Reasons for Delayed Breastfeeding Initiation among Newly Delivered Women in Two First-Category Hospitals in Yaoundé, Cameroon

Introduction: Exclusive breastfeeding is fundamental for the good health and development of the mother and the child. According to the World Health Organization (WHO), breastfeeding after childbirth should be initiated within 30 minutes. For a number of reasons, WHO recommendations on guiding principles for infants and young children feeding are often not followed. Ob-jective: To determine the reasons for the delayed initiation of breastfeeding in newly delivered women. Means and Method: We carried out a mixed cross-sectional study over a period of six months from December 1 st 2018 to May 31 st 2019, at the Yaoundé Gynaeco-Obstetric and Pediatric Hospital. We included all mothers with full-term or premature babies weighing ≥ 2000 grams and those whom initiated breastfeeding more than one hour after delivery. The mother’s reasons for delaying breastfeeding initiation were recorded using a dictaphone and data were accurately extracted for analysis. Results: We interviewed 153 mothers. Their mean age was 27.9 ± 6.2 years. The main reasons for delaying breastfeeding initiation were caesarean delivery (22%), the belief in “spoiled milk” (21%), lack of knowledge undertake the early initiation of breastfeeding in babies from mothers who deliver through caesarean section.


Introduction
The early initiation of breastfeeding (EIBF), or timely initiation of breastfeeding, may be defined as the starting of breastfeeding within the first hour following of childbirth [1]. According to the WHO, breastfeeding should take place within 30 minutes or an hour after childbirth [2] [3]. EIBF practice in low and middle-income countries is relatively higher than in developed countries [4]. Breastfeeding has been accepted as the easiest, effective and most successful intervention for the good physical and mental health of children [2] [5] [6] [7]. Recent studies in Ethiopia, Ghana, Bolivia and Madagascar found that breastfeeding could prevent up to 20% -22% of neonatal deaths [6] [7] [8]. In these countries, the average time for early breastfeeding initiation could reach up to an hour after delivery, but varied within this timeframe from one study to another. This rate was more than 70% in France and Canada in 2016 [9], 68.7% in Iran in 2016 [10] and 83.7% in Ethiopia in 2017 [11]. In the literature, numerous reasons have been put forward as possible explanations for the delay in breastfeeding, among which: the lack of knowledge of the nursing staff and mothers, the geographical origin of mothers, and delivery by caesarean section, just to name a few [9] [11] [12] [13]. In India in the year 2017, the reasons recorded from health workers were: the lack of knowledge about breastfeeding techniques, breast anomalies, obstetric and neonatal complications and cultural practices [12]. In Cameroon, according to observations made during our daily practice, the initiation of breastfeeding at birth seems to be long. However, there is scarcity of data in our context concerning the reason for this delay. This justifies the present study whose outcome may contribute to reinforce public health actions in the light of the results, in order to enhance the reduction of maternal and infant morbidity and mortality in Cameroon.

Means and Method
We conducted a mixed cross-sectional study with prospective data collection, over a six-month period from December 1 st , 2018 to May 31 st , 2019, in the gynecology and obstetrics departments of the Yaoundé Gynaeco-Obstetric and Pediatric Hospital, which is a referral and Teaching Hospital in Cameroon. We included all mothers of full-term or premature newborns weighing at least 2000 grams, who agreed to participate. Mothers with contraindications to breastfeeding and those with newborns presenting emergencies that needed urgent man-F. Nguefack et al. Open Journal of Pediatrics agement at birth, such as major digestive malformation, and neurologic problems with feeding disorders were excluded. As well as Mothers who chose mixed feeding including breastmilk and formula. Whereas, mothers who had initiated breastfeeding more than one hour after delivery were enrolled. The questionnaire was pretested at the maternity service of another hospital in Yaoundé, with standards similar to our study site. This permitted us to correct misunderstandings and complete information necessary for the reliability of the questionnaire, before its use. The questionnaire was then administered by three researchers among the authors of this research study. The sampling procedure was consecutive. The variables recorded were: age, occupation, level of education, region of origin, marital status. The reasons for breastfeeding delay were sought during an inclusive interview, in the course of which mothers could express themselves freely. We submitted the questionnaires to mothers individually. A Dictaphone was used to record the interviews. We analyzed the records and translated them in English. The analyses continued throughout the discussions as newly emerging themes were tested in subsequent discussions. Hence, the initial analysis was inductive and followed by the preparation of the utilization model to enhance the robustness of the emerged domain. Other variables collected in the questionnaire included socio-demographic characteristics of the mothers. The data pertaining to reasons evoked for delaying breastfeeding initiation were faithfully extracted for analysis after grouping them into four categories. These reasons were either related to mothers, the newborns, the medical staff or socio-cultural issues. Quantitative data were entered and analyzed using CS Pro version 6.2 software and SPSS version 20.0. Chi-square testing was used to establish statistical associations between the variables. Qualitative variables were integrated into a simple logistic regression model to determine the Odd Ratio. A p-value < 0.05 was considered statistically significant for all analyzes.
We defined early initiation of breastfeeding as the starting of breastfeeding within the first hour following childbirth. The newborn might have been clothed or not, skin-to-skin contact was however recommended in our context. Delayed breastfeeding was considered as the initiation of breastfeeding after the first hour of life.

Ethical Considerations
Ethical clearances from the Institutional Ethics and Research Committee of the Faculty of Medicine of the University of Yaoundé 1 and the Yaoundé Gynaeco-Obstetric and Pediatric Hospital were obtained before the beginning of the study. The data collected was kept strictly confidential and used only for the purposes of the study.

Results
We interviewed 153 mothers who had put their baby to the breast beyond the first hour of life.

Socio-Demographic Data
The mothers had an average age of 27.9 ± 6.2 years, and most of them originated from the Centre region (44.40%), and had secondary education level (43%) ( Table 1).

Reasons for the Delay of Breastfeeding Initiation
The same mother could mention several reasons (Table 2).

Mother-Related Reasons • Caesarean delivery
The majority of mothers who had a delay in breastfeeding initiation linked it to caesarean delivery (22.0%), although some (38.0%) had an acceptable milk flow, this reason was most of the time revealed by those who were not counseled.
For example, half of them said, "I didn't know that the baby was supposed to be put to the breast immediately, even after the caesarean delivery". Some mothers' reports were: "I thought that the effect of the anesthetic drugs should pass first before putting the baby to the breast"; others responded "I was afraid that the anesthetics would pass into the milk and cause my baby a worry".  • Ignorance about the time of breastfeeding initiation Ignorance (20.4%) was very often recorded in combination with other reasons. For example, some women said: "I never knew that the baby should be put to the breast within an hour after delivery". Some respondents linked the recommended breastfeeding time to the death of their infant, and this is a cultural belief in some localities. They responded "My first baby was breastfed early and died"; other mothers attached to common practices argued "I usually give to my babies formula first until I am well enough to breastfeed them", or "I always give to my babies formula first after delivery".
• No milk production This reason was very often related to unawareness, as these mothers did not know that lactation could also be influenced by breastfeeding. Some would wait for the milk secretion to be effective before putting the baby to the breast: "I would wait until the milk starts to flow before putting the baby to the breast, otherwise if I put the baby to the breast, it would get angry and cry even more". "And in the meantime I would give water/milk…" responded some women.
• Mother's refusal Some mothers (8.4%) refused to put the baby early on to the breast, for a variety of reasons: to avoid breasts damage, some responded "when I breastfeed the baby, my breasts will fall off…", some other women, because they were working mothers argued "I'm going to go out to work anyway so there's no need to put the baby to the breast now and then stopping when I go back to work".
Mothers who chose infants formula for medically proven reasons were also in- In such situations, a number of mothers were waiting for the baby wake-up before initiating breastfeeding and some of them declared: "When the baby sleeps like this, I too can rest and breathe a little before putting him to the breast".

Reasons Related to Health Care Providers
This was about instructions given to the mother by health care provider. Indeed, 3.6% of the mothers revealed that they had never received any instructions from the health personnel concerning the early initiation of breastfeeding. Meanwhile, 2.3% had been advised to stop worrying about breastfeeding, because there was no problem to delay its initiation, the reason being that the newborn has reserves that can hold until it is put to the breast, even if this was done later on. Some mothers (3.2%) with infectious diseases like HIV, hepatitis, were instructed to never breastfeed their baby.

Socio-Cultural Reasons
This concerned the "spoiled milk" issue, with almost 16.0% of mothers believing that their breastmilk was a danger for their newborn. Among these mothers with such beliefs, 3.6% had lost children and thought it was because of breastfeeding.

Discussion
The main limit of this survey is the fact that all possible descriptive analyses that  [20]. Hormones variations after caesarean section including the drop of endorphin, prolactin, and oxytocin blood levels have been incriminated for reducing galactorrhea and the desire to breastfeed during the immediate post-operative period [21]. If we admit an optimal rate of caesarean deliveries around 15% in our context, it may imply that, in the absence of considerable efforts to encourage breastfeeding, almost 15% of mothers will not initiate breastfeeding within the first hour after delivery. This mode of childbirth should not be an excuse for delaying breastfeeding initiation, especially in our limited-resource context, where health care is enormously expensive and cost-worthy. In such situations, anticipatory measures are recommended to promote breastfeeding within the time limit [22].  [26]. The lack of information may therefore account as well among the main reasons for the late initiation of breastfeeding. We found that up to 20.4% of the mothers interviewed, were unaware of the concept of early breastfeeding initiation, and so they could therefore not apply it. The lack of knowledge in our context may be due to the health system that fails to provide enough counselling on infant feeding to women [27]. There is a necessity to reach women and assist them throughout pregnancy, delivery and postpartum by skilled practitioners for reliable counseling and necessary interventions where need be [3] [11]. In Nigeria, the social support during childbirth has catalyzed the early breastfeeding initiation especially for first-time mothers [28]. In the present study, 3.6% of women with delayed breastfeeding mentioned that they had respected instruction given by the attending medical staff. This could reflect the lack of training or qualification of some delivery room staff on breastfeeding.
Furthermore, the low level of information was reinforced by socio-cultural believes such as the "spoiled or bad milk" concept in reference to colostrum, and the fear of "breast sagging", which all led to breastfeeding refusal in more than 8% of these women. Women with initial agalactorrhea were less receptive to the demand of continuous stimulation through repeated baby suckling of the breast, because of limited knowledge and misunderstandings [12] [23]. This wrong belief is frequently encountered in Cameroon, particularly in the Centre region, where some women rely on the fact that "their milk would be spoiled and not worthy to be given to their babies at the risk of "harming or even killing them".
These mothers generally refer to a previous death of a newborn who had been breastfed, and unfortunately link this death to the early intake of breastmilk.
However, in addition to being a cause of delayed breastfeeding initiation, false beliefs in the long term may lead to a total absence of breastfeeding with all the complications that can result from it [29].

Conclusion
Despite the WHO recommendations and its innumerable benefits [30], the delay in initiating breastfeeding at birth is a glaring reality in our context. It is crucial that health care providers reinforce efficient interventions by encouraging skin-to-skin contact between mother and newborn immediately after birth in order to take advantage of the early initiation of breastfeeding. Particular emphasis should be placed on supporting mothers who give birth through caesarean section and mothers from the Centre region of our country who strongly believe in the theory of "spoiled milk". This also requires individual communication by trained health workers on breastfeeding directives.