The present findings show that after controlling for the effects of socio-demographic and delivery-related characteristics the women that had C/S had a 1.428-fold higher risk of non-EIBF and a 1.468-fold higher risk of non-EBF than those that had VD (Table 5). In response to a growing body of evidence scientists stated, “Never before in the history of science has so much been known about the complex importance of breastfeeding for both mothers and children” (17). Mode of delivery is among the factors that play an important role in breastfeeding practices. C/S can negatively affect the physiology of lactation and can cause adverse events that hinder maternal contact with the neonate, resulting in intolerable post-surgical maternal pain and an increase in the level of need for intensive care required by neonates, both of which can negatively affect breastfeeding (10,14,18-20). The present study’s multivariate analysis indicates that maternal level of education, residential region and mode of delivery are significantly related to non-EIBF and that mode of delivery has a significant relationship with non-EBF. The literature shows that maternal level of education is among the most significant determinants of breastfeeding behaviour (21); however, findings related to the effect of maternal level of education on breastfeeding behaviour are inconsistent. Studies from Iran (22) and Bahrain (23) reported that as the maternal level of education increases the likelihood of breastfeeding decreases, whereas studies from Argentina (24) and Italy (25) show there is a positive association between maternal level of education and the likelihood of breastfeeding. Based on the present study’s findings, we think that the benefits of colostrum were well known to the mothers with a high level of education due to their use of modern information resources (healthcare professionals, scientific books and the Internet); therefore, they were highly motivated to feed colostrum to their newborns and fully cooperated with healthcare personnel when they were in-patient, even though their intention for EBF in the days following delivery did not continue in all cases. These results indicate that maternal level of education might be a potential confounder.
Bivariate analysis in the present study shows that there is a significant relationship between place of residence and non-EBF (43.0% of the non-EBF women lived in urban areas, versus 33.9% in rural areas [P = 0.033]), while there isn’t a significant relationship between place of residence and non-EIBF (Table 2). Adewuyi et al. (19) and Pandey et al. (26) reported that the non-EIBF rate is lower in women from rural residences, based on DHSs. The significance of the relationship between place of residence and non-EBF in the present study disappeared in multivariate analysis. As such, we think that place of residence alone did not have a significant effect on breastfeeding practices of the women that delivered in hospitals. The non-EIBF rate (51.2%) was highest in the present study’s women from Eastern Anatolia, which is the least developed region of Turkey, whereas the non-EIBF rate was highest (51.2%) in those from Western Anatolia (the most developed region) (Table 2). The difference in ORs between these two regions was significant according to regression analysis (Table 4), indicating that residential region could potentially be consider another confounder.
In the present study the risk of non-EIBF and non-EBF was calculated, and was observed to be related to C/S. The relative risk of non-EIBF was 1.341 (95% CI: 1.132-1.589) when the C/S and VD groups were compared without adjustments. After controlling for maternal level of education and residential region, the SIR was 1.428 based on the adjusted incidence rates for non-EIBF, which indicates that the risk of non-EIBF in the women that had C/S was 1.428-fold higher (95% CI, 1.212-1.683) than in those that had VD. The risk of non-EBF three days after delivery in the women that had C/S was 1.468-fold higher (95% CI, 1.233-1.748) after adjusting for maternal level of education and residential region.
According to secondary analysis of the WHO Global Survey (27) using data from several countries, the adjusted OR for EIBF was 0.28 (95% CI: 0.22-0.37; P <0.001) for women that had C/S, indicating an evidently high risk of non-EIBF in cases of C/S. Prior et al. (9) also observed that the EIBF rate in cases of C/S was low; their calculated pooled OR was 0.57 (95% CI: 0.50, 0.64; P < 0.00001). Regan et al. (28) reported that women that had successful VD were 1.42-fold more likely to be EIBF than women that had a planned C/S after a previous C/S (95% CI: 1.30-1.56) and that those that had C/S after an unsuccessful attempted VD were 1.15-fold more likely to be EIBF than women that had a planned C/S after a previous C/S (95% CI: 1.01, 1.31).
The results of the present study should be considered with respect to some limitations. The present study was based solely on data obtained from the 2013 TDHS; therefore, factors associated with breastfeeding not included in the survey were not analysed. As such, it is possible that mode of delivery and breastfeeding are correlated with hospital characteristics (such as type, region and size) in which the women delivered; however, the 2013 TDHS data was not sufficient for evaluating this possibility. In addition, the data could not be used to determine if any of the women delivered babies in hospitals that were not baby-friendly. Moreover, the 2013 TDHS did not collect data about the women’s pre-delivery intentions to breastfeed. It is possible that some of the women had decided not to breastfeed or not to use ideal breastfeeding practices before delivery, but such data were not included in the 2013 TDHS. The number of deliveries that could be considered unnecessary C/S was not known and it could not be determined if any of the women had valid barriers to breastfeeding. The survey also did not include any data concerning the number of women that had instrumental or anaesthetic VD, which can cause a delay in mother-baby contact.
On the other hand, the present study has some strengths that should be acknowledged. The study was based on a subsample of a nationally representative survey that gathered high-quality data. The retrospective cohort design of the study facilitated a thorough examination of the relationship between C/S and breastfeeding practices. Several potential influences were excluded through the selection procedure for the study sample and some other confounders were controlled for via standardization; thus, the measurement of the effect of C/S on breastfeeding practices was refined.