|Year : 2022 | Volume
| Issue : 1 | Page : 30-37
>Early initiation of breastfeeding: Antenatal, peripartum, and neonatal correlates
Ismaiel Abu Mahfouz1, Fida Asali2, Tasneem Khalfieh3, Heba Abu Saleem3, Sereen Diab3, Batool Samara3, Hatim M Jaber1
1 Department of Obstetrics and Gynaecology, Faculty of Medicine, Al Balqa Applied University, Al Salt, Jordan
2 Department of Obstetrics and Gynaecology, Faculty of Medicine, Hashemite University, Zarka, Jordan
3 Department of Obstetrics and Gynaecology, Specialty Hospital, Amman, Jordan
|Date of Submission||09-Feb-2021|
|Date of Decision||11-Oct-2021|
|Date of Acceptance||24-Nov-2021|
|Date of Web Publication||03-Jan-2022|
Ismaiel Abu Mahfouz
P.O. Box 850253, Sawifiah, 11185, Amman
Source of Support: None, Conflict of Interest: None
Introduction: The World Health Organization recommends early initiation of breastfeeding (EIBF). This is because breastfeeding is important for the child's development and has maternal benefits. Current literature has focused on sociodemographic factors, and the evidence supporting antenatal, peripartum, and neonatal variables is limited and contradicting. The main aim of this study is to report the rates of early breastfeeding initiation and their antenatal, peripartum, and neonatal correlates. Materials and Methods: A prospective observational study of pregnant women who attended the labor ward of the Specialty Hospital in Amman, Jordan between September 1, 2019, and June 1, 2020, was conducted. Inclusion criteria required women to be 18 years of age or more. Demographic, antenatal, peripartum, and neonatal data were collected. The timing of breastfeeding initiation was recorded in the 1st h and between 1 and 24 h and then data were analyzed. Results: A total of 300 women were recruited with mean age of 29.5 years and mean gestational age being 38.6 weeks. In addition, breastfeeding initiation rates were 26.3% and 65.5% within the 1st h and between 1 and 24 h, respectively. Antenatal, peripartum, and neonatal variables that were associated with lower rates of EIBF (P < 0.05) include antenatal obstetrics complications, induction of labor, assisted vaginal delivery, caesarean section (CS), CS performed on maternal request, CS under general anesthesia, surgical site pain, mother's perception of inadequate pain management, preterm delivery, low Apgar scores, low birth weight, neonatal intensive care unit admission, and less frequent rooming-in. Conclusion: Rates of breastfeeding initiation within the first hour and between 1 and 24 h of delivery were 26.3% and 65.5%, respectively. Compared to antenatal variables, the peripartum and neonatal variables are more likely to have significant effects on EIBF. Therefore, more obstetric attention should focus on these factors to improve rates of initiating breastfeeding early.
Keywords: Antenatal factors, breastfeeding initiation, neonatal factors, peripartum factors
|How to cite this article:|
Mahfouz IA, Asali F, Khalfieh T, Saleem HA, Diab S, Samara B, Jaber HM. >Early initiation of breastfeeding: Antenatal, peripartum, and neonatal correlates. J Clin Neonatol 2022;11:30-7
|How to cite this URL:|
Mahfouz IA, Asali F, Khalfieh T, Saleem HA, Diab S, Samara B, Jaber HM. >Early initiation of breastfeeding: Antenatal, peripartum, and neonatal correlates. J Clin Neonatol [serial online] 2022 [cited 2022 Jan 19];11:30-7. Available from: https://www.jcnonweb.com/text.asp?2022/11/1/30/334734
| Introduction|| |
The World Health Organization (WHO) recommends early initiation and exclusive breastfeeding for the first 6 months of the infant's life and continuation for up to 2 years with appropriate complementary food. This is because human milk is very important for the child's nutrition and overall development. In addition, breast fed infants have a two-fold lower risk of all-cause mortality rates. Furthermore, breastfeeding has various maternal benefits such as reducing postpartum bleeding, facilitating weight loss, and reducing stress, and risks of type II diabetes, cardiovascular disease, and breast and ovarian cancer. Despite all the fetal and maternal benefits of early breastfeeding initiation and continuation, the rates worldwide remain low with only 43% of new-born babies being put to the breast within 1 h of delivery and by the age of 6 months, only 40% are exclusively breast fed.
The WHO defines the early initiation of breastfeeding (EIBF) as the initiation within 1 h of birth and exclusive breastfeeding with no other food or drink, not even water, except human milk for the first 6 months of life, and predominant breastfeeding is defined as the infant's predominant source of nourishment being human milk.
The timing of breastfeeding initiation was reported differently in the published literature. Locally and in keeping with the WHO recommendations, a report showed that 67% of women initiated breastfeeding within 1 h of delivery. Another report showed that 87% of women initiated breastfeeding within 3 h. Al Dasoqi showed that 13% of first-time mothers initiated breastfeeding within the first 4 h. Internationally, the WHO global survey showed that the average rates of initiation of breastfeeding within 1 h and between 1 and 24 h of delivery were 57.6% and 37.2%, respectively and that the rates vary among countries.
Antenatal and peripartum factors may influence the rates of breastfeeding being initiated early. Takahashi et al., showed that more frequent antenatal care (ANC) visits and no antenatal pregnancy complications were associated with higher rates. Regarding peripartum factors, Lau et al. had shown the following factors to be negatively correlated with EIBF: Induction of labor (IOL), operative vaginal deliveries, and cesarean sections (CS). In addition, they showed that intrapartum complications, the use of opioids, epidural analgesia in labor, Apgar score, and birthweight had no significant effects.
The WHO identified the need for further research into factors associated with EIBF in various countries. In addition, a recent review of literature showed that the current evidence on breastfeeding initiation focused on sociodemographic factors, and the evidence supporting antenatal and peripartum variables is not only limited but also contradicting. The main aim of the current study is to report the rates of breastfeeding initiation within 1 h of delivery and between 1 and 24 h and report their correlations with various antenatal, peripartum, and neonatal variables.
| Materials and Methods|| |
This was a prospective observational study of pregnant women who attended the labor ward of a busy general hospital between September 1, 2019 and June 1, 2020. The hospital is accredited by the Jordanian Health Care Accreditation Council as a baby friendly hospital and follow the guidance of baby friendly initiative standards of the United Nations International Children's Emergency Fund. On admission, the women were approached to take part in the study after informed consent. Inclusion criteria required the woman to be 18 years of age or older and willing to take part in the study. Women were excluded if they had withdrawn their consent later during labor or in the peripartum period. Demographic data collected included age, educational achievement, health insurance, smoking status, employment, marital status, duration of marriage, and number of previous deliveries.
Current pregnancy data that were collected included gestational age on admission, if the pregnancy was planned or not, if it was spontaneous or by assisted reproductive technologies (ART), history of sub-fertility prior to the current pregnancy, antenatal complications such as threatened miscarriage, excessive nausea and vomiting, threatened preterm labor, preterm premature rupture of the fetal membranes, antepartum hemorrhage, hypertensive diseases, diabetes mellitus, and if the woman attended early ANC visits before 12 weeks into gestation as per the WHO recommendations.
Regarding the current delivery, data collected included if the labor was spontaneous or induced, what the mode of delivery was (vaginal or CS), for vaginal deliveries, if it was nonassisted or assisted by vacuum or forceps, and for CS deliveries, what the indication was, and type of anesthesia used. In addition, intrapartum complications such as extended genital tears and postpartum hemorrhages were also recorded. Before discharge from the hospital, the sites of postpartum pains were recorded (perineum, CS site, or breast) in addition to measuring women's perception of pain on the visual analogue scale (VAS) and their perception of adequate pain management. Regarding the outcome of the delivery, data collected included birth weight, Apgar scores, skin to skin contact (SSC), and women's perception of how much time they spent rooming-in with the baby while in the hospital in addition to if the new-born baby was admitted to the neonatal intensive care unit (NICU). Regarding breastfeeding, women were asked if they initiated breastfeeding within 1 h of delivery or between 1 and 24 h.
For sample size calculation, the prevalence of EIBF was considered to be 79.6%. For 80% power, 95% confidence level, and 5% confidence interval, the sample size was calculated to be 250 women. Because this study was part of a larger follow-up study on breastfeeding continuation, we assumed a 20% dropout rate, so we recruited 300 women.
For statistical analysis, IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY, USA was used. Continuous variables were expressed by means and standard deviations (SD) and categorical variables by frequencies and percentages. Gestational age, antenatal and intrapartum complications, indications of CS, birth weight, and rooming-in while in the hospital were transformed into groups for better comparisons. Postpartum pain scores were regrouped based on the mean, where values below the mean were considered as low and values above the mean as high scores. Nominal data were expressed using cross tables depending on the timing of breastfeeding initiation. Differences between groups were assessed using Chi-square Pearson's correlation coefficient. A P < 0.05 was considered statistically significant. Ethics were granted by the Institutional Review Board of the Specialty Hospital.
| Results|| |
Three hundred women were recruited with the mean age (SD) of 29.5 (4.9) years and the mean gestational age (SD) of 38.6 (1.5) weeks. All the women in our cohort were married and the mean (SD) for the duration of marriage was 5.9 (4.4) years. Furthermore, 202 (67.7%) women were university graduates, 204 (68%) were not employed, 284 (94.7%) women were not smokers, and 225 (75%) had health insurance.
[Table 1] shows the frequencies and percentages of the various current pregnancy antenatal variables. [Table 2] presents the peripartum variables of the current delivery. The mean (SD) of postpartum pain experienced by the women as measured on VAS was 4.6 (1.6). In addition, the perineum accounted for 58.7% of the pain sites experienced by women.
|Table 1: Frequencies and percentages of current pregnancy antenatal variables (n=300)|
Click here to view
|Table 2: Frequencies and percentages of current pregnancy intrapartum and postpartum variables (n=300)|
Click here to view
Data analysis showed that the numbers and percentages of women who initiated breastfeeding within 1 h of delivery were 79 (26.3%) and between 1 and 24 h were 197 (65.5%). While a total of 276 (92%) women initiated breastfeeding within the first 24 h of delivery, 24 (8%) women did not.
Regarding the timing of the initiation of breastfeeding and the various antenatal variables, data analysis showed that women who had no antenatal complications were more likely to initiate breastfeeding early compared to women who had complications, the difference was statistically significant (P < 0.000). Furthermore, the results showed no significant correlations between the timing of breastfeeding initiation and parity, if the pregnancy was planned or unplanned, history of sub-fertility prior to the current pregnancy, and the timing of the first ANC visit [Table 3].
|Table 3: Antenatal variables and their correlation with initiation of breastfeeding|
Click here to view
Regarding the peripartum variables and timing of breastfeeding initiation, data analysis showed that compared to women who had IOL, women who labored spontaneously were more likely to initiate breastfeeding within 1 h (P = 0.031). In addition, compared to women who had a CS, women who had vaginal deliveries were more likely to have EIBF (P 0.000) as seen in [Table 4].
|Table 4: Association of current breastfeeding initiation and the various peripartum variables|
Click here to view
Data regarding the type of anesthesia in the sub-group of women who had a CS showed that women who had a CS under neuroaxial anesthesia were more likely to have EIBF compared to general anesthesia (GA; P < 0.00). Additionally, among women who had a CS (130), 21 women (16%) had a CS on maternal request, and they were less likely to report EIBF compared to women who had a CS for obstetrics indication (P < 0.000). Regarding postpartum/operative site pain, the results showed that women with CS site pain were less likely to early initiate breastfeeding compared to women with perineal pain (P < 0.000), and women who had low pain scores as measured on VAS were more likely to initiate breastfeeding (P < 0.002) as seen in [Table 4].
Analysis of neonatal variables showed that the mothers of babies who had low Apgar scores, had low birth weights, had no SSC, spent less time rooming in while in the hospital, or were admitted to the NICU were less likely to initiate early breastfeeding. All the differences were statistically significant (all P were < 0.05) as shown in [Table 5].
| Discussion|| |
The rate of EIBF in our cohort was 26.3% and the rate of breastfeeding initiation between 1 and 24 h was 65.5%. In addition, 92% initiated breastfeeding within the first 24 h of delivery. While other local and global reports showed a higher rate of EIBF of 67% and 57.6% respectively, our initiation rate between 1 and 24 h was higher than the global rate of 37.2%. These wide local and international variations may reflect different study populations in different countries and in different geographical areas in the same country.
The results showed that parity did not affect the rate of EIBF. In support of our finding, a recent meta-analysis showed that the differences in EBFI rates among primiparous and multiparous women were not significant. This may be explained by multiparous women's preferences regarding breastfeeding following different deliveries. In addition, it may also be related to different antenatal and obstetrics variables/complications in the current pregnancies compared to previous ones.
Furthermore, there was a trend toward EIBF among women whose pregnancies were planned compared to unplanned pregnancies. This was also shown in another study where unplanned pregnancies were associated with more odds of having a baby who was never breastfed. This may reflect the attitude of the mother toward the newborn baby in cases of unplanned pregnancies.
Women who reported having sub-fertility prior to the current pregnancy and women who conceived by ART were not more likely to initiate breastfeeding early. While there are no reports addressing specifically a prior sub-fertility and its impact on breastfeeding initiation, Cromi et al. showed that the rates were not different between women who conceived spontaneously or by ART (89.4% vs. 90.4%). In keeping with the same theme of sub-fertility, ART, and inherent risk of multifetal gestations, our results showed a positive trend for EIBF in women with singleton pregnancies compared to twins. However, the difference did not reach statistical significance probably because the numbers were small. McAndrew et al. reported a 69% rate of breastfeeding initiation in multifetal gestations compared to 81% of singleton pregnancies. Such differences may be related to the increased burden of nursing two babies.
Over 97% of the women in our study had an early first ANC visit in keeping with the WHO recommendations. Therefore, it was not possible to study if early ANC visits correlate to EIBF. Another report showed that ANC visits before 17 weeks were associated with a two-fold increase in the rate of EIBF compared to ANC after 18 weeks, and women who had more than four ANC visits were more likely to initiate breastfeeding compared to women who had <4 visits. While attendance for an early ANC visit is important, Jinga et al. showed that a woman's decision regarding attendance for an early ANC is a complex process and may in part reflect a woman's acceptance of the pregnancy. In addition, antenatal counseling regarding breastfeeding was shown to have a positive significant effect on EIBF.
Complications during pregnancy may affect the rates of EIBF. Our results showed that women who had complications were less likely to initiate early breastfeeding compared to women who did not. Another report showed a similar pattern. The association may be related to the effects of various antenatal complications on the rate peripartum complications that may affect the mother, the baby, or both such as admission to NICU or the need for a GA CS, therefore acting as a barrier against initiating breastfeeding.
In our cohort, compared to the women who had IOL, the women who labored spontaneously were more likely to report EIBF. In addition, the indication of IOL did not influence the rates of breastfeeding being initiated early. This is probably because of the small sample size. While there is limited evidence in the literature addressing the impact of the indication and method of IOL on breastfeeding initiation, the use of oxytocin for augmentation or IOL was shown to negatively affect the rates of EIBF. We acknowledge we have not studied the method of IOL.
Women who had vaginal deliveries were more likely to early initiate breastfeeding compared to women who had a CS. Similar results were shown in other reports., Furthermore, regarding vaginal deliveries, nonassisted vaginal deliveries were associated with higher rates of EIBF compared to forceps or vacuum assisted deliveries which was also shown in another report. These patterns may be related to various reasons such as the type of anesthesia used for a CS, the indications of delivery which may be fetal compromise, or the complications related to assisted deliveries which may increase the risk of admission to NICU.
Analysis of the type of anesthesia used in the sub-group of women who had CS showed that GA was associated with delayed initiation of breastfeeding compared to neuraxial anesthesia. This was probably related to the delay in awakening from the general anesthetic.
In our cohort, 16% of the CSs were performed on maternal request which is more than a recently published rate of 8.6%. In addition, they were less likely to initiate breastfeeding. Women who requested a CS for no obstetrical reasons had higher levels of antepartum anxiety and depression. Furthermore, Cato et al. showed that women with antenatal depressive symptoms were less likely to initiate breastfeeding. It is therefore important to antenatally identify women who have anxiety and depression and offer them appropriate counseling. We acknowledge that we did not study antenatal anxiety and depressive symptoms in our cohort, and the rate of CSs on maternal request in our cohort may not reflect a national rate because of the small sample size and being a single-center study.
The results showed that postpartum pain, in particular the CS incision site, negatively affected the rate of EIBF. In addition, lower pain scores were associated with increased rates. Karlström et al. showed that while women who had a CS were pleased with the level of analgesics provided, the CS site pain negatively affected breastfeeding initiation. Additionally, another report showed a significant negative association between the level of pain after a CS and breastfeeding initiation. Furthermore, perineal pain may interfere with breastfeeding initiation in the 1st day after delivery. A study showed that women who had episiotomies had lower rates of initiating breastfeeding in the 1st day after delivery compared to women with an intact perineum. Therefore, restricted use of episiotomies and adequate postpartum pain management may increase the rate of EIBF.
Lau et al. showed that intrapartum complications were not related to breastfeeding being initiated early which was also shown in our study. Complications may interfere with breastfeeding initiation because they increase medical interventions such as the need for GA after vaginal deliveries and the occasional maternal administration of sedating medicines for the manual removal of retained placentae. Additionally, they may also separate the baby from the mother. It is not clear why intrapartum complications did not affect the rates. This may be related to the low frequency of these complications.
Mothers whose babies were delivered before 37 weeks, had low Apgar scores, had low birth weights, were admitted to the NICU, had no SSC, or had less frequent rooming-in while in the hospital were significantly less likely to early initiate breastfeeding. These neonatal variables are interrelated, and the reasons for not initiating breastfeeding may be related to the baby being sick and therefore kept fasting or not able to feed. Preterm, sick babies and babies with low birth weights are more likely to be admitted to the NICU. Gertz and DeFranco. showed that compared to mothers of new-born babies who were admitted to the nursery, mothers with babies in the NICU were less likely to early initiate breastfeeding. In addition, Safari et al. showed that SSC increased the rates of EIBF. Furthermore, rooming-in was associated with increased rate. While such variables may not be controlled, efforts should be exercised to encourage women to breast feed their babies in the NICU whenever the neonates medical condition allow.
The current study identified the following antenatal, peripartum, and neonatal factors to negatively affect EIBF which are antenatal pregnancy complications, IOL, assisted vaginal delivery, delivery by CS, CS performed on maternal request, general anesthetic for CS, CS surgical site pain, inadequate pain management, preterm delivery, low Apgar scores, low birth weights, no SSC, NICU admission, and less frequent rooming-in. Addressing such variables may increase the rates of early breastfeeding initiation.
We acknowledge the limitations of our study which were that the study was based in one center, the number was small, we did not study sociodemographic factors, and as it was not our aim, we did not compare women who initiated breastfeeding with women who did not. However, this study reflects a more in-depth analysis of antenatal, peripartum, and neonatal factors and their effect on EIBF.
| Conclusion|| |
Our rates of breastfeeding initiation within the 1st h and between 1 and 24 h of delivery were 26.3% and 65.5%, respectively. Furthermore, compared to antenatal variables, the peripartum and neonatal variables are more likely to have significant effects on the EIBF. Therefore, more obstetric attention should focus on these factors to improve the rates of initiating breastfeeding early.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al
. Breastfeeding in the 21st
century: Epidemiology, mechanisms, and lifelong effect. Lancet 2016;387:475-90.
Sankar MJ, Sinha B, Chowdhury R, Bhandari N, Taneja S, Martines J, et al
. Optimal breastfeeding practices and infant and child mortality: A systematic review and meta-analysis. Acta Paediatr 2015;104:3-13.
Dieterich CM, Felice JP, O'Sullivan E, Rasmussen KM. Breastfeeding and health outcomes for the mother-infant dyad. Pediatr Clin North Am 2013;60:31-48.
WHO. Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals. Geneva: World Health Organization; 2009.
Karim F, Billah SM, Chowdhury MA, Zaka N, Manu A, Arifeen SE, et al
. Initiation of breastfeeding within one hour of birth and its determinants among normal vaginal deliveries at primary and secondary health facilities in Bangladesh: A case-observation study. PLoS One 2018;13:e0202508.
Khasawneh W, Khasawneh AA. Predictors and barriers to breastfeeding in north of Jordan: Could we do better? Int Breastfeed J 2017;12:49.
Dasoqi KA, Safadi R, Badran E, Basha AS, Jordan S, Ahmad M. Initiation and continuation of breastfeeding among Jordanian first-time mothers: A prospective cohort study. Int J Womens Health 2018;10:571-7.
Takahashi K, Ganchimeg T, Ota E, Vogel JP, Souza JP, Laopaiboon M, et al
. Prevalence of early initiation of breastfeeding and determinants of delayed initiation of breastfeeding: Secondary analysis of the WHO Global Survey. Sci Rep 2017;7:44868.
Lau Y, Tha PH, Ho-Lim SS, Wong LY, Lim PI, Citra Nurfarah BZ, et al
. An analysis of the effects of intrapartum factors, neonatal characteristics, and skin-to-skin contact on early breastfeeding initiation. Matern Child Nutr 2018;14:e12492.
Cohen SS, Alexander DD, Krebs NF, Young BE, Cabana MD, Erdmann P, et al
. Factors associated with breastfeeding initiation and continuation: A meta-analysis. J Pediatr 2018;203:190-6.e21.
Wallenborn JT, Chambers G, Lowery EP, Masho SW. Discordance in couples pregnancy intentions and breastfeeding duration: Results from the national survey of family growth 2011-2013. J Pregnancy 2018;2018:8568341.
Cromi A, Serati M, Candeloro I, Uccella S, Scandroglio S, Agosti M, et al
. Assisted reproductive technology and breastfeeding outcomes: A case-control study. Fertil Steril 2015;103:89-94.
Costanian C, Macpherson AK, Tamim H. Inadequate prenatal care use and breastfeeding practices in Canada: A national survey of women. BMC Pregnancy Childbirth 2016;16:100.
Jinga N, Mongwenyana C, Moolla A, Malete G, Onoya D. Reasons for late presentation for antenatal care, healthcare providers' perspective. BMC Health Serv Res 2019;19:1016.
Göl İ. Antenatal care and breastfeeding. Turk J Fam Med Prim Care 2018;12:102-8.
García-Fortea P, González-Mesa E, Blasco M, Cazorla O, Delgado-Ríos M, González-Valenzuela MJ. Oxytocin administered during labor and breast-feeding: A retrospective cohort study. J Matern Fetal Neonatal Med 2014;27:1598-603.
Badaya N, Jain S, Kumar N. Time of initiation of breastfeeding in various modes of delivery and to observe the effect of low birth weight and period of gestation on initiation of breastfeeding. Int J Contemporary Pediatr 2018;5:1509-17.
Paksoy Erbaydar N, Erbaydar T. Relationship between caesarean section and breastfeeding: Evidence from the 2013 Turkey demographic and health survey. BMC Pregnancy Childbirth 2020;20:55.
Kutlucan L, Seker İS, Demiraran Y, Ersoy Ö, Karagöz İ, Sezen G, et al
. Effects of different anesthesia protocols on lactation in the postpartum period. J Turk Ger Gynecol Assoc 2014;15:233-8.
Masciullo L, Petruzziello L, Perrone G, Pecorini F, Remiddi C, Galoppi P, et al
. Caesarean section on maternal request: An Italian comparative study on patients' characteristics, pregnancy outcomes and guidelines overview. Int J Environ Res Public Health 2020;17:4665.
Olieman RM, Siemonsma F, Bartens MA, Garthus-Niegel S, Scheele F, Honig A. The effect of an elective cesarean section on maternal request on peripartum anxiety and depression in women with childbirth fear: A systematic review. BMC Pregnancy Childbirth 2017;17:195.
Cato K, Sylvén SM, Georgakis MK, Kollia N, Rubertsson C, Skalkidou A. Antenatal depressive symptoms and early initiation of breastfeeding in association with exclusive breastfeeding six weeks postpartum: A longitudinal population-based study. BMC Pregnancy Childbirth 2019;19:49.
Karlström A, Engström-Olofsson R, Norbergh KG, Sjöling M, Hildingsson I. Postoperative pain after cesarean birth affects breastfeeding and infant care. J Obstet Gynecol Neonatal Nurs 2007;36:430-40.
Babazade R, Vadhera RB, Krishnamurthy P, Varma A, Doulatram G, Saade GR, et al
. Acute postcesarean pain is associated with in-hospital exclusive breastfeeding, length of stay and post-partum depression. J Clin Anesth 2020;62:109697.
Persico G, Vergani P, Cestaro C, Grandolfo M, Nespoli A. Assessment of postpartum perineal pain after vaginal delivery: Prevalence, severity and determinants. A prospective observational study. Minerva Ginecol 2013;65:669-78.
Gertz B, DeFranco E. Predictors of breastfeeding non-initiation in the NICU. Matern Child Nutr 2019;15:e12797.
Safari K, Saeed AA, Hasan SS, Moghaddam-Banaem L. The effect of mother and newborn early skin-to-skin contact on initiation of breastfeeding, newborn temperature and duration of third stage of labor. Int Breastfeed J 2018;13:32.
Cotto CW, Garcia Fragoso L. Rooming-in improves breastfeeding initiation rates in a community hospital in Puerto Rico. Bol Asoc Med P R 2010;102:30-2.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]