Berde and Yalcin BMC Pregnancy and Childbirth (2016) 16:32

DOI 10.1186/s12884-016-0818-y

RESEARCH ARTICLE Open Access

Determinants of early initiation of

breastfeeding in Nigeria: a population-
based study using the 2013 demograhic
and health survey data
Anselm S. Berde1* and Siddika Songül Yalcin2

Abstract
Background: Provision of mother’s breast milk to infants within one hour of birth is referred to as Early Initiation of
Breast Feeding (EIBF) which is an important strategy to reduce perinatal and infant morbidities and mortality. This
study aimed to use recent nationally representative survey data to identify individual, household and community
level factors associated with EIBF and to update on previous knowlegde with regards to EIBF in Nigeria.
Methods: We used cross-sectional data from the 2013 Nigerian Demographic and Health Survey (NDHS). Chi-square
tests and binary logistic regression were used to test for association between EIBF and individual, household and
community level factors.
Result: The proportion of infants who initiated breastfeeding within 1 h of birth was 34.7 % (95 % Confidence
Interval (CI): 33.9–35.6). In the multivariate analysis, mothers who delivered in a health facility were more likely to
initiate breastfeeding early as compared to mothers who delivered at home (Adjusted Odds Ratio (AOR) =1.40,
95 % CI = 1.22–1.60). The odds of EIBF was three times higher for mothers who had vaginal delivery as compared
to mothers who had caesarean section (AOR = 3.08, 95 % CI = 2.14–4.46). Other factors that were significantly
associated with increased likelihood of EIBF were; multiparity, large sized infant at birth, not working mothers
as compared to mothers working in sales and other sectors, wealthier household index and urban residence.
Mothers in the South West were less likely to inititiate breastfeeding within 1 h of birth as compared to the North
West, however, the following geopolitical zones; North East, North Central, and South South had higher likelihood
of EIBF when compared to the North West geopolitical zone.
Conclusion: EIBF in Nigeria is not optimal with just about 34.7 % of children initiating breastfeeding within one
hour of birth, the results suggest that breastfeeding programmes and policies should give special attention to
“rural mothers, working mothers, primiparous mothers, mothers with ceasarean deliveries, home deliveries and
poor mothers” and this intervention should cut across geopolitical zones with more emphasis to zones with
lower rates of EIBF.
Keywords: Initiation of breastfeeding, Nigeria, Mothers, Infants

* Correspondence: [email protected]
1
Institute of Public Health, Hacettepe University, Ankara, Turkey
Full list of author information is available at the end of the article

© 2016 Berde and Yalcin. 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.
Berde and Yalcin BMC Pregnancy and Childbirth (2016) 16:32 Page 2 of 9

Background [17], prevalence from national studies done in Nigeria

Breastfeeding is a foundation practice for appropriate report low figures for EIBF with just about 31.9 and
care and feeding of newborn infants [1] and has nutri- 38.4 % of mothers initiating breastfeeding within 1 h of
tional, immunological, developmental, psychological, so- birth in 2003 and 2008 respectively [18, 19].
cial, economic and environmental benefits for infants, Previous studies have shown that EIBF is multi-
mothers, families and society [2]. Provision of mother’s factorial in nature and involves factors such as mother’s
breast milk to infants within one hour of birth is re- age, education, place of residence and health service
ferred to as “Early Initiation of Breast Feeding (EIBF)” utilization such as antenatal care (ANC) visits and place
[3]. This practice ensures that the infant receives colos- of delivery [3, 12, 13, 20, 21]. In Nigeria, there is a need
trum which is rich in immunoglobulin (Ig) and other for a more detailed understanding of the factors associ-
bioactive molecule, including growth factors that are ated with EIBF at the national level, so as to help design
important for nutrition, growth and development of programs aimed at increasing breastfeeding initiation
newborn infants and also for passive immunity [4]. within 24 h of birth. This study aimed to use recent na-
Clemens et al. [5] in a cohort study done in rural Egypt tionally representative survey data to identify individual,
found that EIBF was associated with marked reduction household and community level factors associated with
in the rate of diarrhea throughout the first 6 months of EIBF and to update on previous knowledge with regards
life possibly because of the salutary effects of human col- to EIBF in Nigeria.
ostrum. Furthermore, EIBF enhances “Maternal-infant
Bonding” defined as the development of the core rela- Methods
tionship between mother and child which begins in early In this study, we used data from the 2013 Nigerian
infancy and continues over the next few years with tre- Demographic and Health Survey (NDHS). It is the fifth
mendous implications for the child’s future development and most recent in the series of Demographic and
[6]. In addition, infants breastfed within 30 min of birth Health Surveys conducted so far in Nigeria. The 2013
are likely to remain breast fed for a longer period of time NDHS sample was selected using a stratified three-stage
[7]. Research findings in Ghana and Nepal, showed that cluster design consisting of 904 clusters, 372 in urban
approximately one-fifth of all neonatal deaths could be areas and 532 in rural areas. Further details of the sam-
avoided if breastfeeding were initiated within the first pling techniques and data collection method can be
hour of life for all newborns [8, 9]. Furthermore, EIBF is found in the DHS manual [17]. Analysis for this study
also beneficial to mothers as it decreases postpartum was restricted to mothers with last-born children born
bleeding and is associated with rapid uterine involution in the past two years preceeding the survey and the total
due to increase concentrations of oxytocin [10]. sample size was 11851. After accounting for sample
Over the years, the United Nations Children’s Fund weights, this corresponded to a sample size of 11910.
(UNICEF) and World Health Organisation (WHO) have
promoted EIBF as an important strategy to reduce peri- Definition of variables
natal and infant morbidities and mortality through pro- In the NDHS woman’s questionnaire, mothers were
grammes such as the Baby Friendly Hospital Initiative asked “How long after birth did you first put (NAME) to
(BFHI), Community Integrated Management of Child- the breast?” Responses were recorded in number of
hood Illness (C-IMCI) and Infant and Young Child hours or days [17]. Our outcome variable “EIBF” was de-
Feeding (IYCF) [3, 10, 11]. In Nigeria, the Federal Minis- fined as initiation of breastfeeding within 1 h of birth
try of Health in conjunction with UNICEF and WHO and was expressed as a dichotomous variable with cat-
launched the BFHI in 1992 to protect, promote and sup- egory 1 for initiation of breastfeeding within 1 h (early)
port breastfeeding in Nigeria [12]. The initiative pre- and category 0 for initiation of breastfeeding after 1 h
sumes that most mothers would come in contact with (late). The explanatory factors were choosen based on
these specially designated hospitals and be exposed to previous studies [12, 13, 20, 21] and grouped into indi-
better education on breastfeeding [13]. However, the re- vidual, household and community level characteristics.
ported pattern of maternal health service utilization in Some of the variables were recoded while others were
Nigeria is low [14] and this may serve as a major hin- adopted as reported in the 2013 NDHS. Explanatory var-
drance to the initiative. In addition to the BFHI, there iables included ungrouped mothers age at birth recoded
are other programmes promoting EIBF in Nigeria such into “<=19”, “20–24”, “25–29”, “30–34” and “> = 35”
as the national policy on IYCF and the C-IMCI [15, 16]. years. Mothers education was categorized as “no educa-
UNICEF has rated the overall national IYCF policy, tion”, “primary”, “secondary and above”. Birth order was
strategy and plan of action as fair [15]. recoded into “1st”, “2nd–3rd” and “4th and above birth
Though, breastfeeding is almost universal in Nigeria, order”. Number of ANC visit was recoded into “0”, “1–
with 97.9 % of all children breastfed for a period of time 3”, “4 and above visit”. Place of delivery was categorized
Berde and Yalcin BMC Pregnancy and Childbirth (2016) 16:32 Page 3 of 9

as “home” and “health facility”. Also considered was singleton (98.3 %). Approximately 57.2 % of mothers
mode of delivery (“normal” or “caesarean”). Sex of child were employed in sales and other sectors and about
was as reported in the 2013 NDHS (“male”-“female”). 23.2 % of mothers belonged to the poorer wealth quin-
Size of child at birth based on mothers perception was tile. The distribution also showed that a larger propor-
categorized into three groups namely; “large”, “average” tion of mothers (67 %) lived in rural area. Furthermore,
and “small”. Birth type was recoded into “singleton” or the highest proportion of mothers were from the North
“twin/multiple” while mothers education was recoded West (31.2 %) and North East (20.4 %) geopolitical zones
into three groups; “no education”, “primary”, “secondary respectively.
and above”. Mothers occupation was categorized into “not
working”, “agricultural”, “sales and others”. DHS wealth Results of bivariate analysis
index was as reported in 2013 NDHS (“poorest”, “poorer”, A total of 4138 mothers, initiated breastfeeding within
“middle”, “richer” and “richest”), the index was con- one hour of birth (weighted proportion 34.7 %; 95 % CI:
structed using household asset data via a principal compo- 33.9–35.6). The bivariate analysis revealed that EIBF was
nents analysis. Place of residence was as reported in the significantly higher among mothers who delivered in a
2013 NDHS (“urban”-“rural”). In terms of zones, all the health facility (42 %) as compared to 30.4 % of mothers
six geopolitical zones in the country were considered. who delivered at home (p < 0.001). Also, mothers with
2nd–3rd and 4th and above birth order had significantly
Statistical analysis (p = 0.013) higher figures with regards to EIBF (36.2 and
Chi square tests were performed to evaluate the associ- 34.7 % respectively) as compared to mothers with 1st
ation of the independent variables with EIBF. Rate of birth (32.5 %). Increasing mothers age (p < 0.001), higher
EIBF and distribution by different independent variables educational status (p < 0.001), increasing ANC visit (p <
were reported as weighted percentages and 95 % CI 0.001), vaginal delivery (p < 0.001), increasing size of child
using Stata version 13 and then further assessed by bin- at birth (p < 0.001), singleton birth (p = 0.046), not working
ary logistic regression to examine the likely predictors of (p < 0.001), wealthier household wealth index (p < 0.001),
EIBF in Nigeria. Unadjusted and adjusted odds ratios urban residence (p < 0.001) and all zones as compared to
(OR) with their 95 % confidence interval (CI) were the North Western zone (p < 0.001) were all significantly
reported. The multivariate analysis accounted for the associated with higher EIBF rate (Table 1).
sample design and sample weight using Statistical Pack-
age for Social Sciences (SPSS) complex sample analysis Multivariate analysis
method [22] (SPSS version 21). Results from the multivariate analysis (Table 2) indicated
that place of delivery, mode of delivery, birth order, size
Ethics of child at birth, mothers occupation, household wealth
The study was a secondary analysis of freely available index, type of place of residence and zones were the de-
data, as such, no formal ethical clearance was required. terminants of EIBF. Mothers who delivered in a health
Permission to use and analyse the dataset was obtained facility were more likely to initiate breastfeeding within
by registering the study (Project number 64273) on the 1 h of birth as compared to mothers who delivered at
Demographic and Health Survey (DHS) website. home (Adjusted Odds Ratio (AOR) = 1.40, 95 % Confi-
dence Interval (CI) =1.22–1.60). The odds of EIBF was 3
Results times higher for mothers who had vaginal delivery as
Socio-demographic characteristics of the mothers compared to mothers who had caesarean section (AOR =
A total of 11851 mothers with last born children within 3.08, 95 % CI = 2.14–4.46). Likewise, the odds of EIBF was
the past two years preceeding the survey were consid- 1.19 times higher for mothers who perceived their infants
ered for the analysis. As summarized in Table 1, most to be large sized at birth as compared to mothers who per-
mothers where within the age group 20–24 and 25–29 ceived their infants to be small sized at birth (AOR = 1.19,
years at the time of birth (24.9 % and 27.3 % repectively). 95 % CI = 1.03–1.39). Urban mothers were more likely to
The highest proportion of mothers had no education commence breastfeeding early as compared to their rural
(45.4 %) and the highest percentage of mothers (48.2 %) counterpart (AOR 1.46, 95 % CI = 1.23–1.75). Compared
had 4th or higher order births. Over half (53.2 %) of to the North Western zone, mothers who lived in the fol-
mothers had at least 4 ANC visit. Of the total births, lowing geopolitical zones of Nigeria were significantly
38 % took place in a health facility. The highest propor- more likely to initiate breastfeeding within 1 h of birth:
tion of deliveries (97.8 %) were vaginal and male and North East (AOR = 1.69, 95 % CI = 1.38–2.07); North
female children were more or less equal in the sample. Central (AOR = 1.93, 95 % CI = 1.56–2.39); and South
44.1 % of mothers percieved the size of their child at South (AOR = 1.42, 95 % CI = 1.12–1.81); with the excep-
birth as large and the highest proportion of birth were tion of the South West (AOR = 0.56, 95 % CI = 0.43–0.73).
Berde and Yalcin BMC Pregnancy and Childbirth (2016) 16:32 Page 4 of 9

Table 1 Individual, household, community level characteristics and rates (%) of initiation of breastfeeding within one hour of child
birth, Nigeria 2013 (N = 11851)
Characteristics Total Initiation of breastfeeding within 1 h of birth
a b
N % nc %d 95 % CI p valuee
Individual level factors
Mother’s age at birth
<=19 1661 14.0 526 30.3 (28.2–32.5) <0.001
20–24 2953 24.9 1002 34.0 (32.3–35.7)
25–29 3237 27.3 1190 36.3 (34.6–36.9)
30–34 2119 17.9 772 36.8 (34.7–38.8)
> = 35 1881 15.9 649 35.1 (32.9–37.2)
Mothers education
No education 5379 45.4 1702 30.0 (28.8–31.2) <0.001
Primary 2290 19.3 789 36.8 (34.8–38.9)
Secondary and above 4182 35.3 1647 40.2 (38.7–41.7)
Birth order
1st 2331 19.7 774 32.5 (30.6–34.4) 0.013
2nd–3rd 3807 32.1 1392 36.2 (34.7–37.7)
4th and above 5713 48.2 1972 34.7 (33.5–35.9)
ANC visit (n = 11553)
0 3837 33.2 1083 27.6 (26.1–28.9) <0.001
1–3 1573 13.6 580 36.8 (34.4–39.1)
4+ 6143 53.2 2343 38.3 (37.1–39.6)
Place of delivery (n = 11846)
Home 7339 62.0 2266 30.4 (29.4–31.5) <0.001
Health facility 4507 38.0 1872 42.0 (40.5–43.4)
Mode of delivery (n = 11771)
Vaginal delivery 11508 97.8 4057 35.1 (34.2–35.9) <0.001
Caesarean section 263 2.2 56 22.4 (17.1–27.4)
Sex of child
Male 6021 50.8 2076 34.7 (33.5–36.0) 0.985
Female 5830 49.2 2062 34.8 (33.5–36.0)
Size of child at birth (n = 11791)
Small 1811 15.4 536 29.5 (27.4–31.6) <0.001
Average 4776 40.5 1608 33.3 (32.0–34.7)
Large 5204 44.1 1977 37.9 (27.4–31.6)
Birth type
Singleton 11654 98.3 4081 34.9 (34.0–35.7) 0.046
Twin/mutiple 197 1.7 57 27.9 (21.8–34.1)
Mothers occupation (n = 11789)
Not working 3704 31.4 1368 36.6 (35.0–38.1) <0.001
Agricultural 1341 11.4 461 37.6 (34.9–40.3)
Sales and others 6744 57.2 2295 33.3 (32.2–34.4)
Berde and Yalcin BMC Pregnancy and Childbirth (2016) 16:32 Page 5 of 9

Table 1 Individual, household, community level characteristics and rates (%) of initiation of breastfeeding within one hour of child
birth, Nigeria 2013 (N = 11851) (Continued)
Household level factors
Wealth Index
Poorest 2618 22.1 646 23.4 (21.8–25.0) <0.001
Poorer 2754 23.2 849 31.3 (29.5–33.0)
Middle 2368 20.0 854 37.9 (35.9–39.9)
Richer 2207 18.6 932 43.5 (41.4–45.6)
Richest 1904 16.1 858 41.9 (39.8–44.1)
Community level factors
Type of place of residence
Urban 3908 33.0 1766 41.9 (40.4–43.4) <0.001
Rural 7943 67.0 2372 30.8 (29.8–31.8)
Zone
North Central 1739 14.7 790 48.3 (45.8–50.7) <0.001
North East 2420 20.4 816 39.9 (37.8–42.1)
North West 3699 31.2 1171 26.9 (25.6–28.2)
South East 1076 9.1 374 34.5 (31.7–37.4)
South South 1431 12.1 506 45.1 (42.2–48.0)
South West 1486 12.5 480 28.7 (26.5–30.8)
Overall 11851 100.0 4138 34.7 (33.9–35.6)
a
Unweighted case numbers (the numbers and percentages reported are unweighted to facilitate reading as weighted count (frequency) will be in decimal points
generated by the software). bUnweighted column %, cWeighted case numbers, d Weighted row %. eChi square test was applied to test statistical significance

Furthermore, mothers with 1st birth had lower odds for India (24.5 %) and China (23.2 %) [24]. These variations
EIBF as compared to mothers who had 2nd–3rd and 4th observed among countries might partly be attributed to
and above birth order (AOR = 1.25, 95 % CI = 1.06–1.46 cross-cultural difference in breastfeeding practice, for
and AOR = 1.26, 95 % CI = 1.05–1.51, respectively). Ac- instance; Oche et al. [12] in their study found that the
cording to the findings of our study, mothers who were major reason for late initiation of breastfeeding in
working in sales and other sectors were less likely to com- Kware, Northern Nigeria, was that most of the respon-
mence breastfeeding within 1 h of birth as compared to dents believed colostrum was not pure and therefore
mothers who were not working (AOR = 0.81, 95 % CI = could harm the infant [12]. Another study confirmed
0.71–0.91). Also, mothers from the poorest households that a mothers decision to initiate and continue breast-
were less likely to commence breastfeeding early as com- feeding was determined by the perceived breastfeeding
pared to mothers from poorer (AOR = 1.41, 95 % CI = culture of her environment [25].
1.15–1.73); middle (AOR = 1.61, 95 % CI = 1.27–2.04); We found statistically significant associations between
richer (AOR = 2.01, 95 % CI = 1.57–2.58) and richest EIBF and the following variables; birth order, place of
(AOR = 1.92, 95 % CI = 1.42–2.59) households. The fol- delivery, mode of delivery, size of child at birth, mothers
lowing variables were not significantly related to EIBF; occupation, household wealth index, place of residence
Mothers age at birth, mothers education, ANC visit, and and region. Similar findings were observed by Babatunde
birth type. and Adebayo [26] in a trend analysis of EIBF rate in
Nigeria between 1990 and 2008, however, their study did
Discussion not control for mothers occupation, household wealth
According to the WHO, 0–29 % prevalence of EIBF is and size of child at birth.
considered as poor, 30–49 % as fair, 50–89 % as good In our study, mothers who delivered in a health facility
and 90–100 % as very good [23]. Our result showed that were significantly more likely to inititate breastfeeding
the prevalence of EIBF EIBF in Nigeria is fair and stand within 1 h of birth as compared to mothers who deliv-
at 34.7 %. The prevalence of EIBF observed in our study ered at home. This is not surprising since many of the
is much lower than what is observed in some African Primary Health Care Centers and hospitals in Nigeria
countries such as Ghana (46 %), Gambia (48 %) and have adopted the BFHI and the policy in those health
Malawi (56 %) but much higher than in Pakistan (29 %), care facilities is for the midwife or any other available
Berde and Yalcin BMC Pregnancy and Childbirth (2016) 16:32 Page 6 of 9

Table 2 Factors associated with early initiation of breastfeeding, Nigeria, 2013

Characteristic Initiation of breastfeeding within 1 h of birth
Unadjusted OR Adjusted OR
OR 95%CI p value AOR 95%CI p value
Mother’s age at birth
<=19 1.00 1.00
20–24 1.18 (1.01–1.39) 0.042 0.95 (0.79–1.14) 0.547
25–29 1.31 (1.10–1.55) 0.002 1.10 (0.89–1.36) 0.359
30–34 1.33 (1.12–1.59) 0.001 1.08 (0.85–1.36) 0.535
> = 35 1.24 (1.04–1.47) 0.017 1.07 (0.84–1.38) 0.570
Mothers education
No education 1.00 1.00
Primary 1.36 (1.18–1.57) <0.001 0.99 (0.85–1.16) 0.928
Secondary and above 1.57 (1.37–1.79) <0.001 1.02 (0.86–1.21) 0.801
Birth order
1st 1.00 1.00
2nd–3rd 1.18 (1.02–1.35) 0.024 1.25 (1.06–1.46) 0.007
4th and above 1.10 (0.98–1.25) 0.121 1.26 (1.05–1.51) 0.013
ANC visit
0 1.00 1.00
1–3 1.53 (1.41–1.90) <0.001 1.08 (0.89–1.30) 0.425
4+ 1.64 (1.27–1.84) <0.001 1.07 (0.91–1.27) 0.419
Place of delivery
Home 1.00 1.00
Health facility 1.65 (1.47–1.86) <0.001 1.40 (1.22–1.60) <0.001
Mode of delivery
Caesarean section 1.00 1.00
Vaginal delivery 1.88 (1.31–2.71) 0.001 3.08 (2.14–4.46) <0.001
Size of child at birth
Small 1.00 1.00
Average 1.20 (1.04–1.38) 0.015 1.07 (0.93–1.24) 0.348
Large 1.45 (1.25–1.70) <0.001 1.19 (1.03–1.39) 0.023
Birth type
Twin/mutiple 1.00 1.00
Singleton 1.37 (0.96–1.97) 0.078 1.33 (0.92–1.92) 0.133
Mothers occupation
Not working 1.00 1.00
Agricultural 1.04 (0.87–1.26) 0.650 0.90 (0.73–1.12) 0.359
Sales and others 0.87 (0.78–0.96) 0.008 0.81 (0.71–0.91) 0.001
Wealth Index
Poorest 1.00 1.00
Poorer 2.37 (1.90–2.95) <0.001 1.41 (1.15–1.73) 0.001
Middle 2.51 (2.06–3.09) <0.001 1.61 (1.27–2.04) <0.001
Richer 2.00 (1.62–2.48) <0.001 2.01 (1.57–2.58) <0.001
Richest 1.49 (1.22–1.83) <0.001 1.92 (1.42–2.59) <0.001
Berde and Yalcin BMC Pregnancy and Childbirth (2016) 16:32 Page 7 of 9

Table 2 Factors associated with early initiation of breastfeeding, Nigeria, 2013 (Continued)
Type of place of residence
Rural 1.00 1.00
Urban 1.62 (1.43–1.85) <0.001 1.46 (1.23–1.75) <0.001
Zone
North West 1.00 1.00
North East 1.81 (1.48–2.20) <0.001 1.69 (1.38–2.07) <0.001
North Central 2.53 (2.09–3.06) <0.001 1.93 (1.56–2.39) <0.001
South East 1.43 (1.13–1.82) 0.003 0.75 (0.56–1.01) 0.061
South South 2.23 (1.81–2.73) <0.001 1.42 (1.12–1.81) 0.004
South West 1.09 (0.89–1.33) 0.401 0.56 (0.43–0.73) <0.001

skilled providers to encourage and assist in the process In addition, this study showed that small sized babies
of achieving earlier initiation as defined by the BFHI tar- were less likely to commence breastfeeding within 1 h of
get [27]. In a study done in Port-Harcourt, in the South birth as compared to large sized infants and the finding
South geopolitical zone of Nigeria, the authors observed was similar to what was observed in Turkey and Brazil
that the presence of more than one delivery assistance as [31, 32]. One of the possible explanation for this finding
well as the presence of a breastfeeding trained delivery is that depending on birth weight, premature children
assistance in a health facility enhanced the mothers have peculiarities and specific characteristics related to
practice of EIBF [20]. However, the rate of EIBF among their own immaturity which may limit the abilities
mothers who delivered in a health facility as reflected in needed for breastfeeding within the first hour of life,
our study is still low (42 %). Awi et al. in a study done at such as good coordination of the suction-deglutition-
Port Harcout found an EIBF rate of 33.6 % among respiration cycle and the breast-seeking reflex [33]. On
mothers who delivered in the hospital and had vaginal the other hand, large sized babies may be perceive as
delivery and none among mothers who had caesarean healthy and fully matured with good coordination of the
section. They observed that routine labour ward prac- suction-deglutination-respiratory cycle and breast seek-
tices and help recieved to initiate breastfeeding where ing reflex and therefore, may lead to initiating early
the most important determinants of EIBF as compared breastfeeding [21].
to sociodemographic variables in a hospital setting [20]. Association between breastfeeding and socioeconomic
In Nigeria, under staffing and over worked health care status (SES) are complex as differing aspects of SES may
staff in health facilities might play a significant row in be associated with knowledge, attitudes, experiences,
delaying EIBF. There is a need for a more detailed study and beliefs leading a woman to a particular infant feed-
on factors associated with lower rates of EIBF observed ing practice [34]. Among the measures of SES are; occu-
among mothers who delivered in a health facility. pation, household wealth index and education [34, 35].
The result of this study revealed that mothers who had In our study, mothers occupation had a strong influence
vaginal delivery were more likely to inititiate breastfeed- on EIBF. Mothers who were working in sales and other
ing within 1 h of birth as compared to mothers who had sector were less likely to initiate breastfeeding early as
caesarean section and this finding is comparable to a compared to mothers who were not working, this is in
study done by Rajan [28]. The difference between the consonance with a previous study done by Fein and Roe
two groups could be explained by the morbidity associ- [36] which revealed that full time employment de-
ated with ceasearean section, the effect of anesthesia, creased breastfeeding initiation and duration. On the
the emotional adjustment to the fact that the mother other hand, the finding in this study was different
was unable to deliver normally and the exhaustion from from what was observed in Turkey [31]. The Turkish
a difficult labour that may have included many other study showed that working status had no effect on
intervention [20, 29]. initiation of breastfeeding, however, the association
We also observed a positive association between birth between maternal employment and initiation of
order and EIBF. In consonance, Lessen et al. [30] re- breastfeeding has not been uniform and raises the
ported that previous breastfeeding experience was posi- need for further investigation.
tively associated with both intention and initiation of Our results indicates that mothers from wealthier
breastfeeding, and the number of children was positively households were more likely to commence breastfeeding
associated with initiation and inversely associated with early as compared to mothers from poorest household.
intention to breastfeed. Similar result have being observed in a previous study
Berde and Yalcin BMC Pregnancy and Childbirth (2016) 16:32 Page 8 of 9

which revealed that richer household wealth was associ- health facilities as compared to mothers who delivered at
ated with increased likelihood of EIBF [37]. home. Futhermore, zonal variations in EIBF need to be
Our findings showed that occupation and household researched further.
wealth index were the significant SES variables that were
associated with EIBF, maternal education on the other Strength and limitations
hand was not. This contradicts a study done in Nepal EIBF was based on self-report. This is a potential source
which indicate that both maternal education and occu- of measurement bias in the outcome, where mothers
pation had significant effect on EIBF, whereas, household may incorrectly recall when the child initiated breast-
wealth index was observed not to be significantly related feeding. The findings are also based on cross-sectional
to EIBF [21]. A more detailed research might attempt to data and therefore caution must be exercised in making
measure all aspects of SES to discern which dimenstions causal influence of the identified determinants of EIBF.
play’s the most important roles with regards to EIBF in However, the study has a strength of being a nationally
Nigeria. representive study.
We observed that urban mothers were more likely to
initiate breastfeeding within 1 h of birth as compared to Conclusion
mothers in rural area, this is in consonance with a previ- Overall, this research have shown that in Nigeria, breast-
ous study [38]. In rural areas, lower levels of education, feeding initiation within 1 h of birth is not optimal and
incomes, lack of health insurance and access restrictions EIBF programmes and policies should focus on; rural
to health care may partly explain why breastfeeding initi- mothers, working mothers, primiparous mothers, mothers
ation rates may differ for mothers in rural as compared with ceasarean deliveries, mothers with home deliveries
to urban areas. and poor mothers.” It is also important that this interven-
The odds of mothers inititiating breastfeeding within tions cut across geopolitical zones with more emphasis to
1 h of birth were relatively low in the South South as zones with lower rates of EIBF.
compared to the North West, however the following
Competing interests
geopolitical zones; North East, North Central, and South The authors declare that they have no competing interests.
South had higher likelihood of EIBF as compared to the
North West geopolitical zone. Such regional differences Authors’ contributions
SSY designed and supervised the study, ASB wrote the manuscript.
in breastfeeding practice have been observed in previous
SSY made contributions to the interpretation of results and revised
studies done in other countries [21, 37]. In Nepal for in- the manuscript. Both authors read and approved the final version.
stance, the authors attributed the variations within re-
gions to differing regional availability of infant formula Acknowledgements
The authors acknowledge Measure DHS for making available the 2013 NDHS
and television advertisements, difficult terrain, poverty data set for this study.
status and lower socioeconomic development indicators
[21]. In Nigeria, the large geographic variation in EIBF Author details
1
Institute of Public Health, Hacettepe University, Ankara, Turkey. 2Department
(especially low rates in the North West and high rates in of Social Peadiatrics, Hacettepe University, Ankara, Turkey.
North Central region) need to be studied further.
Received: 31 March 2015 Accepted: 26 January 2016

Policy and practice implication

Neonatal, infant and child mortality as well as malnutri- References
tion continue to be major health issues affecting Nigeria. 1. Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions
for improving perinatal and neonatal health outcomes in developing
Nigeria’s neonatal mortality rate stands at 37 deaths per countries: a review of the evidence. Pediatrics. 2005;115:519–617.
1000 live births [17] and EIBF rates in Nigeria as envi- 2. Anatolitou F. Human milk benefits and breastfeeding. J Pediatr Neonat
dence in our study is below the WHO recommendation. Individual Med. 2012;1:11–8.
3. United Nations Children’s Fund (UNICEF). Infant and Young Child Feeding:
A substantial increase in EIBF rate can be achieved in Programme Guidance. New York: UNICEF; 2011.
Nigeria by promoting hospital deliveries. Also, EIBF pro- 4. Godhia ML, Patel N. Colostrum - its Composition, Benefits as a Nutraceutical
motion programmes should target all mothers, but with - A Review. Curr Res Nutr Food Sci. 2013;1:37–47.
5. Clemens J, Elyazeed RA, Rao M, Savarino S, Morsy BZ, Kim Y, et al. Early
special focus given to primiparous mothers, poor mothers, initiation of breastfeeding and the risk of infant diarrhea in rural Egypt.
rural mothers and working mothers. In addition, breast- Pediatrics. 1999;104, e3.
feeding interventions as they pertain to EIBF should cut 6. Himani BK, Praveen K. Effect of initiation of breastfeeding within one hour of
the delivery on maternal-infant bonding. Nurs Midwifery Res J. 2011;7:99–109.
across zones with more empasis to zones with lower rates 7. Perez-Escamilla R, Pollitt E, Lönnerdal B, Dewey KG. Infant feeding policies
of EIBF. Future research should focus on the low rates of in maternity wards and their effect on breast-feeding success: an analytical
EIBF observed among mothers who delivered in health overview. Am J Public Health. 1994;84:89–97.
8. Edmond KM, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-Agyei S,
facilities even though the rate of EIBF was observed to be Kirkwood BR. Delayed breastfeeding initiation increases risk of neonatal
considerable higher among mothers who delivered in mortality. Pediatrics. 2006;117:e380–6.
Berde and Yalcin BMC Pregnancy and Childbirth (2016) 16:32 Page 9 of 9

9. Mullany LC, Katz J, Li YM, Khatry SK, LeClerq SC, Darmstadt GL, et al. Breast- 33. Walker M. Breastfeeding the late preterm infant. J Obstet Gynecol Neonatal
feeding patterns, time to initiation, and mortality risk among newborns in Nurs. 2008;37:692–701.
southern Nepal. J Nutr. 2008;138:599–603. 34. Heck KE, Braveman P, Cubbin C, Chavez GF, Kiely JL. Socioeconomic status
10. American Academy of Pediatrics. Workgroup on Breastfeeding. Breastfeeding and breastfeeding initiation among California mothers. Public Health Rep.
and the Use of Human Milk. Pediatrics. 1997;100:1035–9. 2006;121:51–9.
11. World Health Organization (WHO), UNICEF. Handbook IMCI Integrated 35. Vyas S, Kumaranayake L. Constructing socio-economic status indices: how
Management of Childhood Illness. Geneva: WHO; 2005. to use principal components analysis. Health Policy Plan. 2006;21:459–68.
12. Oche MO, Umar AS, Ahmed H. Knowledge and practice of exclusive 36. Fein SB, Roe B. The effect of work status on initiation and duration of
breastfeeding in Kware, Nigeria. Afr Health Sci. 2011;11:518–23. breast-feeding. Am J Public Health. 1998;88:1042–6.
13. Ogunlesi TA, Dedeke IO, Okeniyi JA, Oyedeji GA. The impact of the baby 37. Mihrshahi S, Kabir I, Roy SK, Agho KE, Senarath U, Dibley MJ, et al.
friendly hospital initiative on breastfeeding practices in Ilesa. Niger J Paed. Determinants of infant and young child feeding practices in Bangladesh:
2005;32:46–51. secondary data analysis of Demographic and Health Survey 2004. Food
14. Idris SH, Sambo MN, Ibrahim MS. Barriers to utilisation of maternal health Nutr Bull. 2010;31:295–313.
services in a semi-urban community in northern Nigeria: The clients’ 38. Thu HN, Eriksson B, Khanh TT, Petzold M, Bondjers G, Kim CN, et al.
perspective. Niger Med J. 2013;54:27–32. Breastfeeding practices in urban and rural Vietnam. BMC Public Health.
15. UNICEF. Infant and Young Child Feeding Programming Status, Results of 2012;12:964.
2010–2011 assesment of key actions for comprehensive infant and young child
feeding programmes in 65 countries. http://www.unicef.org/nutrition/files/IYCF_
65_country_assessment_report_UNICEF.pdf Accessed September 22, 2015.
16. Ebuehi OM. Health care for under-fives in Ile-Ife, South-West Nigeria: effect
of the integrated management of childhood illnesses (IMCI) strategy on
growth and development of under-five. Afr J Prm Health Care Fam Med.
2009;1:63–70.
17. National Population Commission (NPC) [Nigeria] and ICF International.
Nigeria Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville,
Maryland, USA: NPC and ICF International; 2014.
18. National Population Commission (NPC) [Nigeria] and ICF International.
Nigeria Demographic and Health Survey 2003. Abuja, Nigeria, and Rockville,
Maryland, USA: NPC and ICF International; 2004.
19. National Population Commission (NPC) [Nigeria] and ICF International.
Nigeria Demographic and Health Survey 2008. Maryland: NPC and ICF
International; 2009.
20. Awi DD, Alikor EA. Barriers to timely initiation of breastfeeding among
mothers of healthy full-term babies who deliver at the University of Port
Harcourt Teaching Hospital. Niger J Clin Pract. 2006;9:57–64.
21. Adhikari M, Khanal V, Karkee R, Gavidia T. Factors associated with EIBF
among Nepalese mothers: further analysis of Nepal Demographic and
Health Survey, 2011. Int Breastfeed J. 2014;9:21.
22. West BT. Statistical and methodological issues in the analysis of complex
sample survey data: practical guidance for trauma researchers. J Trauma
Stress. 2008;5:440–7.
23. Infant and Young Child Feeding: A tool for assessing national practices,
policies and programmes. http://www.who.int/nutrition/publications/inf_
assess_nnpp_toc_eng.pdf Accessed March 12, 2015.
24. Initiative WBT. The State of Breastfeeding in 33 Countries. India: BPNI /
IBFAN Asia; 2010. http://www.bfmed.org/Media/Files/Documents/pdf/
WBTi%20The-state-of-breastfeeding-in-33-countries-2010.pdf. (Accessed 27
January 2016).
25. Brand E, Kothari C, Stark MA. Factors related to breastfeeding discontinuation
between hospital discharge and 2 weeks postpartum. J Perinat Educ.
2011;20:36–44.
26. Yahya WB, Adebayo SB. “Modelling the Trend and Determinants of
Breastfeeding Initiation in Nigeria,” Child Dev Res. 2013;2013 Article ID
530396:9. doi:10.1155/2013/530396
27. Okafor IP, Olatona FA, Olufemi OA. Breastfeeding practices of mothers of
young children in Lagos, Nigeria. Niger J Paed. 2014;41:43–7.
28. Rajan L. The impact of obstetric procedure and analgesia/anaesthesia
during labour and delivery on breastfeeding. Midwife. 1994;10:87–103. Submit your next manuscript to BioMed Central
29. Prez-Escamilla R, Maulen-Radovan I, Dewey KG. The associaition between and we will help you at every step:
cesarean delivery and breast-feeding outcomes among Mexican women.
Am J Public Health. 1996;86:832–6. • We accept pre-submission inquiries
30. Lessen R, Crivelli-Kovach A. Prediction of initiation and duration of breast- • Our selector tool helps you to find the most relevant journal
feeding for neonates admitted to the neonatal intensive care unit. J Perinat
• We provide round the clock customer support
Neonatal Nurs. 2007;21:256–66.
31. Orün E, Yalçin SS, Madendağ Y, Üstünyurt-Eras Z, Kutluk S, Yurdakök K. • Convenient online submission
Factors associated with breastfeeding initiation time in a Baby-Friendly • Thorough peer review
Hospital. Turk J Pediatr. 2010;52:10–6. • Inclusion in PubMed and all major indexing services
32. Vieira TO, Vieira GO, Giugliani ER, Mendes CM, Martins CC, Silva LR.
Determinants of breastfeeding initiation within the first hour of life in a • Maximum visibility for your research
Brazilian population: cross-sectional study. BMC Public Health. 2010;10:760.
Submit your manuscript at
www.biomedcentral.com/submit