 1. Maternal postoperative pain and immobility were the most frequent contributors (45.4%, p < 0.001). Healthcare-related barriers, including lack of immediate breastfeeding support, accounted for 38.2% of delays (p < 0.001). Neonatal factors such as poor suckling contributed 19.3% (p = 0.032), while cultural practices, including prelacteal feeding, were reported by 12.5% of mothers (p = 0.054).

Overall, 87.1% of mothers expressed a positive intention to breastfeed early but were hindered by preventable barriers. The results demonstrate that most delays were linked to modifiable factors, supporting the need for enhanced postnatal counselling and breastfeeding assistance.

Table 1. Maternal Demographic Characteristics and Association

Table 2. Obstetric and Delivery Characteristics

Table 3. Neonatal Characteristics and Association

Table 4. Reasons for Delayed Initiation of Breastfeeding

Figure 1: Distribution of key reasons contributing to delayed initiation of breastfeeding among postpartum women.

In this study, multiple barriers to initiation of breastfeeding within one hour of birth were explored in 264 mothers. Maternal, newborn and health-system level factors that could have been modified if proper support were given, were identified as major causes for this delay. In the face of abundant knowledge about breastfeeding worldwide, it remains evident from this study that delayed breastfeeding initiation is persistent.

Caesarean delivery was a significant predictor of initiation delay in this cohort. Notably, nearly 84% of women who delivered through caesarean section could not start breastfeeding early. This finding is in line with growing evidence that women who undergo caesarean section are less likely to initiate breastfeeding within one hour due to post-operative pain, immobility, residual effects of anesthesia, separation from the newborn, and other factors. Recent large cohort and multicounty studies have shown two-to-fourfold increased likelihood of breastfeeding initiation delay after caesarean birth when compared with vaginal birth [9,10]. Therefore, focused counselling and post-operative care that support breastfeeding within one hour of birth, should be included in standard maternity unit protocols.

Secondly, this study identified healthcare-related factors such as lack of early guidance and no skin-to-skin contact as the second most common cause of initiation delay. This finding was consistent with the literature where studies from various low- and middle-income countries have shown that lack of health-system readiness and staff responsiveness were important causes of late initiation [11]. Facilities with Baby-Friendly Hospital Initiative (BFHI) accreditation showed better performance for early initiation of breastfeeding, as per national-level data in this country as well. BFHI units follow standard breastfeeding counselling practices including immediate and on-bed assistance, which is likely the reason for higher early initiation rates compared with non-BFHI facilities [12].

In this study, neonatal factors like poor suckling and early postnatal sleepiness also increased the risk of delayed breastfeeding initiation. In other studies, poor neonatal feeding adaptation has been shown to be a cause of delayed breastfeeding [13]. As a result, proper monitoring of latch, suck reflex, and position by trained staff immediately after birth is important to promote timely initiation.

On the other hand, cultural factors such as prelacteal feeds were also identified as a cause of breastfeeding initiation delay, but only a small proportion of women reported this as a reason. Prelacteal feeds, other family members expressing their milk and beliefs against colostrum and first milk are common practices reported in other South Asian studies [14]. Therefore, antenatal counselling as well as social and community-based counselling may be effective to prevent these traditional practices that go against immediate breastfeeding.

A crucial finding of this study was the fact that most mothers in this cohort had reported an intention to breastfeed early. As much as 87% of participants who were unable to initiate within one hour had reported that they intended to breastfeed soon after birth but were impeded by various causes. This finding is not uncommon and is in line with many other studies that have reported an association between late initiation of breastfeeding and a lack of preparedness in facilities to provide lactation support [15]. As a result, there is scope for modifiable factors such as post-operative care practices in women who deliver through caesarean, standardized lactation counselling practices, and immediate skin-to-skin contact to improve early initiation rates.

In conclusion, this study found that most women wanted to breastfeed early and were prevented by various modifiable causes including caesarean delivery, health-system and neonatal factors. This shows that early initiation of breastfeeding is not for lack of will among mothers but for lack of maternal and child health system support to facilitate the process. This gap can be filled by improved breastfeeding support immediately after birth. This is especially true in cases following caesarean delivery where mothers are likely to be unable to breastfeed within the golden hour for a variety of reasons. The study provides potential for interventions at maternity units which are targeted at improving breastfeeding within one hour of birth, which in turn would lead to improved neonatal outcomes.