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Revista chilena de nutrición

versión On-line ISSN 0717-7518

Rev. chil. nutr. vol.46 no.6 Santiago dic. 2019

http://dx.doi.org/10.4067/S0717-75182019000600708 

Original Article

Care practices associated with breastfeeding among pregnant and lactating women

Prácticas de cuidado en mujeres gestantes y lactantes asociadas a la lactancia materna

Yibby Forero-Torres1  * 

Gina Morales1 

Alexandra Hernández1 

Marisol Galindo1 

Jhon Jairo Romero1 

Pablo Chaparro2 

1Nutrition Group, Directorate of Public Health Research, Subdirectorate of Scientific and Technological Research, National Institute of Health. Bogotá, Colombia

2National Health Observatory Directorate, National Institute of Health. Bogotá, Colombia

ABSTRACT

Descriptive cross-sectional study with 417 pregnant women and 388 lactating women, belonging to a Comprehensive Care Program in Bogotá. A modular survey was applied with sociodemographic and health variables analyzed by frequency distributions, central tendency, and dispersion, with bivariate and multivariate analyses used to calculate odds ratios (OR) with 95% confidence intervals. 17% were under 18 years of age. Only 66.8% of all of the women had immediate skin-to-skin contact with their child. The risk factors for skin-to-skin contact and early initiation of breastfeeding were type of delivery (cesarean) (OR: 23.15, 95% Cl: 12.99,41.25) and (OR: 2.6, 95% Cl: 1.43, 4.73) respectively; In addition, newborn hospitalization for more than 3 days was also a risk factor for the early initiation of breastfeeding (OR: 2.85, 95% Cl: 1.42, 5.72). Not having skin-to-skin contact between the mother and her newborn was a risk factor for the early initiation of breastfeeding (OR: 2.43; Cl: 1.34; 4.41).

Keywords: Breastfeeding; Education; Pregnancy; Puerperium; Skin to skin contact and childbirth

RESUMEN

Estudio descriptivo transversal con 417 gestantes y 388 mujeres lactantes, perteneciente a Programa de Atención Integral en Bogotá. Encuesta modular aplicada con variables sociodemográficas y salud analizadas por distribuciones de frecuencia, tendencia central, dispersión, análisis bivariados y multivariados para calcular odds-ratios (OR) con intervalos de confianza (95%). 17% menores de 18 años. Solamente el 66.8% de todas las participantes tuvieron contacto piel a piel con sus hijos. Los factores de riesgo para el contacto piel a piel y el inicio temprano de la lactancia materna fueron el tipo de parto (cesárea) (OR: 23.15, IC95%: 12.99, 41.25) y (OR: 2.6, IC95%: 1.43, 4.73) r espectivamente; además, para el inicio temprano de la lactancia materna también fue factor de riesgo la hospitalización del recién nacido por más de 3 días (OR: 2.85, IC95%: 1.42, 5.72). No tener contacto piel a piel entre la madre y su recién nacido fue un factor de riesgo para el inicio temprano de la lactancia materna (OR: 2.43, 1C: 1.34, 4.41).

Palabras clave: Lactancia; Educación; Embarazo; Puerperio; Contacto piel con piel y parto

INTRODUCTION

Monitoring and evaluation of prenatal care are considered strategic approaches in the decision-making processes in health services1,2 and on the preparation for not only childbirth but also childrearing and breastfeeding.

Currently, during the first 24 hours after childbirth, more equitable attention is being paid to improving the survival of the mother-child dyad. However, during labor and the postnatal and puerperal period, critical opportunities to apply simple practices that can benefit the long-term nutrition, health, and outcomes of child development well beyond the neonatal period are being overlooked3. According to the World Health Organization (WHO)4: “Delayed umbilical cord clamping, immediate mother-to-newborn skin-to-skin contact, and initiation of exclusive breastfeeding are three simple practices that can be implemented”.

It has been shown that skin-to-skin contact provides multiple benefits for both the newborn and the mother5,6. Several studies have concluded that it not only favors the changes that occur in the newborn during the adaptation period4,7 (transition from intrauterine to extrauterine life)8. Among the advantages and benefits achieved with the practice of skin-to-skin contact are that, in the newborn, it provides stabilization of vital functions4, improves oxygen saturation levels, maintains stable body temperature4,9, decreases the perception of pain4,10, and favors early breastfeeding11, among others.

Within the goals of the Ten-Year Plan for Breastfeeding 2010-202012, the early initiation of breastfeeding is established as a sentinel quality indicator, considered as breastfeeding the newborn within the first hour after birth, incorporated in the quality monitoring indicators for Institutions Providing Services (Instituciones Prestadoras de Servicios - IPS) since 2011. Likewise, it is part of the 10 steps contemplated in the global strategy of Women- and Children-Friendly Institutions (Instituciones Amigas de la Mujer y la Infancia - IAMI)13.

In Colombia, according to the 2010 National Survey of the Nutritional Situation in Colombia (Encuesta Nacional de la Situación Nutricional en Colombia 2010 - ENSIN 2010)14, 56.6% of Colombian women breastfed their children in the first hour following birth, which reflects an improvement in this practice since in 2005, when only 49% of women breastfed within the first hour.

The early initiation of breastfeeding has benefits for the survival of the infant, promotes health, and brain and motor development. Although breastfeeding provides lifelong benefits to the child, the risks of not receiving it are much more pronounced in childhood15,16. The early initiation of breastfeeding and its exclusive use during the first 6 months of life are related to decreased risk of mortality, largely because it reduces the risk of contracting infectious diseases.

Despite the knowledge of the advantages and benefits that come with skin-to-skin contact and early initiation of breastfeeding as care practices, health professionals and policymakers have paid little attention to these simple preventive strategies, except for some annual campaigns that try to highlight their importance, such as World Breastfeeding Week. Therefore, this research saught to determine pre- and postpartum care practices related to breastfeeding in a group of pregnant and lactating women of a comprehensive care program in the capital district of Colombia to strengthen care strategies aimed at the pregnant and lactating population.

MATERIALS AND METHODS

A cross-sectional descriptive study was conducted among female beneficiaries of a Comprehensive Care Program in the city of Bogotá who were in the third trimester of pregnancy. From a total of 2,000 women and by means of simple random sampling, a sample of 382 women was estimated, for which a prevalence of 50%, a confidence level of 97%, and an error of 5% were considered. Due to the high mobility of the participants in the program, the sample was inflated by 10%, considering possible losses. The study was initiated with the collection of information for the indicators related to the pregnancy in 417 women; then, during a period of approximately 6 months, information was obtained from 388 mothers and their newborns up to 2 months of age who belonged to the Program. This information included food support and education on health and nutrition issues. A modular survey was administered for data collection, where sociodemographic (age, ethnicity, socioeconomic stratum, educational level, General System of Social Security in Health (Sistema General de Seguridad Social en Salud - SGSSS)1, among others), health, and care variables related to perinatal conditions were analyzed.

All of the information was collected between May-October 2015 by trained professionals of the research team through a capture program, which was designed in CSPro software, a Computer Assisted Personal Interviewing (CAPI) application developed for mobile capture devices, used for the intelligent capture of studies and surveys, establishing a validation mesh for the quality control of each of the proposed questions. The information was systematized in Excel databases. Skin-to-skin contact and early initiation of breastfeeding were dependent variables for the analysis. The results are presented as measures of frequency, central tendency, and dispersion. To explore the association between the associated factors and the dependent variables, bivariate analyses were performed, calculating odds ratios (OR) with 95% confidence intervals. The factors that were significantly related to the outcomes in bivariate analyses (p<0.05) were included in a multivariate model, using non-conditional multiple logistic regression to adjust for confounding factors. We used Stata 12 for data analysis.

This research embraced the regulations for health research studies, established in the Declaration of Helsinki17. In addition, it took into account the Scientific, Technical, and Administrative Norms of Health Research established in resolution No. 008430 of 19939 in Colombia18, which defined it as minimum risk. Likewise, each of the participants signed an informed consent. The project was approved by the Technical and Ethics Committees of the National Institute of Health of Colombia.

RESULTS

Initially, 417 pregnant women whose ages varied between 14 and 45 years with an average of 23.7 +/- 6.4 years were included. Of these, 17% were under the age of 18. Moreover, 66.9% belonged to stratum two (209.2 USD average income/month), and 76.5% achieved a secondary educational level. In relation to the General System of Social Security in Health, 48.4% were paid by worker-employer, 47.2% people with no ability to pay, 4.1% not affiliated in any of the two regimes, and only 0.2% were not affiliated (not PUP) (Table 1).

Table 1 Socio-demographic characteristics of the participants. 

Variables n %
Age (n= 417)*
< 18 years 71 17.0
18 and > years 346 83.0
Socioeconomic stratum*
0 1 0.2
1 73 17.5
2 279 66.9
3 62 14.9
5 1 0.2
No information 1 0.2
Educational level*
Primary 23 5.5
Secondary 319 76.5
Higher education 74 17.7
None 1 0.2
General System of Social Security in Health (SGSSS)*
Contributory regime 202 48.4
Subsidized regime 197 47.2
Not affiliated with the system 1 0.2
Poor uninsured 17 4.1

p value < 0.001

Note: Socioeconomic stratum: stratum 1 (196.1USD average income/month), stratum 2 (209.2 USD average income/month), stratum 3, (USD) y stratum 3 (231.8USD). SGSSS: Law 100 of 1993 of Colombia. Whose fundamental purpose is to achieve universal coverage in the provision of health care services, through regimes: contributory, fully financed with compulsory worker-employer contributions; the one of social or subsidized security, financed with subsidies to the demand of fiscal origin and parafiscal solidarity. Poor uninsured population (PUP), person who is not affiliated in any of the two regimes, but the State acts as Responsible and Non-Affiliated Population, not identified as PUP.

In table 2 shows that among pregnant women, 98.3% attended their prenatal check-ups, and only 1.4% did not attend, stating that the service was far from their home, that they did not know where the service was being provided, that they did not have time, that transportation was expensive, and that there were delays in assigning appointments. Mothers who attended prenatal check-ups during the first 3 months of pregnancy amounted to 63.1%.

Table 2 Participant risk factors. 

Number of prenatal check-ups* 410 98.3
Numer of prenatal check-ups during the first 3 months of pregnancy* 263 63.1
Number of prenatal check-ups*
1 a 5 196 47.0
6 a 10 199 47.7
> 10 14 5.3
Professional who attended prenatal care
General doctor* 246 59.0
Gynecologist* 254 60.9
Nurse* 125 30.0
Nursing Assistant* 16 3.8
Training or education in breastfeeding* 230 55.2
Institution that gave the training
Service Provider Institution* 174 75.7
Comprehensive care program* 104 45.2
Relatives* 48 20.9
Other* 5 2.2
Type of delivery*
Caesarean section 147 37.8
Vaginal 233 59.9
Vaginal / Instrumented 9 2.3
Professional who attended the birth *
Nurse 19 4.9
Gynecologist 304 78.1
General doctor 64 16.5
Other 2 0.5
Complications during childbirth* 78 20.1
Mother hospitalized after childbirth for more than three days* 38 9.8
Child hospitalized after childbirth for more than three days* 48 12.3
Skin to skin contact immediately* 260 66.8
Early start of breastfeeding* 268 68.9
Breastfeeding by sex of the newborn*
Man 127 47.4
Woman 141 52.6
Postpartum medical control* 318 82.0
Period of time to attend postpartum control*
7 days 151 47.3
8 to 15 days 134 42.0
16 and + days 33 10.3
Did not assist 71 0.3

p-value < 0.001

Although almost all of the pregnant women attended the check-ups, 47% of the women had a reduced number of appointments with less than six check-ups; however, 47.7% attended between 6 and 10 check-ups, and 5.3% attended more than 10 check-ups. For the women participating in the study, 60.9% of the prenatal check-ups were attended by a gynecologist. In 100% of the minors and 98.2% of those over 18 years old, the prenatal check-ups were attended by health professionals.

More than half (55.2%) of the respondents acknowledged that they received training or education on breastfeeding before childbirth. Of those under 18 years old, 19.1% reported having received training, in contrast to 80.9% of women 18 years of age or older. Of those who received training or education, 75.7% of the pregnant women received it from the IPS and 45.2% from the comprehensive care program of the capital district, 20.9% from relatives, and only 2.2% from their own experiences and information received from friends, the National Training Service (Servicio Nacional de Aprendizaje - SENA), and work colleagues.

Information about childbirth was collected for 388 of the 417 pregnant women who participated. It was established that 100% of births were cared for in a hospital institution, and more than half (59.9%) of births were vaginal. Cesarean sections, considering the age groups, were presented in percentages close to the total of the population (37.8%); that is, 37.8% for those 18 years and older and 36.9% for those under 18. Instrumented deliveries (referring to those births where instruments such as forceps and a vacuum extractor were used)19 represented a lower proportion (2.3%) of the total population. In 78.1% of cases, the delivery was attended by an obstetrician/gynecologist, 16.5% by a general practitioner, 4.9% by a nurse, and only 0.5% by a medical practitioner.

During delivery, 79.9% of the women did not present complications; among the remaining 20.1%, the main complications were arterial hypertension, fetal distress, abnormalities in the dynamics of labor, and hemorrhages. For these complications, 9.8% of the mothers were hospitalized for more than 3 days after the birth. In addition, 12.3% of the newborns were hospitalized for this same period due to jaundice, aspiration of amniotic fluid, respiratory problems, hypoglycemia, feeding problems (breastfeeding), and other complications.

Only 66.8% of all of the women had immediate skin-to-skin contact with their child, that is, by placing the naked newborn in the prone ventral position on the mother's abdomen and cover them with a heated blanket3. Likewise, it was found that 68.9% of the women started breastfeeding early, with a higher percentage in girls (52.6%).

It is important to note that 82% of the lactating women attended postpartum medical check-ups. Almost half (47.3%) of them came in the first 7 days after the delivery, 42% between 8 and 15 days, and 10.3% after more than 16 days. A total of 18% of women did not attend their postpartum check-up because they did not schedule an appointment, it was not authorized, it was lost, there was no affiliation with the health system or it was not active, they did not know that they had to go to the check-up, it was forgotten, and other reasons.

71.9% of the mothers received education in breastfeeding after the delivery, which was mostly supplied by the staff of the IPS (88.9%), while 8.2% obtained this advice from the staff of the comprehensive care program of the Capital District, and 2.5% obtained this information from family members. More than half of the mothers in the study received this advice during the first day after the delivery, and 28.7% received it during the first week after the birth. In table 3 all the variables were included in the bivariate analysis for the skin-to-skin contact and the early initiation of breastfeeding.

Table 3 Bivariate analysis for skin-to-skin contact and early initiation of breastfeeding. 

Skin-to-skin contact Early initiation of breastfeeding
Variable n % OR Lo. Lim Up. Lim p n % OR Lo. Lim Up. Lim p
Ages
< 18 years 24 35.3 1.13 0.65 1.96 0.656 18 26.5 0.76 0.42 1.36 0.356
> 18 years 104 35.2 1 Reference 103 32.2 1 Reference
Socioeconomic stratum
1 a 2 112 34.4 1.5 0.82 2.78 0.189 103 31.6 1.13 0.62 2.05 0.690
3 a 5 16 25.8 1 Reference 18 29 1 Reference
Educational level
< secondary 41 28.7 0.73 0.47 1.14 0.167 37 25.9 0.67 0.42 1.06 0.085
>= secondary 87 35.5 1 Reference 84 34.3 1 Reference
General System of Social Security in Health
No 2 12.5 0.28 0.06 1.25 0.075 2 12.5 0.3 0.07 1.36 0.099
Yes 126 33.9 1 Reference 119 32 1 Reference
Prenatal check-ups
No 2 33.3 1.02 0.18 5.62 0.986 2 33.3 1,11 0,20 6.12 0.909
Yes 126 30 1 Reference 119 31.2 1 Reference
Prenatal check-ups during the first 3 months of pregnancy
No 46 33.3 1.03 0.66 1.6 0.913 40 29 0,85 0,54 1,34 0.492
Yes 80 32.8 1 Reference 79 32.4 1 Reference
Number of prenatal check-ups
1 to 4 38 32.2 0.94 0.59 1.5 0.810 42 35.6 1.33 0,84 2.12 0.219
5 and more 88 33.5 1 Reference 77 29.3 1 Reference
Gynecologist attended prenatal care
Yes 90 37.5 1.77 1.12 2.8 0.015 81 33.8 1.39 0,88 2.2 0.154
No 36 25.4 1 Reference 38 26.8 1 Reference
Training or education in breastfeeding
No 61 35.9 1,26 0,82 1,93 0.285 55 32.3 1,10 0,71 1,70 0.661
Yes 67 30.7 1 Reference 66 30.3 1 Reference
Institution that gave the training
No 62 37.1 1,39 0,91 2,12 0.132 56 33.5 1.21 0.77 1.91 0.386
Yes 66 29.9 1 Reference 65 29.4 1 Reference
Type of delivery
Caesarean sect on 105 71.9 24.4 13.9 42.7 < 0.0001 75 51.4 4.5 2.85 7.11 < 0.0001
Vaginal 23 9.5 1 Reference 46 19 Reference
Gynocologist-obstetrician attended the delivery
Yes 111 36.6 2.31 1.29 4.13 0.004 103 34 1.92 1.08 3.4 0.024
No 17 20 1 Reference 18 21.2 1 Reference
Institution that gave the trainng
Yes 34 43.6 1.77 1.07 2.95 0.026 36 46.2 2.27 1.36 3.78 0.001
No 94 30.3 1 Reference 85 27.4 1 Reference
Mother hospitalized after childbirth for more than three days
Yes 19 50,0 2.21 1.13 4.34 0.019 15 39.5 1.5 0.75 2.99 0.246
No 109 31.1 1 Reference 106 30.3 1 Reference
Child hospitalized after childbirth for more than three days
Yes 18 37.5 1.25 0.67 2.35 0.478 24 50 2.51 1.36 4.62 0.003
No 110 32.4 1 Reference 97 28.5 1 Reference
Sktin to skin contact immediately
No 69 53.9 4,68 2,95 7,42 < 0.0001
Yes 52 20 1 Reference
Newborn sex
Man 72 36.6 1.39 0.91 2.13 0.130 70 35.5 1.51 0.96 2.39 0.061
Woman 56 29.3 1 Reference 51 26.7 1 Reference
Attend postpartum check-up
No 21 30 0,85 0,48 1,48 0.557 18 25.7 0,72 0,40 1,30 0.275
Yes 1 07 33.7 1 Reference 1 03 32.4 1 Reference
Period of time to attend postpartum check-up
Did not attend 107 33.8 1,21 0,69 2,12 0.499 103 32.5 1,42 0,79 2,54 0.240
Attended 21 29.6 1 Reference 18 25.4 1 Reference

In the multivariate analysis, table 4 showed that the factor associated with lack of skin-to-skin contact was the type of delivery (cesarean section) (OR 23.15, IC 95% 12.99 41.25) and in table 5 the factors related to not initiating breastfeeding were type of delivery (caesarean section) (OR 2.60; CI 95%: 1.43; 4.73), and hospitalization of the newborn for more than 3 days after the delivery (OR 2.85; CI 95%: 1.42; 5.72). Additionally, it was found that not having skin-to-skin contact between the mother and her newborn is a risk factor for the early initiation of breastfeeding (OR: 2.43; CI 95%: 1.34; 4.41).

Table 4 Multiple regression model for factors associated with skin-to-skin contact. 

Variable Confidence interval
OR Lower Limit Upper Limit P value
Prenatal-gynecologist check-up
Yes 1,49 0,82 2,71 0.193
No 1
Type of delivery
Caesarean section 23,15 12,99 41,25 <0.001
Vaginal 1
Professional attended labor: Gynecologist
Yes 2,01 0,94 4,30 0.073
No 1
Complications during childbirth
Yes 0,92 0,44 1,91 0.827
No 1
Hospitalization of the mother for more than 3 days after the delivery
Yes 1,60 0,61 4,19 0.334
No 1

Table 5 Multiple regression model for factors associated with the early initiation of breastfeeding. 

Variable Confidence interval
OR Lower Limit Upper Limit P value
Type of delivery
Caesarean section 2,60 1,43 4,73 0.002
Vaginal 1
Professional attended labor: Gynecologist
Yes 1,60 0,85 3,01 0.146
No 1
Complications during childbirth
Yes 1,63 0,92 2,87 0.093
No 1
Child hospitalized after childbirth for more than three days
Yes 2,85 1,42 5,72 0.003
No 1
Skin to skin contact immediately
No 2,43 1,34 4,41 0.003
Yes 1

DISCUSSION

The care practices (prenatal care, postnatal care, and breastfeeding) of women in the pregnancy and lactation stages are very important, not only for their health status but also for the nutrition and development of their children. Considering the above, the Clinical Practice Guidelines for the prevention, early detection, and treatment of the complications of pregnancy, childbirth, or puerperium20 show that if prenatal check-ups are initiated during the first trimester of pregnancy, in a pregnancy without complications, a program of 10 check-ups is recommended, whereas for a multiparous woman, a program of seven check-ups is recommended.

Nevertheless, a prenatal check-up program with a reduced number of appointments is not recommended, as it is associated with an increase in perinatal mortality, especially in developing countries20. In this sense, the study showed a low number of appointments, due to the fact that almost half of the participants had fewer than six prenatal exams, which could be a risk factor. Likewise, according to WHO figures, only 63% of pregnant women in Africa, 65% in Asia, and 73% in Latin America attend at least one prenatal consultation21. Other studies have reported a prevalence of 69%22 and 38.8%23, with a median of four consultations per pregnant woman24. In 2014, on average, only 52% of pregnant women in developing regions received the recommended number of prenatal visits during pregnancy25.

In terms of coverage and quality of prenatal care and delivery, the National Survey of Demography and Health 201526 (Encuesta Nacional de Demografía y Salud 2015 - ENDS 2015) reported that 98% of pregnant women received prenatal care provided by a qualified health professional (physician and nurse). In the last three decades, there have been significant changes in delivery care in health facilities, from 76% in 1990, to 88% in 2000, to 92% in 2005, and to 95% in 201027, data that coincide with those found in this study, where all of the births of the participants were institutionalized, and 99.5% were attended by a health professional from the hospital network of the district.

The WHO28 reports that there are 136 million deliveries each year, 20 million of which have complications, such as depression, postpartum hemorrhage, pregnancy-induced hypertension, and puerperal sepsis, and although the pregnant women attend all of their prenatal check-ups, they can present some sudden complications during labor. In this study, the 3 most frequent causes of complications presented during delivery in two out of 10 mothers were high blood pressure, lack of dilation of the cervix, and hemorrhages. This situation continues to be worrisome since maternal and child morbidity and mortality have become serious public health problems in developing countries29.

In spite of that, it has been demonstrated that some health interventions can prevent or manage these complications, including prenatal care during pregnancy, skilled attendance during delivery, and postpartum care and support25. Furthermore, the humanization of childbirth includes favoring and modifying the care conditions of the same, with the purpose of reducing the medicalization of the care of the mother and the newborn when other simple procedures can be effective and sufficient20. Among these practices are skin-to-skin contact and early initiation of breastfeeding.

Current studies indicate that direct contact of the mother's skin with that of the child shortly after birth helps initiate early breastfeeding and increases both the likelihood of maintaining breastfeeding exclusively between the first and fourth months of life and the total duration of breastfeeding30. In addition, the WHO recommends that mothers should be encouraged, by offering help if necessary, to recognize the signs that indicate they are ready to start breastfeeding31.

Faced with this issue, the results showed that the lack of skin-to-skin contact between the mother and her newborn limits the early onset of breastfeeding, as in the results of the study by Kolsoom et al (2018)32 showed an association between skin-to-skin contact between mothers and their newborns and early onset of breastfeeding (OR 2.86, 95% CI 1.68, 4.85), which also it was reported by Aghdas et al (2014)33. Additionally, Moore, Anderson, Bergman (2007)34, in a systematic review that included 30 controlled clinical trials with 1,925 mother and child dyads, they found that skin-to-skin contact had positive effects on breastfeeding up to 4 months after delivery and on the duration of the same, in accordance with the Clinical Practice Guidelines20 that considered this high-quality scientific evidence and recommend that women maintain skin-to-skin contact with their children immediately after birth.

Furthermore, cesarean section is one of the most frequent surgical operations in the world, and its rates continue to increase, particularly in middle- and high-income countries35. When the cesarean section is medically justified, it is effective in preventing maternal and perinatal morbidity and mortality. Though, this procedure can be an impediment to the first skin-to-skin contact in many environments, hence the early initiation of breastfeeding due to the usual procedures established in the hospital network.

Rowe-Murray, Fisher (2002)36 designed a study to test the hypothesis that hospital practices in the immediate postpartum period that are associated with a surgical intervention in childbirth can affect the first mother-child contact and the initiation of breastfeeding. Therefore, their study revealed that women who had a cesarean section experienced a significant delay in breastfeeding compared with women who deliver vaginally, with or without instrument assistance (p<0.001). This result is similar to that obtained in our study, where having had a cesarean section was associated with a lower odds of early initiation of breastfeeding.

In 2010, Zanardo et al.37 studied the effect of cesarean section on breastfeeding and observed that the prevalence of breastfeeding in the delivery room was significantly higher after vaginal delivery compared with that after delivery by cesarean section (71.5% versus 3.5%, p<0.001). In newborns delivered by cesarean section, there was a longer interval between birth and the initiation of breastfeeding (mean ± SD, hours, 3.1 ± 5 vs. 10.4 ± 9, p<0.05).

In the same way, other factors also favor or disfavor the early initiation of breastfeeding, as was observed in the study by Dennis (2002)38, where adolescent mothers were less likely to initiate breastfeeding compared with older mothers, contrary to what was found in this research, in which we found no effect of age on breastfeeding.

Furthermore, the reviews performed by Lumbiganon P et al. (2012)39 demonstrated the importance of formal education in the subject of breastfeeding before birth and its positive effect on the duration of the practice. Education is a key element in the promotion of health and a means for the development of critical and reflective awareness for the production of learning that helps people to take better care of themselves and their families40. The information obtained in this study does not confirm what was established in the previous literature review since it was not possible to establish an association between education and/or training in breastfeeding and its early initiation and skin-to-skin contact. However, as proposed by Catunda HLO et al. (2015)41, whose objective was to evaluate the determining factors of adherence to exclusive breastfeeding in the first month of life and the participation of institutional actors in the promotion of this process, the results obtained from our research provide information for the promotion of exclusive breastfeeding through proper guidance during pregnancy and after delivery.

Though, it is important to mention that one of the difficulties presented in this research is related to the sample since it was performed in a particular context, among pregnant women in a comprehensive care program in Bogotá. Therefore, the results cannot be generalized to the entire pregnant population. Nevertheless, they are true for the population studied and can be inferred to the total population from which the sample was obtained. Considering that one of the information collection strategies was the survey, memory biases could be presented, since it is based on questions that require a certain degree of recall over time.

CONCLUSION

Sociodemographic factors (age, socioeconomic status, marital status, affiliation with the SGSSS and education or training in breastfeeding) were not statistically related to skin-to-skin contact and early initiation of breastfeeding. Instead, some variables, such as cesarean delivery and newborn hospitalized for more than 3 days were risk factors for skin-to-skin contact in the mother-child dyad and early initiation of breastfeeding. Also, not having skin-to-skin contact between the mother and her newborn is a risk factor for the early initiation of breastfeeding.

Considering the different variables that can relate to skin-to-skin contact and the early initiation of breastfeeding, it is important to establish strategies, especially in the hospital setting, common to all professionals for directing and performing these simple interventions. Likewise, it is important to offer continuing education in the care of the mother and the newborn in relation to current international, national, and institutional policies related to breastfeeding and skin to skin contact.

1Law 100 of 1993 of Colombia. Whose fundamental purpose is to achieve universal coverage in the provision of health care services, through regimes: contributory, fully financed with compulsory worker-employer contributions; the one of social or subsidized security, financed with subsidies to the demand of fiscal origin and parafiscal solidarity. Poor Uninsured population(PUP), person who is not affiliated in any of the two regimes, but the State acts as Responsible y Non-Affiliated Population, not identified as PUP.

REFERENCES

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Received: July 23, 2018; Revised: February 29, 2019; Accepted: August 06, 2019

*Dirigir correspondencia a: Yibby Forero Torres, Grupo de Nutrición, Dirección de Investigación en Salud Pública, Subdirección de Investigación Científica y Tecnológica, Instituto Nacional de Salud. Avenida Calle 26 N° 51-20, B-250/B-247. Bogotá, D.C., Zona 6, Colombia. Teléfono: 2207700 Ext 1222. E-mail: aforero@ins.gov.co

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