Caesarean Delivery as a Predictor of Inadequate Breastfeeding among a Group of Neonates in Yaoundé, Cameroon

Abstract

Though caesarean section has been recognized as an indispensable intervention to improve infants and mothers' outcomes in dystocic deliveries, recent research emphasizes the fact that it is associated with a lower rate of breastfeeding initiation. Whereas, suboptimal breastfeeding may be responsible for up to 11% deaths in children under 5 years. This study aimed at investigating beyond risk factors, the predictors of inadequate breastfeeding practices among which delivery by caesarean section, in a group of Cameroonian neonates. We conducted a cross-sectional analytic study over a period of six months from December 2018 to May 2019. We included all livebirth neonate infants weighing > 2000g and with no contraindication to breastfeeding. A total of 250 neonates were enrolled in the survey, the mean age of mothers was 27.9 ± 6.2 years. Poor breastfeeding practices was found in 153 neonates (61.2%), though 208 mothers (83.2%) had a school education ≥ secondary level. Seventy-eight (78) neonates were delivered through Caesarean section, with a rate of 31.2%. Among various risk factors identified, caesarean delivery appeared as a strong predictive factor for inadequate breastfeeding after multivariate analysis by logistic regression. From these results, we concluded more emphasis should be laid on improving antenatal follow-up and counselling of mothers to reduce the increasing rate of emergency caesarean deliveries and promote breastfeeding practices. More so, elective caesarean section by spinal anesthesia should be favored in case of necessity, thereby enabling timely and adequate breastfeeding after surgical delivery.

Full text

1 Volume 2; Issue 01
Journal of Perinatology & Clinical Pediatrics
Caesarean Delivery as a Predictor of Inadequate Breastfeeding
among a Group of Neonates in Yaoundé, Cameroon
Georges Pius Kamsu Moyo*, Ngwanou Dany Hermann
Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaoundé, Cameroon
*Corresponding author: Georges Pius Kamsu Moyo, Faculty of Medicine and Biomedical Sciences, University of Yaoundé,
Yaoundé, Cameroon
Citation: Moyo GPK, Hermann ND (2020) Caesarean Delivery as a Predictor of Inadequate Breastfeeding among a Group of Neo-
nates in Yaoundé, Cameroon. J Perina Clin Pediatr: 2: 105. DOI: 10.29011/JPCP-105.100005
Received Date: 07 July, 2020; Accepted Date: 14 July, 2020; Published Date: 20 July, 2020
Research Article Moyo GPK and Hermann ND J Perina Clin Pediatr: 2: 105.
DOI: 10.29011/JPCP-105.100005
Abstract
Though caesarean section has been recognized as an indispensable intervention to improve infants and mothers’ outcomes
in dystocic deliveries, recent research emphasizes the fact that it is associated with a lower rate of breastfeeding initiation.
Whereas, suboptimal breastfeeding may be responsible for up to 11% deaths in children under 5 years. This study aimed at
investigating beyond risk factors, the predictors of inadequate breastfeeding practices among which delivery by caesarean
section, in a group of Cameroonian neonates. We conducted a cross-sectional analytic study over a period of six months
from December 2018 to May 2019. We included all livebirth neonate infants weighing > 2000g and with no contraindication
to breastfeeding. A total of 250 neonates were enrolled in the survey, the mean age of mothers was 27.9 ± 6.2 years. Poor
breastfeeding practices was found in 153 neonates (61.2%), though 208 mothers (83.2%) had a school education ≥ secondary
level. Seventy-eight (78) neonates were delivered through Caesarean section, with a rate of 31.2%. Among various risk factors
identied, caesarean delivery appeared as a strong predictive factor for inadequate breastfeeding after multivariate analysis
by logistic regression. From these results, we concluded more emphasis should be laid on improving antenatal follow-up and
counselling of mothers to reduce the increasing rate of emergency caesarean deliveries and promote breastfeeding practices.
More so, elective caesarean section by spinal anesthesia should be favored in case of necessity, thereby enabling timely and
adequate breastfeeding after surgical delivery.
Keywords: Breastfeeding; Caesarean section; Cameroon
Introduction
Adequate breastfeeding may be dened as the timely
initiation of the act, its effectiveness in terms of the technique,
exclusiveness, and necessary duration. In newly delivered women,
the Early Initiation of Breastfeeding (EIBF) also referred to as
timely breastfeeding, may be dened as the proportion of newly
born infants who are breastfed within the rst hour following
delivery [1]. In effect, according to the WHO recommendations,
breastfeeding should take place within 30 minutes to an hour at
most, following childbirth [1,2]. A number of research studies
have reported considerable delays in breastfeeding initiation
among women with caesarean delivery, thereby contributing to
poor breastfeeding practices in this subpopulation [3]. Whereas,
the act of breastfeeding is thought to be reinforced in developing
countries due to its cost-effectiveness and natural availability,
making it accessible for the neonate at any time from its mother.
Moreover, the WHO recommends exclusive breastfeeding during
the rst six months of life, given that recent studies in developing
countries such as Ethiopia, Ghana, Bolivia and Madagascar just
as many others before, have revealed that breastfeeding could
prevent as much as 20-22% neonatal and under 5 infant mortality
[2-7]. However, the average time for the initiation of breastfeeding
as well as the effectiveness of its technique, its exclusiveness and
duration, seems to vary from one population to another and may be
prolonged by caesarean delivery [2-7]. Continuously rising levels
of caesarean section due to poor antenatal follow-up, suboptimal
delivery practices, progressive psychological accommodation,
acceptation and request may further worsen the situation [3,8]. The
aim of our research study was to investigate beyond risk factors,
the predictors of inadequate breastfeeding among which caesarean
section, in a group of neonates in our context.
Methodology
We conducted a cross-sectional analytical study with
prospective data collection, over a six-month period from
December 2018 to May 2019, at the Yaoundé Gynaeco-Obstetric

Citation: Moyo GPK, Hermann ND (2020) Caesarean Delivery as a Predictor of Inadequate Breastfeeding among a Group of Neonates in Yaoundé, Cameroon. J Perina
Clin Pediatr: 2: 105. DOI: 10.29011/JPCP-105.100005
2 Volume 2; Issue 01
and Paediatric Hospital which is a University Teaching Hospital
in Cameroon. We included all livebirth newborn infants weighing
more than 2000g, with no contraindication to breastfeeding and
who consented to participate in our study. The enrolled neonates
and mothers were observed during the rst week of postpartum to
detect those that would practice adequate breastfeeding in terms of
the time of initiation, the effectiveness, exclusiveness and duration
in conformity with the WHO’s recommendations. However, the
duration of exclusive breastfeeding could only be evaluated after
6 months, and so we rather assessed the mother’s intention to do
so. We conducted simple, adapted, and oriented interviews using a
pretested questionnaire, so as to improve investigations. Bivariate
analysis made possible the identication of risk factors, and was
followed by multivariate analysis to isolate predictive factors. The
data were analyzed using CS Pro version 6.2 and SPSS version
20.0. Chi-square testing was used to identify statistical associations
between variables. The P value < 0.05 was used to characterize
statistical signicance. The Odds ratio with 95% condence
interval was used to reveal risk factors.
Ethical clearances from the Institutional Ethics and Research
Committee of the Faculty of Medicine and Biomedical sciences of
the University of Yaoundé 1 and the Yaoundé Gynaeco-Obstetric
and Paediatric Hospital were obtained before the beginning of the
survey. The data collected was kept condential and used for the
purpose of the study only.
Results
We enrolled 250 newborns and their mothers, the
mean age was 27.9 ± 6.2 years. Seventy-eight neonates were
delivered through caesarean section (31.2%), out of which 50
(64.1%) were emergency caesarean sections. Complication after
caesarean delivery occurred in 7 women (8.9%) with postpartum
hemorrhage in 4 women (57.1%) and sepsis in 3 women (42.9%).
Poor breastfeeding practices was found in 153 neonates and
mothers (61.2%), even though 208 women (83.2%) had a school
education ≥ secondary level. Among all neonates with inadequate
breastfeeding, 72 (47%) had been delivered through caesarean
section. Likewise, 92.3% neonates delivered through caesarean
section had inadequate breastfeeding, and this was mainly due to
delayed initiation of the process. Close to 174 women (69.6%) had
at least 02 living children, previously delivered by vaginal route
and so were used to breastfeeding practice.
Characteristics of inadequate breastfeeding
The various characteristics of inadequate breastfeeding
practices among neonates and their mothers with caesarean
delivery are summarized in table 1 below.
Variables N (72) Percentage (%)
Delayed initiation of breastfeeding >
60 minutes 70 97.2
Formula use or other breastmilk
substitute 62 86.1
No intention for 6 months exclusive
breastfeeding 58 80.5
Ineffective breastfeeding technique 45 62.5
Table 1: Characteristics of inadequate breastfeeding among
neonates and mothers with caesarean delivery.
Factors associated with inadequate breastfeeding practices
Primary education level of mothers, Centre region
as sociocultural origin, Caesarean delivery, HIV infection,
gestational age below 37 weeks of pregnancy, low birthweight
and neonatal infection at birth were associated with inadequate
breastfeeding after bivariate analysis. Logistic regression isolated
the Centre region as sociocultural origin, and caesarean delivery
as independent predictors of inadequate breastfeeding (Tables 2
and 3).
Variables
Breastfeeding practice
OR p-Value
Inadequate Adequate
Primary education 22 (78.6) 6 (21.4) 2.5 0.045
Centre region 60 (66.7) 30 (33.3) 2.4 0.002
HIV infection 16 (88.9) 2 (11.1) 5.5 0.012
Caesarean section 72 (92.3) 6 (7.7) 13.5 <0.001
Gestational age <
37 weeks 18 (85.7) 3 (14.3) 4.2 0.016
Low birthweight
<2500g 15 (83.3) 3 (16.7) 3.4 0.045
Neonatal infection 13 (92.9) 1 (7.1) 10.9 0.009
Table 2: Factors associated with inadequate breastfeeding.

Citation: Moyo GPK, Hermann ND (2020) Caesarean Delivery as a Predictor of Inadequate Breastfeeding among a Group of Neonates in Yaoundé, Cameroon. J Perina
Clin Pediatr: 2: 105. DOI: 10.29011/JPCP-105.100005
3 Volume 2; Issue 01
Variables Adjusted OR (CI à
95%)
Adjusted
p-value
Primary school
education level 2.3 (0.8 – 6.5) 0.110
Centre region 2.54 (1.8 – 4.5) 0.033
HIV Infection 4.5 (0.9 – 22.3) 0.062
Caesarean section 11.3 (4.6 – 27.7) < 0.001
Gestational age <
37months 2.3 (0.5 – 10.4) 0.267
Low birthweight <
2500g 1.2 (0.2 – 5.8) 0.847
Neonatal infection 6.6 (0.8 – 56.9) 0.088
Table 3: Predictors of inadequate breastfeeding after multivariate
analysis.
Discussion
The assessment of breastfeeding practices was based on four
characteristics including timely initiation, the use of breastmilk
substitute, the effectiveness of the breastfeeding technique and
the duration. Among the various characteristics, the delay of
breastfeeding initiation was the most contributive, occurring
in more than 97% of neonates and mothers with caesarean
delivery with poor breastfeeding practices. This induced the use
of formula milk or other substitutes in over 86%, and more than
80% not having the intention to do exclusive breastfeeding over 6
months. The rate of early breastfeeding initiation after caesarean
delivery was therefore as low as 2.8 % in this survey, which is in
conformity with predictions from the literature [3,8-10]. While the
effectiveness of the act of breastfeeding was dened by deep, tonic
and slow suctions separated or not by short pauses and yielding
breastmilk into the baby’s mouth, duration was assessed in terms
of intention to breastfeed exclusively during the rst six months.
This was due to the difculty to follow all women over a six-
month period. As a matter of facts, a number of research works
have revealed associations between breastfeeding initiation and
exclusive breastfeeding [3,11]. There is evidence that mothers
with caesarean delivery are likely to feed their infants with formula
milk in the rst 3 days following childbirth, and are as well less
susceptible to breastfeed exclusively during the rst six months
[3,11]. Therefore, high rates of delayed breastfeeding initiation
may be responsible for differences in breastfeeding rates between
babies born through cesarean section and those born by vaginal
delivery [3]. This effect may be amplied by the rising preference
for caesarean delivery in women. Likewise, low rates of early
breastfeeding initiation may be responsible for reduced exclusive
breastfeeding.
In this survey, caesarean section appeared as the main cause
of maternal indispositions to breastfeeding. This was mainly due
to mother-infant separation immediately after the intervention,
post-surgical pains, hemodynamic instability, initial agalactorrhea
or hypogalactorrhea, emotional and mood disorders [12]. Indeed,
caesarean section is a well-known documented determinant for
delayed breastfeeding initiation, already described by a number of
researchers in various contexts [13-15]. It was even more strongly
associated to inadequate breastfeeding in this study, occurring as an
independent predictive factor. There are some pertinent hypotheses
according to which women delivering through caesarean section
may have less endocrinal and psychological preparedness to
breastfeeding [16]. The reinforcement of maternal education and
counselling, as well as special training sessions on breastfeeding
after caesarean delivery for the medical staff, should be considered
in order to promote early breastfeeding initiation and adequate
breastfeeding in such women.
There are various hormone variations after caesarean section
including the drop of endorphin, prolactin, and oxytocin blood
levels, which have been incriminated for reducing galactorrhea
and breastfeeding desire in the immediate post-operative period
[3]. While a drop of prolactin hormone synthesis from the anterior
pituitary gland is responsible for reduced breastmilk production
from alveolar cells of the breast acini, a drop in oxytocin release
from the hypothalamus through the posterior pituitary gland into
the blood, causes reduced stimulation of perialveolar and ductal
myoepithelial cells, and so diminishes milk ejection. On the other
hand, endorphin enhancement of positive emotional and affective
interaction in the mother, which is generally associated with the
desire and the satisfaction in breastfeeding is reduced as well [3,17-
20]. Therefore, there may exist an inclination to agalactorrhea,
hypogalactorrhea and reduced lactation after caesarean section,
which contrasts with the normal expected hormonal changes
after vaginal delivery to favor breastfeeding. In theory, lactation
is thought to be higher after emergency caesarean section, as
labor would have induced higher oxytocin and prolactin secretion
in the mother [3]. However, a newborn which has gone through
labor and delivered by vaginal route is thought to have more
appetite and improved suckling reexes [21]. The improvement
of antenatal care involving early diagnoses and management of
some pregnancy-related disorders would considerably reduce the
increasing rate of caesarean section, with favorable repercussions
on breastfeeding [3]. In such a context, most caesarean sections
would be elective with regional anesthesia which has less impact
on the breastfeeding process. Husband’s presence may be allowed
in the theatre during the intervention as well, as advocated by some
studies which showed positive effects with anxiety relief and better
lactation [3].

Citation: Moyo GPK, Hermann ND (2020) Caesarean Delivery as a Predictor of Inadequate Breastfeeding among a Group of Neonates in Yaoundé, Cameroon. J Perina
Clin Pediatr: 2: 105. DOI: 10.29011/JPCP-105.100005
4 Volume 2; Issue 01
Caesarean section is generally associated with considerable
maternal sedation, pain, post-operative complications such as
hemorrhage, infection, and post-traumatic stress, which may further
render breastfeeding undesirable [17-20,22]. After caesarean
section, especially when practiced with general anesthesia, mother
and baby are generally separated for a while, to enable the mother’s
continuous monitoring and awakening [22]. Furthermore, opioid
pain killers administered to mothers post-operatively may induce
sleep in the baby preventing it from feeding regularly and reducing
the suckling tonus. The avoidance of mother-infant separation may
be achieved by designing hospital services such that the delivery
room, the theatre, the recovery room and the neonatology unit
should not be far separated from each other [3]. Better still, mother
and newborn skin-to-skin contact immediately after cesarean
delivery should be enabled right from the theatre. Recovery rooms
should be provided with cradles and incubators to keep the baby
near its mother thus favoring the early initiation of breastfeeding.
The necessary staff for mother and baby care should be allocated,
with special emphasis on nursing support [3]. Side-lying and
clutch positions are recommended as comfortable postures for
breastfeeding after caesarean section. More so, placing the baby
on properly positioned pillows relieve pressure and pain from the
incision site [23].
From an epidemiological stand point, the admitted rate of
caesarean section which is 15% deliveries, may consequently
induce a risk for inadequate breastfeeding in almost 15% neonates
if no appropriate intervention is put in place to support and improve
breastfeeding practices [20,22]. This tendency should seriously be
considered, as the rate of caesarean delivery continuously rises
with time, especially among urban communities. Moreover, it has
been shown that once the rate of caesarean section exceeds 15%,
adverse maternal and neonatal outcomes become more prevalent
[3]. Therefore, caesarean delivery should not be a hindrance for
breastfeeding, especially in a context of limited nancial resources,
where it may have considerable economic value in addition to
its medical importance. As a matter of fact, rigorous vigilance
for timely initiation of breastfeeding after caesarean delivery is
recommended [21-23].
Conclusion
The rate of caesarean section seems to be continuously rising
in developing countries, especially among urban communities such
as in Yaoundé, where there is increasing emergency obstetrical
care. From this survey, it appeared that caesarean section was a
predictive factor for inadequate breastfeeding in mothers, giving
way to the use of substitutes including formula milk. Therefore,
more emphasis should be laid on the improvement of antenatal
follow-up in order to reduce the rate of emergency caesarean
section. Maternal education, medical staff training on breastfeeding
and post-operative delivery care, should be reinforced as well, in a
bid to improve breastfeeding practice.
Author Contributions
Authors participated in all steps of the study.
Acknowledgements
To the Yaoundé Gynaeco-Obstetric and Paediatric Hospital
authorities and all collaborators to this project.
Conict of Interest
The authors declare that they have no competing interest
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