Introduction

Early initiation of breastfeeding, within one hour of birth is recommended by WHO (1). Although it is one of the core indicators for assessing infant and young child feeding practices (2), it is a far from universal practice. Data from 2002-2005 show that 46 low- and middle-income countries (LMIC) had included early initiation of breastfeeding in Demographic Health Surveys. Of these, 54% recorded that less than half of all new-borns were put to the breast within an hour of birth. Furthermore, no country had more than 80% of babies breastfeeding within an hour of birth. Global estimates are that less than half (42%) of all newborns are put to the breast within the first hour of birth (3).

A recent study published in The Lancet (4), allows for a comparison of the prevalence of early initiation of breastfeeding in LMIC and high-income countries. Of the 68 LMIC for which data were available, 49% reported having more than half of babies put to the breast within one hour and just one country (Kyrgyz Republic) recorded 80%. Worth noting is that 50% of LMIC had no data on early initiation of breastfeeding. In high-income countries, however, there was far less data available: a mere 6 out of the 27 countries examined had data on early initiation of breastfeeding (4), with the highest rate reported in Italy (94%) and the lowest in Saudi Arabia (23%).

While breastfeeding rates for the UK are published by the National Health Service (NHS) , the number of newborns put to the breast within an hour of birth is not clear. NHS publications report, however, that for the period 2013-14 an estimated 75% of babies initiated breastfeeding (5) without specification on when that occurred. In the USA, the percentage of hospitals implementing a majority of the “Ten Steps to Successful Breastfeeding” increased from about 29% in 2007 to nearly 54% in 2013. Of these hospitals only 65% implemented step four of the ten steps, which is early initiation of breastfeeding (6).

The benefits to the child of exclusive breastfeeding for the first six months are well established in terms of morbidity and mortality (7). In addition, evidence indicates that breastfeeding also promotes good health in mothers including reduced risk of breast and ovarian cancer, maternal obesity, diabetes, hypertension, and coronary heart disease (8).

The purpose of this commentary is to explore the evidence for the birthing practices that facilitate early initiation of breastfeeding, as well as evidence that early initiation of breastfeeding brings benefits, be it to the mother and/or to the child. To do this three systematic reviews are analysed and their findings duly considered.

Methodology summary

All three reviews used relevant databases including PubMed, Cochrane Pregnancy and Childbirth Group´s Trials Register, as well as selected journals and the bibliography of articles encountered. The review of Moore et al. (9) included only randomized or quasi-randomized controlled trials with or without blinding. The reviews of Debes et al. (11) and of Khan et al. (12) considered prospective studies, including randomized controlled trials, observational studies and cohort studies. The reviewers for each of the three studies independently assessed trial eligibility, extracted data where and when possible, contacted the trial investigators as necessary for additional information, and assessed trial quality.

The Moore et al. review (9) examined the effects of early skin-to-skin contact as compared to usual hospital care on breastfeeding, physiological adaption and behaviour in healthy mother-newborn dyads and included 38 randomized controlled trials involving 3472 women and infants. The Debes et al. review (11) focused on time to initiation of breastfeeding and neonatal mortality and morbidity. The search included only studies conducted in LMIC. After abstract review, 291 were considered for full text review. Of these, 18 studies reported a direct association between early breastfeeding initiation and neonatal mortality and just three were included in the meta-analysis looking at early (within 24 hours) versus late (after 24 hours) initiation of breastfeeding and neonatal mortality. The Khan et al. review (12) identified 123 articles based on their abstracts as potentially relevant, 11 papers were identified that were eligible for inclusion in this systematic review. Early initiation was defined as breastfeeding occurring in the first hour after birth and low birth weight, preterm, or infants having congenital malformations or other health problems were excluded.

Evidence summary

The reviews of maternity practices and their effects on breastfeeding indicators both found that separation of the newborn from their mother at birth is not beneficial. The Moore et al. (9) review found that mothers practicing early skin-to-skin contact were more likely to be breastfeeding in the first four-months post-partum (risk ratio [RR] 1.24; 95% CI: 1.07, 1.43) and on average breastfed their infants for 43 days longer than those mothers not practicing early skin-to-skin contact (95% CI: 37.96, 89.50) although data were somewhat limited for the effect on breastfeeding duration (six studies with 264 participants). Infants had better cardio-respiratory stability with early skin-to-skin contact (standardized mean difference [SMD] 1.24; 95% CI: 0.76, 1.72), however data were limited (two studies with 81 participants). Blood glucose 75 to 180 minutes following birth was significantly higher in early skin-to-skin contact infants (mean difference [MD] 10.49; 95% CI: 8.39, 12.59), and they also reportedly cried less, though the latter result was based on only two studies.

The two reviews of early initiation of breastfeeding and neonatal mortality and morbidity both found a positive effect. The Debes et al. review (11) reported the results of random effects meta-analyses of data from 3 studies, which demonstrated that initiation of breastfeeding (within 24 hours of birth) was associated with lower risks of all-cause neonatal mortality among all live births (RR 0.56; 95% CI: 0.40, 0.79) and among low birth weight babies (RR 0.58; 95% CI: 0.43, 0.78), and lower risks of infection-related neonatal mortality (RR 0.55; 95% CI: 0.36, 0.84). The Khan et al. (12) meta-analysis found that initiation of breastfeeding within 1 hour of birth was associated with a reduced risk of neonatal mortality. Neonates who started to breastfeed after the first hour of life had twice (pooled odds ratio [OR] 2.02; 95 % CI: 1.40, 2.93) the risk of dying in the first month of life compared to those breastfed within first hour.

Discussion

Taken together, the results of these three systematic reviews provide a solid body of evidence that poor birthing practices in maternity hospitals can disrupt the early initiation of breastfeeding with negative consequences in terms of exclusive breastfeeding during the first month and an increased risk of neonatal mortality.

Applicability of the results

The results of these three trials are largely applicable in most settings, and especially so in LMIC. The neonatal mortality results reported by both Debes et al. (11) and Khan et al. (12) come from three trials carried out in Ghana, India and Nepal. The overall quality of evidence for these neonatal mortality outcomes was considered to be moderate, as they were generated from well-conducted observational studies. Results of a large cohort analysis covering nearly 100,000 babies in Ghana, India and Tanzania provide further evidence that early initiation of breastfeeding within 1 hour after birth reduces neonatal and early infant mortality both through increasing rates of exclusive breastfeeding and by additional mechanisms (13). The claim that a fifth of neonatal mortality could be prevented by achieving universal early initiation of breastfeeding (14) seems plausible. Between 1990 and 2013 the proportion of under-five mortality that occurred in the neonatal period rose from 37% to 44%, with 2.8 million dying in the first month of life (15). Efforts to reduce young child mortality will increasingly depend on reducing neonatal mortality, and improving rates of early initiation of breastfeeding could make an important contribution to this.

The Moore et al. review (9) reported that the overall methodological quality of trials of early skin-to-skin contact was mixed, and there was high heterogeneity for some outcomes. As has been noted elsewhere, the terms “contact” and “suckling” are often used interchangeably, when in fact each is important in its own right (16). The mother should hold the baby on her chest with skin-to-skin contact immediately after birth. But it still might take twenty minutes before the baby starts spontaneously suckling, and most should have started suckling within an hour.

Implementation in settings with limited resources

As the coverage of skilled birth attendance is around 73% globally (17), the potential for increasing early initiation rates is considerable. It will require considerable training of birth attendants, to help establish skin-to-skin contact immediately after birth, as well as suckling within the first hour. The greatest challenge will be in Sub-Saharan Africa and South Asia, where coverage of skilled birth attendants is still only around 50%, as compared to almost 90% in other regions. Once trained birth attendants are available, effort should be placed in developing family and community based interventions, as these seem to have the greatest effect on early initiation of breastfeeding (18). A recent review of the impact of the Baby-friendly Hospital Initiative on breastfeeding outcomes found a dose-response relationship between the number of the “ten steps” women are exposed to and the likelihood of improved breastfeeding outcomes, including early initiation (19).

Further research

There was general consensus among all the reviews that future research should utilise standardised definitions of both the interventions being used and the outcomes being studied. In addition, the methodologies used for carrying out trials should be clearly detailed. Information about timing of skin-to-skin contact as well as suckling initiation should also be highlighted. Other outcomes to be included in future reviews and trials could include measures of uterine activity, oxytocin release and reduction of post-partum blood loss in the mother, as well maternal/infant interaction and psycho-social development of the infant. Studies to better elucidate the protective effect of colostrum in reducing infection would also be useful, as the practice of expelling and discarding first milk is still common in many societies (19).

References

1. WHO/UNICEF. Global strategy on infant and young child feeding. Geneva: World Health Organization; 2003. (https://www.who.int/nutrition/publications/infantfeeding/9241562218/en/)

2. WHO/UNICEF/IFPRI/UC Davis/USAID/FANTA. Indicators for assessing infant and young child feeding practices. Part 3: country profiles. Geneva: World Health Organization; 2008. (http://www.who.int/nutrition/publications/infantfeeding/9789241599757/en/)

3. Health in 2015: from MDGs, Millennium Development Goals to SDGs, Sustainable Development Goals. Geneva: World Health Organization; 2015. (https://www.who.int/gho/publications/mdgs-sdgs/en/)

4. Victora CG, Bahl B, Barros AJD, França GVA, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC, for The Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016; 387:475–90.

5. Statistical Release. Breastfeeding Initiation & Breastfeeding prevalence 6-8 weeks. Quarter 1 2014/15. Wakefield, NHS England, 2014.

6. Vital Signs: Hospital Actions Affecting Breastfeeding. Atlanta, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2015. (https://www.cdc.gov/vitalsigns/breastfeeding2015/index.html)

7. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic Reviews. 2012; Issue 8. Art. No.: CD003517.

8. Schwarz EB, Nothnagle M. The Maternal Health Benefits of Breastfeeding. Am Fam Physician. 2015. 91(9):602-604

9. Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews. 2016; Issue 11. Art. No.: CD003519.

10. Debes AK, Kohli A, Walker N, Edmond K, Mullany LC. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health. 2013; 13(Suppl 3): S19.

11. Khan J, Vesel L Bahl R, Martines JC. Timing of Breastfeeding Initiation and Exclusivity of Breastfeeding During the First Month of Life: Effects on Neonatal Mortality and Morbidity—A Systematic Review and Meta-analysis. Matern Child Health J. 2015; 19:468–479.

12. NEOVITA Study Group. Timing of initiation, patterns of breastfeeding, and infant survival: prospective analysis of pooled data from three randomised trials. Lancet Glob Health. 2016;4(4):e266-75.

13. Lutter C. Early Initiation of Breastfeeding: The Key to Survival and Beyond. Washington DC: Pan American Health Organization; 2010. (http://new.paho.org/hq/dmdocuments/2010/Eight%20Pager%20English%20FINAL.pdf)

14. World health statistics 2015. Geneva: World Health Organization; 2015. (https://www.who.int/gho/publications/world_health_statistics/2015/en/)

15. Evidence for the ten steps to successful breastfeeding. Geneva: World Health Organization: 1998. (https://www.who.int/maternal_child_adolescent/documents/9241591544/en/)

16. WHO/World Bank. Tracking universal health coverage. First global monitoring report. Geneva: World Health Organization; 2015. (https://www.who.int/healthinfo/universal_health_coverage/report/2015/en/)

17. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piwoz EG, Richter LM, Victora CG, for the Lancet Breastfeeding Series Group. Why invest and what it will take to improve breastfeeding practices? Lancet. 2016; 387: 491-504.

18. Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr. 2016; 12(3):402-17.

20. Morse JM, Jehle C, Gamble D. Initiating breastfeeding: a world survey of the timing of postpartum breastfeeding. Int J Nurs Stud. 1990; 27(3):303-13.

Disclaimer

The named authors alone are responsible for the views expressed in this document.

Declarations of interests

Conflict of interest statements were collected from all named authors and no conflicts were identified.