JCDR - Register at Journal of Clinical and Diagnostic Research
Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X
Public Health Section DOI : 10.7860/JCDR/2020/43041.13437
Year : 2020 | Month : Jan | Volume : 14 | Issue : 01 Full Version Page : LC06 - LC10

Exploring Barriers for Early Initiation of Breastfeeding among Mothers in the Post-natal Ward: A Cross-sectional Study

Arunava Pariya1, Adwitiya Das2

1 Intern, Department of Community Medicine, Medical College, Kolkata, West Bengal, India.
2 Assistant Professor, Department of Community Medicine, Medical College, Kolkata, West Bengal, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Adwitiya Das, Assistant Professor, Department of Community Medicine, MCH Main Hospital Building, Medical College, Kolkata, West Bengal, India.
E-mail: doc.adi.007@gmail.com


Early Initiation of Breast Feeding (EIBF), referred to as “provision of mother’s breast milk to infants within 1 hour of birth”, is the cornerstone of infant survival and health. In spite of an increase in proportion of mothers practising EIBF over the past decade, the number is still less than satisfactory.


To find out the proportion of mothers who practised EIBF, and the factors influencing the same.

Materials and Methods

Ninety-seven post-natal mothers were interviewed from June 2017 to August 2017 using a pre-designed, pre-tested semi-structured questionnaire. Other relevant information collected from in-patient records. Logistic regression analysis was done.


Out of 97 mothers, EIBF was practised by 59 (60.82%). Main reason for not initiating EIBF according to the mothers was “baby not roomed/bedded-in” soon after birth, followed by exhaustion from delivery. Knowledge regarding benefits of EIBF was inadequate. Colostrum feeding was done by 83.51% of mothers. On logistic regression analysis, it was observed that in the multivariate model, education of mother, higher age at marriage, vaginal/vaginal assisted delivery and term/post-term baby were significant factors promoting EIBF.


EIBF was practised by less than two-thirds of study subjects. Knowledge regarding EIBF was unsatisfactory. This study revealed education of mother, higher age at marriage, vaginal/vaginal assisted delivery and term/post-term baby were significant factors promoting EIBF.



Early initiation of breastfeeding, as recommended by WHO and UNICEF is a critical step in both short and long term survival and sustenance of an infant irrespective of other socio-demographic and healthcare delivery parameters [1]. National Coverage Evaluation Survey of India conducted in 2009 revealed an increase in the rate of EIBF from 24.5% to 34% annually [2]. In spite of 81.1% of the deliveries conducted by skilled health care providers nationwide, an annual 10.3% rise (44.6% in 2014 from 24.5% in 2006) indicates the gap in implementation of EIBF policy under the Baby Friendly Hospital Initiative by World Health Organisation [2,3].

Globally, only two out of five newborns are initiated with breastfeeding within the first hour since birth, as per UNICEF 2018 database [4] Studies conducted globally showed that EIBF is associated with reduced neonatal mortality and morbidity, and is a matter of concern worldwide [5-9]. EIBF also has an inverse co-relation with Infant Mortality Rate (IMR). Studies revealed that initiation of breastfeeding within an hour of birth is associated with 44% lower IMR [5,7,8,10]. Various studies indicate that failure to initiate breastfeeding early can lead to a 33% increase in preventable mortality and morbidity from respiratory and gastrointestinal infections [11,12]. EIBF also ensures continued and sustained breastfeeding which fosters maternal and child bonding as well as is beneficial for neonatal health and development [13].

Though there are a few studies from different parts of India about EIBF, data from eastern India is lacking in the literature [14-18]. With this background, this cross-sectional, institution based study conducted within a stipulated timeline and limited resources, attempts to find out the proportion of mothers who breastfed their infants within 1 hour of birth, their socio-demographic and clinical profile and their knowledge regarding various aspects of breastfeeding. It also aimed at exploring the facilitating and inhibitory factors influencing EIBF.

Materials and Methods

It was a descriptive, observational, institution-based, cross-sectional study; conducted among mothers admitted in the post-natal ward of a tertiary care hospital in Kolkata, West Bengal, India. Study period was from June 2017 to August 2017. Confidentiality of respondents was maintained. Before inclusion in the study, informed consent was sought from parents and/or caregivers. The study got clearance from Institutional Ethics Committee (Reference number: MC/KOL/IEC/Non-spon/510/02-2017).

Sample size was calculated using the formula:

where n was required sample size, Zα is critical value for normal distribution at 95% confidence level which equals to 1.96 (z value at alpha 0.05), P is prevalence of early initiation of breastfeeding in India=44.6% [3]. Q equals 100-P, L is an absolute precision (10%). Thus calculated sample size was 95.

Based on previous three years record, the average seasonal in-patient load in the post-natal ward approximately equalled 30/day. Eight days were stipulated for data collection. Applying systematic random sampling, sampling interval came to be (240/95) 2.53, approximately 2. So, every alternate mother was selected by applying inclusion and exclusion criteria, after selecting first mother randomly.

Inclusion criteria were the mothers admitted in the post-natal ward during the stipulated study period. Mothers who were severely ill and unable to respond, whose babies are born with birth asphyxia, sepsis or very low birth weight (<1800 grams) or needing transfer to Neonatal Intensive Care Unit (NICU), those with contraindications to breastfeeding, and those not giving consent were excluded.

A predesigned and pretested semi-structured schedule containing sections for socio-demographic, income and clinical profile, maternal health care and infant feeding-related information, the knowledge of the mother regarding breastfeeding, and Bed Head Tickets (BHT) and Mother and Child Protection Card (MCPC) were used for data collection. Face validity of the questionnaire was checked by two public health experts and one linguistic expert. Cronbach’s alpha was 0.81 indicating good agreement. Details of mother’s knowledge assessment questionnaire are given in [Annexure 1].

Statistical Analysis

Data were entered into MS excel and analysed using SPSS version 20.0. Different parameters were evaluated first by their frequency distributions and finally were assessed in a logistic regression model (ENTER method). Odds ratio with 95% Confidence Interval (CI) of all variables was taken and those found statistically significant were entered into final regression model. Model fitness was assessed using standard tests like Nagelkerke’s (r2). Possible variables interactive effects (indicated by the significant p-value) were ruled out and robustness of the model fitness (as per Nagelkerke’s (r2) and Likelihood Ratio value) was done. For all statistical tests of significance, p-value <0.05 were considered to reject the null hypothesis or significant to prove the theory.


Final sample size was 97; mean age was 23.44±6.92 years. Majority of mothers belonged to the age group of 18-24 years [Table/Fig-1]. EIBF was initiated in 59 subjects [Table/Fig-2]. Authors reviewed the causes for not initiating EIBF (38 subjects), which included ‘too sick to hold the baby’ (14 patients) and ‘baby not roomed/bedded-in’ (24 patients). Colostrum feeding was done by 81 (83.51%) subjects. 83 (85.57%) received advice regarding breastfeeding from some health personnel.

Socio-demographic characteristics of the respondents (n=97).

Age (in years)
Education of mother
Below primary1919.59
Higher secondary and above1717.52
Education of father
Below primary1313.40
Higher secondary and above3536.08
Occupation of mother
Occupation of father
Others (includes farmers, bank employees, workers in different shops etc.,)4849.48
Per capita income
Less than 5000 INR8284.54
≥5000 INR1515.46

Clinical and biological characteristics of the respondents (n=97).

Age at marriage (in years)NumberPercentage
20 or more6162.89
Age at first pregnancy (in years)
20 or more6769.07
Birth order
Second or more3536.08
Gender of the newborn
Types of delivery
Vaginal/Vaginal assisted4748.45
Caesarian section5051.55
Birth weight
<2.5 kg4445.36
2.5 kg or more5354.64
Preterm or not
No of antenatal visits
3 or more5152.58
Advice regarding breastfeeding received
EIBF initiated

Forty-six patients received advice from Auxiliary Nurse Midwife (ANM), 23 received advices from nurses, 11 received advices from ASHAs and only 3 from doctors. Though 58 (59.79%) mothers gave correct answers regarding the ideal time of breastfeeding, none of them had any knowledge regarding the advantages of EIBF [Table/Fig-3].

Knowledge regarding various aspects of breastfeeding (n=97).

QuestionNo of mothers who gave at least one correct answer% of mothers who gave at least one correct answer
Ideal time for breastfeeding5859.79
Ideal frequency of breastfeeding2020.62
Ideal duration of breastfeeding1919.59
Advantage of EIBF to mother00.00
Advantage of EIBF to baby3435.05
Advantage of EIBF in reducing neonatal death3940.21

To assess the factors associated with EIBF, several socio-demographic and clinical variables were at first subjected to bivariate analysis and subsequently multivariate analysis. Variables taken were: age, religion, residence, mother’s education, father’s education, mother’s occupation, age at marriage, age at first pregnancy, birth order, gender of newborn, type of delivery, birth weight, preterm or not, number of antenatal visits, advice regarding breastfeeding received or not. In the bivariate model, it was observed that education of mother, education of father, higher age at marriage, higher age at first pregnancy, vaginal/vaginal assisted delivery, higher birth weight, term/post-term, 3 or more antenatal visits and receiving advice regarding breastfeeding all facilitated early initiation of breastfeeding. However, in the multivariate model, it was noticed that education of mother, higher age at marriage, vaginal/vaginal assisted delivery and term/post-term baby were significant factors promoting EIBF [Table/Fig-4].

Logistic regression analysis to assess the factors associated with EIBF (n=97).

VariablesCategoriesEIBF done (59)EIBF not done (38)OR (95% CI)AOR (95% CI)
Age (in years)18-2436231.02 (0.44-2.35)
25 or more23151
ReligionHinduism40211.70 (0.74-3.95)
ResidenceRural31191.10 (0.49-2.50)
Education of motherPrimary or less173011
Secondary or above4289.26 (3.54-24.25)3.82 (1.95-10.22)
Education of fatherPrimary or less132011
Secondary or above46183.93 (1.62-9.53)2.06 (0.93-5.33)
Occupation of motherHome-maker55351.18 (0.25-5.59)
Per capita income<500050321
≥5000960.96 (0.31-2.95)
Age at marriage (in years)15-19122411
20 or more47146.71 (2.69-16.76)3.54 (2.12-8.69)
Age at first pregnancy (in years)15-1962411
20 or more531415.14 (5.19-44.20)6.87 (0.78-62.76)
Birth orderFirst34281
Second or more25102.06 (0.85-5.00)
Gender of newbornMale35171.80 (0.79-4.11)
Types of deliveryVaginal/Vaginal assisted3895.83 (2.33-14.61)3.99 (1.82-8.04)
Caesarian section212911
Birth weight<2.5 kg182611
2.5 kg or more41124.94 (2.05-11.90)2.71 (0.90-13.41)
Preterm or notPreterm132411
Term/post-term46146.06 (2.46-14.95)2.64 (1.43-11.26)
No. of antenatal visits2 or less133311
3 or more46523.35 (7.59-71.87)12.14 (0.78-59.13)
Advice regarding BF receivedYes54293.35 (1.03-10.94)1.58 (0.79-2.94)

AOR: Adjusted odds ratio; Nagelkerke r2: 0.475, indicating good model fitness


In the current study conducted in a tertiary care hospital, it was found that the practice of EIBF was prevalent among 60.82% of the study subjects. The study also shed light on various factors influencing EIBF.

An Indian study reported that 40% of the respondents initiated breastfeeding within 1 hour of birth [19]. Another study reported that 20% of their study subjects initiated breastfeeding within an hour while other 30% started breastfeeding their newborns after 24 hours [20]. A study conducted for estimating the prevalence of EIBF in Tamil Nadu, southern India reported an impressive value of 97.5% of their study subjects to have indulged in EIBF, which is way higher than the values of the present study [21]. Study conducted by El-Mouzan MI et al., showed that 23% of mothers practised EIBF while the same conducted by El-Gilany AH et al., showed that only 11.4% of mothers breastfed their infants within an hour of their birth [22,23]. Patel A et al., reported that among institution delivered infants in India, EIBF rates were 36.4% [24]. Key findings from some recent Indian studies on EIBF are shown in [Table/Fig-5] [14-18, 25-27].

Comparison of various Indian studies on EIBF [14-18,25-27].

Author nameYear of publicationSample sizeGeographic areaFindings
Babu RA et al., [14]2018216 mothersSouth-eastern region of IndiaEIBF in 3 (1.39%)Delay in rooming-in was major cause of delayFactors favouring EIBF: early rooming in, mother’s knowledge regarding breastfeeding
Bhanderi DJ et al., [15]2019330 mothersCentral Gujarat, IndiaEIBF in 218(66.1%)
Rao MVR and Fathima N [16]2018100 mothersTelengana, IndiaEIBF in 10%Causes of delayed initiation: unawareness, baby not roomed in
Senanayake P et al., [17]201994,104 women, from NFHS 4 dataAll over India41.5% EIBFBarriers to EIBF were: Caesarean deliveryNon-health professional assistanceRural regions of Central India
Sharma A et al., [18]2016210 mothersTribal area of Madhya Pradesh, IndiaEIBF in 38.6%Education and occupation of mothers, and mothers who received post-natal advice were most significant associations of EIBF
Subhadra KT [25]2018277 mothersRural part of Kerala, IndiaLess than 30% EIBF
Prasad KN and Ahmed N [26]2015350 babiesPondicherry, IndiaEIBF rate was 75%Factors favouring EIBF:Mother’s educationMother’s ageMode of delivery
Majra JP and Silan VK [27]2016FGD involving 34 nursing care providersHaryana, IndiaBarriers to EIBF: Lack of awareness, Inverted/retracted nipples,Obstetric/neonatal complications, cultural practices like giving pre-lacteals, gender discrimination.

The present study brings to light several factors having significant bearing on timely initiation of breastfeeding such as education of both the parents, age of the mother at marriage, age of the mother at first pregnancy, type of delivery conducted, and also if the mother went for antenatal visits during her pregnancy period and if she received any counselling or advice regarding the advantages and need for breastfeeding and EIBF. The present study revealed that among the study subjects, mothers who had received education of secondary level or more were 9.26 times more likely to conduct EIBF. Similarly, it is also seen in the present study that even education of secondary level or more in the father’s part increases the chances of EIBF by about 3.93 times. Education, in general, creates the sense of awareness, understanding and learning. These parents were more informed and concerned regarding the benefits that EIBF has for their child. Setegn T et al., reported that formal education receiving mothers were 1.4 times more likely to breastfeed their infants within the first hour of delivery than mothers who didn’t receive any formal education at all {OR: 1.4 (95% CI: 1.032.03)} [28]. Sandor M and Dalal K, revealed in their study that women without any education were 50% less likely to indulge in EIBF when compared to educated women [29]. Patel A et al. demonstrated mothers with higher education were more associated with EIBF (adjusted OR 2.00, 95% CI: 1.10-3.60) [24]. The present study has gone on to reveal both antenatal visits (OR: 23.35, 95% CI: 7.59-71.87) and mothers receiving advice regarding breastfeeding (OR: 3.35, 95% CI: 1.03-10.94) to have huge bearing on EIBF practice. At this juncture, education also happens to play a major part. The tendency of visiting health professionals for antenatal check-up during the antepartum period is in general seen more among the parents having received formal education. Wolde T et al., in his study showed antenatal visits to have a statistically significant outcome on EIBF [30]. Archana P et al., reported similar findings [24]. In the present centre, post-natal counselling was also regularly done by on-duty doctors and nurses; however, the quality of counselling lacks uniformity. Sharma A et al., reported in his study that prevalence of EIBF was more among mothers receiving counselling during antenatal visits (OR: 7.681, 95% CI: 1.750-33.711) and post-natal advices (OR: 31.271, 95% CI: 7.367-132.742) regarding breastfeeding [18].


The present study was limited by time and resource constraints. Sample size was relatively less. The percentage of patients practising EIBF derived from this study may be subject to Berkesonian (hospital) bias. This may be the reason for a relatively higher percentage of EIBF.


The present study has revealed various factors as education of mother, higher age at marriage, vaginal/vaginal assisted delivery and term/post-term baby were significant factors promoting EIBF. They significantly affect initiation of breastfeeding within one hour of birth of infants. Multicenter studies with larger sample size are required to further assess the impact of these factors on initiation of breastfeeding.

AOR: Adjusted odds ratio; Nagelkerke r2: 0.475, indicating good model fitness


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