Discussion
This study sought to determine the prevalence of delayed initiation of breastfeeding in PNG and to examine the association between household, maternal, child and health services determinants. Women who had not planned their last pregnancies, had a caesarean section, had no newborn skin-to-skin contact immediately after birth, watched television and were from the Momase region were more likely to experience a delay in initiating breastfeeding. The findings in this study underscore the demand for tailored programme interventions to improve breastfeeding initiation practices, particularly among rural women.
While timely breastfeeding initiation is crucial for the growth and survival of infants, the practice remains suboptimal in PNG. In this study, about one-quarter (24.7%) of women have delayed breastfeeding initiation. This result was lower than the findings from an earlier study in PNG,12 including those in Bangladesh,4 South Sudan10 and Uganda.21 The variation in prevalence may be due to sample size, maternal sociodemographic factors (ie, socioeconomic status, educational status, social norms and beliefs concerning breastfeeding practice), and health service utilisation.
Findings from this study revealed that women with unplanned pregnancies were more likely to delay initiation of breastfeeding. This is in agreement with studies done in sub-Saharan Africa.22 Women who have unplanned pregnancies are not likely to utilise maternal health services, such as family planning and antenatal care, which often include appropriate information and education on breastfeeding for pregnant women.23 24 Despite this finding, the increased odds of delayed initiation of breastfeeding from women with unplanned pregnancies are an observation that would necessitates further qualitative investigation.
Caesarean section was positively associated with delayed initiation of breastfeeding in this study, consistent with several studies conducted elsewhere.25–27 Women who underwent caesarean section were three times more likely to delay early initiation of breastfeeding. This could be explained by the hospital practice of separating newborns from their mothers after the procedure.27 In addition, maternal exhaustion and the effects of anaesthesia following a caesarean section may impede early breastfeeding initiation.21 28 While maternal recovery from this procedure generally takes some time, immediate breastfeeding is required once the woman regains consciousness and alertness.29 30
Interestingly, women who gave birth at home or in the village had lower odds of delayed initiation of breastfeeding compared with those who gave birth in a health facility. This was similar to findings from several LMICs,31 indicating that home-birthed infants were more likely to be breastfed in the first hour of birth. The type and level of support from skilled birth attendants, family members, particularly partners/husbands and a familiar home birthing environment may reduce stress, leading to intervention-free birth and consequently influence breastfeeding outcomes.31 32 Evidence from studies conducted in PNG has demonstrated an inverse association between social and family support that adversely affects breastfeeding initiation for mothers who had given birth at home or in the village.13–15 However, it is unclear what underlies the observed association between delayed initiation of breastfeeding and home/village birth in the current study. Furthermore, the association between home/village birth and breastfeeding initiation is improbable to be directly causal, which will require further research to confirm the factors driving the observed differences.
From the results, poor newborn skin-to-skin contact immediately after birth was significantly associated with delayed initiation of breastfeeding. Women who did not initiate skin-to-skin contact immediately after birth with their newborns were more likely to delay initiation of breastfeeding. They may be unaware of the importance of skin-to-skin contact as a means of promoting warmth and thermoregulation for their newborns, thus their lower odds of embracing and practising it.12 33 The lack of information may therefore account for the delayed initiation of breastfeeding. Certain sociocultural norms and beliefs may disapprove of these women for practising newborn skin-to-skin contact.13 15 33 Furthermore, poor knowledge on the part of health workers, shortages of health workers, poor newborn care and limited time can impede the practice of newborn skin-to-skin contact.33 34 Qualitative inquiry is necessary to investigate the knowledge, attitudes and practices regarding breastfeeding initiation among health workers and mothers, particularly those in rural settings.
Women who were exposed to mass media in this study, particularly television, were more likely to delay initiation of breastfeeding, consistent with studies done in sub-Saharan Africa.22 35 Social marketing and advertising of infant formula feedings, milk substitutes, teats and bottles on various media platforms have been shown to affect breastfeeding initiation.36 37 In contrast, this study further revealed that those who read newspapers or magazines had lower odds of delaying breastfeeding initiation. Print media (ie, newspapers or magazines) are available and accessible to the public compared with television, which could explain the reason for this finding. Access to print media improves information and health literacy on breastfeeding and its benefits and fosters positive behavioural beliefs about breastfeeding which have been reported as important determinants of optimal breastfeeding practice.38–40 Print media can be also an influential tool for breastfeeding communication and promotion, for persuading breastfeeding behaviours, creating positive social norms and garnering support from stakeholders and policymakers.39 However, limited information exists on how mass media coverage influences breastfeeding practice in PNG’s context. Further qualitative inquiry could provide a deeper understanding of mass media coverage on breastfeeding practices.
Regarding the region, delayed initiation of breastfeeding was not common among women from the Highlands and Southern regions. This finding is in agreement with a similar study conducted in PNG.12 Expansion of access to healthcare services and ongoing economic developments in these two regions are possible explanations for this observation. On the contrary, the odds of delayed breastfeeding initiation remained higher among women from the Momase region compared with women in the Island region. This is likely attributed to the lack of qualified health workers with adequate resources in this region of the country, impeding access to maternal, newborn and child health services as reported in similar studies.12 41 This can also be elucidated in terms of the socioeconomic condition, frequently characterised by poor household wealth and low education levels, including accessibility, attitudes to antenatal care and interpersonal issues affecting women from accessing the services provided by health workers in this region.41 42 Most of the provinces in the Momase region are relatively economically unstable and geographically remote, which makes healthcare, services problematic.42 The regional variations relating to breastfeeding initiation could be attributed to poor healthcare service and resource distribution. This is also consistent with previous studies, which found that variations exist in various regions and the utilisation of antenatal care services.41 42 Thus, mobile and outreach programmes should be strengthened to reach women, especially in rural areas and the disadvantaged.
This study has several strengths. It investigated household, maternal, and child factors and healthcare utilisation with delayed initiation of breastfeeding using a nationally representative survey. In addition, appropriate analysis techniques such as weighting and complex samples analysis were used to ensure that the results were representative of women in PNG. The two-stage sampling approach ensured that no selection bias could influence the results of this study. However, the study has limitations and should be interpreted with caution. As it was a cross-sectional study, the analysis could not determine a cause-and-effect relationship between breastfeeding initiation and independent variables. The role of health workers and skilled birth attendants (eg, midwives or nurses) regarding breastfeeding was not captured in the dataset; therefore, it was not possible to establish the extent of breastfeeding counselling and support provided during antenatal and early postpartum periods. Since the outcome of the study was assessed based on the women’s responses regarding the timing of breastfeeding initiation, results may have been influenced by self-report and social desirability biases. Furthermore, the DHS did not collect some information, such as maternal beliefs and knowledge about breastfeeding, so there may be residual confounding.