Study population and prevalence of breastfeeding initiation within the first hour of life
The prevalence of breastfeeding initiation within the first hour of life in Feira de Santana, Bahia, Brazil in this study was 47.1%. This is considered "low" according to the classification of the World Health Organization. This prevalence was lower than the values published in a recent survey about breastfeeding prevalence, conducted in the Brazilian state capitals and the Federal District by the Ministry of Health, which showed a rate of breastfeeding within the first hour of life of 67.7% [2]. It was also lower than the percentage found in the survey carried out in Feira de Santana in 2001 (52.2%), in which the same methodology as in the Ministry of Health survey was used, i.e. a cross-sectional design [5].
However, it is important to note that the data from the present and previous studies are not perfectly comparable, since they were obtained using different methodologies. The present study was a cross-sectional study extracted from the results of a cohort of live births in which the information on breastfeeding was gathered directly from the mothers within the first 72 hours after delivery. In the cross-sectional study carried out by the Ministry of Health the information on time of breastfeeding initiation was gathered at an interview with mothers of children less than one year of age, 71.3% of them having more than three months old [2]. This implies a possible recall bias, which could have overestimated the results. In addition, in Brazil a series of governmental and non-governmental initiatives aimed at promoting breastfeeding within the first hour of life has been implemented, including many activities in the 2007 World Breastfeeding Week, which central topic was promotion of early initiation of breastfeeding This would certainly have generated positive attitudes and activities that may have contributed towards increased levels of this practice over the last few years. It is worth emphasizing that the children in the present survey were born in the years 2004 and 2005.
In this sense, the percentage of breastfeeding within the first hour of life in Feira de Santana was greater than in other studies with similar recall methods that were conducted before the 2007 World Breastfeeding Week. For example, in a study conducted in Rio de Janeiro between 1999 and 2001, only 22.4% of babies born through a vaginal delivery were breastfed within the first hour after birth [9]. In another study, in Pelotas, with births between 2002 and 2003, it was found that 35.5% of the mothers initiated breastfeeding within the first hour after delivery [4].
It is also important to draw attention to conceptual differences that, in turn, could have interfered with the results. The prevailing recommendation at the time when the data for the present study were gathered focused on breastfeeding within the first half hour of life, while still in the delivery room [10]. However, from 2006 onwards, the concept was expanded towards giving more value to skin-to-skin contact between newborns and their mothers immediately after birth, for at least an hour or for as long as the mother wished. During this time, mothers are encouraged to recognize the first signs that her baby was ready for breastfeeding [11].
Influence of the characteristics of the mother, child and prenatal care
In this study, three factors were identified as predictors for breastfeeding within the first hour of life: mothers who received prenatal guidance regarding the advantages of breastfeeding; vaginal delivery; and full term pregnancy.
With regard to the positive association between prenatal education with guidance on the benefits of breastfeeding and greater prevalence of breastfeeding initiation within the first hour of life, no other studies focusing specifically on the first hour of life were identified. However, divergent results relating to prenatal education and the initiation of breastfeeding have been presented in different studies. A randomized controlled trial carried out by MacArthur et al. [12], in Birmingham showed that guidance and information on the advantages of breastfeeding in prenatal follow-up clinics among a needy population of various ethnicities with at least three contacts at different stages of pregnancy, were ineffective for increasing the rate of breastfeeding initiation. On the other hand, Fairbank et al [13] indicated that implementation of pre- and postnatal support programs, along with prenatal education programs among low-income women, either individually or in small groups, had a positive effect on initiation of breastfeeding. World Health Organization and the United Nations Children's Fund have emphasized that it is important to inform pregnant women about the advantages of breastfeeding during the prenatal period, so that they can make a decision based on facts regarding how to feed their children [11].
Another risk factor for delaying the first breastfeeding identified in the present study was delivering by a cesarean section. Several studies have confirmed that even with hospital practices with norms and routines favoring breastfeeding, birth by cesarean section is a significant barrier that inhibits breastfeeding within the first hour of life [9, 14]. The first point to consider in this respect is the limitation on the mother's ability to touch her baby, if her arms have been restrained during the surgical procedure. Another point is the analgesia for the mother, which may cause disorganized behavior in the newborn and may result in delay and impairment of the first breastfeeding [15]. Children born from deliveries with analgesia suffer interference with regard to spontaneous seeking of the mother's breast after birth. This is shown through lower frequency of finger and hand movements, less touching of the nipple and breast (licking and sucking) and more crying than observed among children whose mothers did not receive analgesia [16, 17]. Even small doses of narcotic analgesics, when administered between three and one hours before delivery, may impair breastfeeding for hours or days [18].
A study in a Chinese society, with high rates of cesarean deliveries, showed that this was a risk factor for weaning in the first and third months of life, whereas there was an inverse outcome among children who were breastfed within the first 30 minutes after birth [19]. Brazilian studies have shown that cesarean birth in the city of Pelotas was associated with twice as much risk of non-breastfeeding within the first hour of life [4]. A study carried out in Rio de Janeiro found that visual or physical contact between mother and baby, along with breastfeeding in the delivery room, was less frequent among women who underwent cesarean delivery, and this was reflected in longer time intervals between delivery and the first breastfeeding [9]. Consequently, additional support is needed for women who undergo cesarean delivery, in order to help them to start breastfeeding as early as possible [20].
As expected, in the present study premature newborns were less breastfed within the first hour of life than did those born at full term. A cohort study in Pelotas, Brazil, in 2004, showed that 10.8% of newborns were late premature births and, in comparison with the full-term newborns, they were at greater risk of not being breastfed within the first hour after birth [21]. Likewise, a study in Japan [22] and another in Massachusetts [23] reported that premature newborns were less likely to receive maternal milk.
It is worth commenting that, depending on birth weight, premature children have peculiarities and specific characteristics related to their own immaturity. These limit the abilities needed for breastfeeding within the first hour of life, such as good coordination of the suction-deglutition-respiration cycle and the breast-seeking reflex [24]. Furthermore, premature newborns spend less time awake and their mothers may have some difficulty in recognizing the signs of hunger.
