Abstract

Introduction Breastfeeding initiation is the critical part of post-natal events, especially after a caesarean delivery. There has been an increase in caesarean section delivery in the past few decades, which has also led to a significant decrease in breastfeeding initiation as early as possible. Methods A descriptive study was conducted to assess the challenges faced by the caesarean delivered mothers in early initiation of breastfeeding and coping strategies adopted by them in order to counter act them. Descriptive statistics, Chi square and Karl Pearsons correlation coefficient were used to find out the frequency, associations and relationship among the study variables. Result The findings revealed that 75 (83.3%) participants faced moderate challenges. Majority of the participants 63 (70%) adopted to partially adaptive coping. Karl Pearson correlation coefficient was r = -0.20 for challenges score with coping strategies adopted. It indicates that there is a negative co- relation between the challenges and coping strategies. Chi square value for p<0.05 was significant for type of caesarean section and challenges score, also for coping strategies and birth weight of infant. Conclusion Majority of the participants did faced challenges in early initiation of breastfeeding but their coping strategies may differ according to their socio- demographics.

1. Introduction

Breast milk is the natural and optimal food for newborn infant. It is superior to any alternative form of infant formula and is uniquely designed to meet the nutritional needs of the infant. The benefits are greatly enhanced if breastfeeding starts within one hour after birth. Early breastfeeding allows the baby to enjoy the benefits of Colostrum and prevent any infant feeding problems. Human milk contains a host of dynamic and unique feeding properties. Studies have demonstrated that the health benefits of breast milk are associated with how long an infant can receive it and whether breast milk is given exclusively or supplemented with other feedings. ^{1, 2, 3}.

However, breast milk is recognised as the best source of nutrition for the babies. Many of the reviewed literature suggested that breastfeeding and exclusive breastfeeding rates worldwide are relatively low, especially after a caesarean section (CS). ⁴. As the rate of caesarean section is rising worldwide, a World Health Organization report published in 2021 reveals that rate of caesarean section is rising accounting for more than 1 in 5 (21%) of all childbirths.

A relationship between caesarean section and breastfeeding was observed through a demographic and health survey in Turkey, revealed that 42.7% had late initiation of breastfeeding, and 41.0% had non-exclusive breastfeeding incidence rates. Also, among the women who had late initiation of breastfeeding, 35.34% delivered through vaginal delivery, and 50.49% were those who delivered through caesarean delivery. It was concluded that caesarean section is a reason behind delayed initiation of breastfeeding as it is a major abdominal surgery and the post-surgical pain had adverse effect on the baby friendly hospital initiative (EIBF). ⁵

There is evidence which says that if the early initiation of breastfeeding is delayed by > 1 hour on the first day would double the risk of dying from infection, and delaying from 24 to 48 hours would always almost triple the risk of dying. ^{6, 7}

Studies reveal that for achieving exclusive breastfeeding by mothers. There is immense need that early initiation of breastfeeding is to be promoted. Also, many studies reported that there is a negative association and caesarean section with successful implementation of BFHI. ^{1, 8, 9, 10}

Within the Indian subcontinent there is rather very less available evidences for the factors which are associated with early initiation of breastfeeding. A study performed to evaluate the prevalence and determinants of early initiation of breastfeeding in India among the rural and urban mothers concluded that in India half or more of mothers with different rural and urban prevalence had delayed breastfeeding initiation. ¹¹ According to the report card of states and union territories under the program MAA (mother absolute affection) by the Ministry of Health and Family Welfare, Government of India, in 2019, Madhya Pradesh holds 24th rank which is far lacking in its practices to initiate breast feeding. The report card depicts that according to the NFHS 4 it is 34.6% of breastfeeding initiated within the first hour of delivery as compared to eastern states where it is 73.3% (Mizoram), 60.8% (Meghalaya), and 65.6% (Manipur). Also, the report of NFHS 5 reveals that there is a significant rise in the rates of C- section deliveries in India. As per the recommendation of the WHO the ideal caesarean rates should fall within 10% -15%, the only state in India which fall in this group is the state of Mizoram. (NFHS 5, 2020)

In the state of Madhya Pradesh, a cross-sectional study conducted in 2019 regarding assessing of infant feeding practices carried out in the urban slums of province of Bhopal reveals that there is still prevalence of practices like giving pre- lacteal feeding, discarding of colostrum, and delayed initiation of breastfeeding in urban slums of Bhopal. ¹¹

A report by National Institute of Child Health and Human Development had revealed which addresses the common barriers to breastfeeding at home and at work that are faced by mothers include lack of experience, pain, too little or too much milk, depression or anxiety, difficulty accommodating breastfeeding at work place. A network of support group was identified which enrolled health care providers, partners and family members in overcoming the above-mentioned challenges. ¹²

Breast feeding is essential for ideal growth, development and health of neonates and infants. According to the World Health Organization (WHO) and the United Nation’s International Children’s Emergency Fund (UNICEF), breastfeeding should be started within one hour after delivery. Additionally, for endorsing early initiation of breastfeeding for all neonates, both organizations recommend sustaining exclusive breastfeeding through six months of age.

There are several advantages of breastfeeding for both the mother and infant. Among the several factors which contribute to the negative effect on initiation of breastfeeding, mode of delivery is one amongst them. As per the recent data caesarean delivered mothers needs more help specially in acquiring position to breastfeed their babies. (Report on breastfeeding, WHO) According to UNICEF, the first 1000 days is a crucial of a child’s life (9 months of pregnancy and the first 2 years of life).

In this period the child is vulnerable to respiratory tract infection, gastroenteritis and malnutrition. The consequent findings were reported related to the predictors of hospital admissions identified were delayed initiation of breastfeeding, non- exclusive breastfeeding, maternal unemployment, mother giving birth to more than two children etc. For improving the health condition of children during the first few years of life, there is a set of recommendations by World Health Organization which includes: putting baby on mother’s chest soon after the delivery (skin- to- skin contact) and unrestricted access to breastmilk, in an attempt to encouraging early initiation of breastfeeding. ¹³

In India however there are many additional factors lying behind delayed initiation of breastfeeding. Lack of awareness among Indian women regarding proper technique of breastfeeding and benefits of colostrum was observed. Also influences of cultural practices in several parts of India like that of giving pre-lacteals and discrimination based on gender of the child born.

At the secondary level hospital in Northern India, a quality improvement intervention was implemented to improve early initiation of breastfeeding among new-born. Where reduced neonatal mortality was found to be associated with EIBF. Method involved introducing and strict implementation of baby- friendly hospital initiative (BFHI) into hospital policy and promoting breastfeeding, failing to which the hospital was not BFHI certified. ¹⁴

A yet another cross- sectional study was carried out in a teaching hospital of Kolkata, India to assess early initiation of breastfeeding among post- natal mothers. The major delays were found due to delay in handing over the baby to the mother usually following a caesarean delivery (22.22%), pain (11.11%), and lack of awareness (14.81%). Also, it revealed that in comparison to caesarean mothers, normal vaginal delivered mothers were able to early initiate breastfeeding and were able to adopt emotionally with the new-born. ¹⁵

Therefore, the data suggest that with the efforts of the policy makers as well as the health care personals it would be easier to overcome this barrier. The study would be useful in finding the challenges that facing the mothers delivered by C.S. and coping strategies to overcoming which could be modified in logical manner so as to uplift the graph of early initiation of breastfeeding in the state.

The findings can offer valuable information for healthcare professionals to help women breastfeed after caesarean sections. To promote women’s breastfeeding behaviours after caesarean sections, it is necessary to change women’s attitudes, belief systems, and the external environments and help them become more confident.

2. Operational Definition

Coping Strategies: Coping is defined as the strategies and tactics employed to manage stressful situations on both an internal and external level. Problem- focused coping, emotion- focused coping, meaning- focused coping, and social coping are the four basic sub- categories of coping ^{16, 17, 18}.

3. Aim of the Study

Assess challenges that caesarean section mothers were facing and coping strategies adopted by them in early initiation breastfeeding. The aims of this study achieved through:

1. Assess initiation of breastfeeding by the mothers who delivered through caesarean section

2. Assess the challenges faced by the mothers who delivered through caesarean section in initiating early breastfeeding.

3. Assess the coping strategies adopted by mothers who delivered through caesarean section in initiating early breastfeeding.

4. Find out the relationship between the challenges faced and coping strategies adopted by the mothers in early initiation of breastfeeding.

5. Find out the association between the challenges faced and selected demographic variables.

6. Find out the association between the coping strategies adopted with the selected demographic variables.

4. Subjects and Methods

Study design

This study was a quantitative descriptive study.

Sample

This study was conducted in post-natal wards of obstetrics units of All India Institute of Medical Sciences, Bhopal, Madhya Pradesh and Jai Prakash District Hospital, Bhopal, Madhya Pradesh. The study sample included 90 post- natal caesarean section mothers. The sample size was calculated using the Taro Yamana 1962 sample size calculation formulae

n = N/ 1+ N(e)2

where, n= sample size

N= Population under study

e= margin of error (here, 0.05)

Inclusion criteria

1. The mother had delivered through caesarean section.

2. The mother had no history of maternal or foetal complications.

3. The mothers whose babies are not in intensive care units after delivery.

4. The mothers who have signed the informed consent.

5. The mothers who could read and understand English and or Hindi.

Data Collection

A self- developed interview questionnaire was used to assess the breastfeeding challenges faced by caesarean section mothers and coping strategies adopted. The developed tool assessed challenges using a four- point Likert type questions and multiple-choice questions for the assessment of challenges.

The researcher identified four domains to assess the challenges based on the Roy’s adaptation Model, upon which nursing care of a post- partum mother could be focused. These were physical domain, physiological domain, psychological domain, and social domain. The researcher incorporated the questions from the mentioned domains in both the assessment of challenges as well as assessment of coping strategies adopted. A total of 18 items were included in the four-point Likert type scale for the assessment of challenges ranging from 0- never, 1- Often, 2- Almost always, 3- Always. The score card was classified into score of 41 and above as high challenges, 27-41 as moderate challenges and < 27 as mild challenges. The score of coping strategies adopted were classified into adaptive coping (< 23), partially adaptive coping (23-30) and maladaptive coping (30 and above).

The data collection was carried out from September 2022 to November 2022. Sampling technique employed was consecutive sample in two settings of Bhopal province of state of Madhya Pradesh, India. A total of 90 participants were included in the study. List of mothers who underwent caesarean section, type of caesarean section, parity, birth weight of infant, and time of delivery were obtained from the records of labor rooms of the respective setting.

Statistical analysis

The effect was analyzed at the level of significance (p< 0.05). Descriptive and inferential statistics was used to analyze the data. In descriptive statistics, frequency and percentage distribution was used to analyze initiation of breastfeeding, the challenges faced by the mothers in initiating early breastfeeding and coping strategies adopted by the caesarean section mothers in early initiation of breastfeeding. Inferential statistical test Chi- square was applied to compute associations between socio demographic variables with challenges faced and coping strategies adopted. Karl Pearson co- relation was used to carry out relationship with challenges faced and coping strategies adopted by caesarean section mothers in early initiation of breastfeeding.

Ethical considerations

Ethical approval was taken by the Institute Human Ethics Committee, Post- Graduate Researches (IHEC, PGR), with LOP No: IHEC-PGR/2021/MSC NURSING/JULY/19. Before initiating the pilot study, permission was taken from Principal, Nursing College, Medical Superintendent, AIIMS Bhopal, and Office of Civil Surgeon, Jai Prakash, District Hospital, Bhopal. After taking the permission from the Senior Nursing Officers of obstetric units of both the setting, the researcher introduced herself to the participants. The participants were disclosed the details of the study and after their assurance, informed consent forms were signed by the participants. Information obtained was kept confidential with the researcher.

5. Results

Majority of the mothers underwent emergency caesarean section (73.3%), most of mothers were of age 25-30 years (41.11%), were graduation (43.3%), most of them belonged to Hindu religion (85.6%). Among the reasons for planned caesarean section large foetus size (10.0%) was the major portion of reasons. For the unplanned caesarean section any of the mentioned causes like prolonged labor, cephalon pelvic disproportion, non-reassuring fetal heart rate and other reasons occupied 20%, 20%, 11.1%, and 40 % respectively. The birth weight of the infant was between 2500-3000 grams for majority of the mothers.

Table 2 illustrates distribution of assessment of initiation of breastfeeding comprising of questions regarding the early establishment of mother- baby bond. Nearly half of the sample 45 (50%) of the mothers first hold their child after 2 hours post-delivery, and first after more than 2 hours post-delivery 56 (62.2%). 37.80% of mothers opt to feed their baby only when the baby cries and most of the mothers feed for 10 minutes 57.80%. Majority of mothers do not use formula feed in 24 hours of birth 42.2%m 30% use around 30 ml, 22,2% use 60 ml and 5.5% use more than 60 ml of formula feed. Due to cultural influences still 4.4 % of the mothers have fed with pre- lacteal feed and 95.6% did not fed with any pre- lacteal feed.

Table 3 depicts the frequency and percentage distribution of challenges faced by the caesarean section mothers in early initiation of breastfeeding. 83.3% of the mothers faced moderate challenges and 16.7% faced higher challenges. Table 4 interprets the domain of challenges faced by caesarean section mothers in early initiation of breastfeeding. 84.51% of the mothers face challenges in the physical domain, 56.85% in physiological domain, 76.42% psychological domain and 60.90% in social domain respectively.

Table 5 depicts Frequency and percentage distribution of assessment of coping strategies adopted by the caesarean section in early initiation of breastfeeding. 63(70%) adopt to partially adaptive coping strategies. 20 (22.2%) adopt to maladaptive coping strategies and 7 (7.8%) adopt to adaptive coping strategies. Table 7 illustrates distribution of the domains of the coping strategies by the caesarean section mothers in early initiation of breastfeeding. 83.10% adopted to emotional focussed coping in which 76.94% of mothers cope emotionally in social domain.

Table 8 illustrates Karl Pearson’s co- relation between challenges faced and coping strategies adopted by the caesarean section mothers in early initiation of breastfeeding. there is slight negative co- relation between the social domain of challenges faced in early initiation of breastfeeding and coping strategies adopted by the caesarean section mothers at the level of significance p <0.05.

Table 9 explains Chi- square association between challenges faced by the caesarean section mothers in early initiation of breastfeeding with selected socio demographic variables. Type of caesarean section is having significant association with level of challenges faced by the caesarean section mothers in early initiation of breastfeeding with selected socio demographic variables (type of caesarean section) at the level of significance p< 0.05 (p- value=0.011).

Table 1 explains Chi- square association between coping strategies adopted by the caesarean section mothers in early initiation of breastfeeding with selected socio demographic variables. Birth weight of infant is having significant association between the level of coping strategies adopted by the caesarean section mothers in early initiation of breastfeeding with selected socio demographic variables (birth weight of infant) at the level of significance p< 0.05 (p- value= 0.007).

6. Discussion

However, early initiation of breastfeeding has many benefits not only for mothers, but also for their babies, whole family and society; caesarean section may hinder the early initiation due to delayed mothers’ amputation and return to their normal daily activity ^{18, 19, 20}.

Delivery by C.S. need coping from delivered mothers for early initiation of breast feeding. Coping mechanisms are behavioral and cognitive techniques used to deal with stressful situations, environments and demands. As a result of this generally recognized transactional perspective, coping has come to be seen as the cognitive and behavioral responses made in response to demands that an individual perceives as threats to their wellbeing, whether they come from inside or outside of them ^{2, 17, 21, 22, 23, 24, 25}.

So, the current study was conducted to asses challenges that caesarean section mothers were facing and coping strategies adopted by them in early initiation breastfeeding.

Regarding assessment of challenges faced by the caesarean section mothers in early initiation of breastfeeding it was found from the results of current study that 75 (83.3%) of the sample population faced moderate challenges, and 15(16.7%) of sample population faced high challenges. Assessment of coping strategies adopted by caesarean section mothers in early initiation of breastfeeding it was found that 20(22.20%) of the participants adopted maladaptive coping, 63 (70 %) of the participants adopted partially adaptive coping, and 7(7.80%) adopted to adaptive coping strategies. For the correlation between the challenges faced and coping strategies adopted by caesarean section mothers in early initiation of breastfeeding it was revealed that there is slight negative co- relation between the social domain of challenges faced in early initiation of breastfeeding and coping strategies adopted by the caesarean section mothers at the level of significance p<0.05.

In caesarean section the shorter time of skin-to-skin contact was significantly associated with breastfeeding initiation and maintenance ²⁶. The effect of caesarean section on initiation of breastfeeding from Ethiopian demographic and health survey, found that caesarean section had increased chances i.e., four times chances of late initiation of breastfeeding than those who had vaginal delivery ²⁷.

There were certain motivating factors to breastfeeding after caesarean section. The benefits of human milk, support groups like healthcare personnel and responsibility to feed their infants. The challenges included physical discomfort, deficit knowledge, lactation deficiency and lack of coping skills in managing their depressive moods after caesarean sections ²⁸.

Regarding the contribution of maternal physical health and breastfeeding problems to maternal moods in the early post-partum period. A high burden of physical problems in the study were classified as to having more than 3 problems, (back pain, caesarean pain, constipation, hemorrhoids, urinary or bowel incontinence) and high burden of breastfeeding problems was associated to be having more than 2 problems (nipple pain, mastitis, over or under supply of milk, and frequent expressing). It was concluded that combined with comorbid physical problems and high burden of breastfeeding problems could have a significant effect on mothers’ mood and mental health. ²⁹

An empirical analysis of how husbands, mother- in- law, health workers and mothers influence breastfeeding practices in Uttar Pradesh, India reveals that mother and mother- in- law does play a role in reducing the use of pre-lacteal feeding and thus are a preferred choice for social support by the mother who had vaginal or caesarean delivery. ³⁰

Study Limitations

The study explored the challenges on the maternal aspects only, neonatal aspects must have been included. The study was conducted on a small population which limits its generalizability. As the study design is quantitative, limited amount of information could be found.

Conclusion and Recommendations

The present study had found that caesarean section delivery who possess varied degrees of challenges for the mothers. Most evident are the physical challenges which comprises of surgical pain, breast pain and engorgement. Mothers need to cope with these challenges in order to early initiate the breastfeeding and promote exclusive breastfeeding. Mothers adopt to partially coping strategies to combat with these challenges. The coping strategies were centered at emotional coping adopted according to their cultural influences

It is established that early initiation of breastfeeding does take due time in case of caesarean section mothers. The need arises to minimize the time of establishment of EIBF among caesarean section mothers. Family and social surrounding play an important role. Promoting family centered and partner centered approach is need of the hour.

Financial Support & Sponsorship

The authors declared that this project had not received any financial aid.

Conflict of Interest

The authors have no conflict of interest to declare.

References