In 2020, only 49% of babies globally received breast milk within the first hour after delivery, despite extensive evidence highlighting the advantages of early initiation of breastfeeding EIB.(1). Significant geographical differences exist in the timing of breastfeeding onset. In the Middle East and North Africa, the onset rate stands at 35%, whereas East Africa, South Africa, and Latin America exhibit a higher rate of 65%.(1). The percentage of women who start breastfeeding early varies greatly amongst nations as well, from 3.2% to 97.3%. Additionally, in the first three days of life, roughly 25% of breastfed infants are given fluids other than breast milk, including tea or plain water (1).

A meta-analysis conducted across 29 sub-Saharan African countries revealed significant variation in the rates of exclusive breastfeeding, with the lowest prevalence of 23.7% observed in Middle Africa and the highest prevalence of 56.57% reported in Southern Africa.(2)

In Uganda, the percentage of children who are exclusively breastfed declines significantly as they grow older, dropping from 83% among infants aged 0–1 month to 69% among those aged 2–3 months, and further to 43% among infants aged 4–5 months(3). Only about 43% of moms in Kampala's informal sector reported exclusively nursing their children (3).

A recent study encompassing 76 countries found that in higher-income nations, pre-lacteal feeds predominantly consisted of milk. In contrast, the opposite trend was observed in lower-income nations, with water-based feeds being more prevalent. (3)

Studies found a connection between pre-lacteal feeding and exclusive BF cessation and any BF cessation. (3)A prospective cohort study involving 1,049 infants revealed that initiating EBF significantly reduced the risk of hospitalization due to suspected pneumonia and diarrhea.(4)

A retrospective cohort study using data from Multiple Indicator Cluster Surveys (MICS) conducted in low- and middle-income countries (LMICs) between 2010 and 2019, along with 85 nationally representative Demographic and Health Surveys (DHS), found the prevalence rates for water-based only pre-lacteal feeding (WTR), milk-based only pre-lacteal feeding (MLK), and overall pre-lacteal feeding (PLF) to be 9.4%, 22.2%, and 33.9%, respectively. The crude analysis revealed that children who were given pre-lacteal feeds were nearly twice as likely to receive formula and 40% less likely to be exclusively breastfed. These associations remained consistent across different income levels and geographic regions (5).

A previous study carried out in Bushenyi District found that only three in ten children were exclusively breastfed. highlighting a substantial deviation from both national and global targets. As a result, infants in this area face the risk of malnutrition and avoidable childhood illnesses, including diarrhea and respiratory infections.(6). This reflects a serious gap in maternal and child health practices, with potential long-term consequences for child survival and well-being.

Moreover, most existing studies on breastfeeding practices in Uganda, including those in Bushenyi District, have been cross-sectional. the timing of breastfeeding initiation was often estimated, with limited ability to track breastfeeding practices over time or assess related adverse health outcomes. To address this gap, there is a pressing need for a prospective cohort study to examine inadequate breastfeeding practices and their associated health consequences. Notably, no such study has been conducted in Uganda, particularly within Bushenyi District.

The study was done at Kampala International University Teaching Hospital (KIU-TH), Ishaka Adventist Hospital (IAH), and Bushenyi Health Centre IV (BHC). All the 3 health facilities are located in Bushenyi district. The health facilities receive mothers referred from other lower-level facilities in the district making them representative of the district. All the above facilities conduct deliveries including vaginal deliveries and operative deliveries. All facilities offer antenatal care services in which mothers are educated about the recommended neonatal feeding practices.

All mother-infant pairs in the Bushenyi district were targeted by the study.

Independent variables include: mother related factors( maternal age, marital status, maternal educational level, maternal occupational status, residence, family income, tribe ) pre and perinatal factors ( ANC visit number, place of delivery, mode of delivery, duration of labour, time of delivery, chronic illness, complication during labour, labour duration) infant related factors ( Birth order, sex, gestational age, birth Weight, twin pregnancy, birth trauma, medical illness), the dependent variable was the incidence of inadequate breastfeeding practices which were the result of interactions between different independent variables.

This study was conducted from November 2024 to March 2025

Babies who were born before arrival to hospital since it was difficult to ascertain the exact time of delivery. Neonates with obvious congenital malformations were excluded as well.

The sample size was determined using OpenEpi's online sample size calculator (https://www.openepi.com/SampleSize/SSCohort.htm). Using findings from a study done in eastern Uganda where the proportion of delayed initiation of breastfeeding was 77% among exposed and 60% among unexposed taking mode of delivery as an exposure characteristic (Kusasira et al., 2023), for a power of 80% and 95% level of confidence, the sample size required was 236 using the Fleiss method. Taking the larger sample size of 236 and adding 10% to account for loss to follow-up, the final sample size required was 260.

Participants were proportionally allocated based on deliveries recorded over the past three months: KIU-TH (42), Ishaka Adventist Hospital (105), and Bushenyi HCIV (113).

This study aimed to determine the incidence, risk factors, and adverse outcomes of inadequate breastfeeding practices among 10-week-old infants delivered at Kampala International University Teaching Hospital (KIU-TH), Ishaka Adventist Hospital (IAH), and Bushenyi Health Centre IV (BHC) in Bushenyi District. We enrolled 260 newborns, 12 of whom were lost to follow-up by the 10th week. The meaning of our findings and the implication to our practice had been discussed in detail in the subsections that follow, and this discussion has been structured according to the specific objectives of the study.

Regarding breastfeeding practice, 56.0% were considered to have had inadequate breastfeeding practices by the 10th week. Early initiation of breastfeeding was seen in 79.2%. Exclusive breastfeeding was seen in 83.7% at 6 weeks, dropping to 65.7% at 10 weeks. The fact that more than half of the neonates did not have adequate breastfeeding is alarming. Almost 80% had early initiation of breastfeeding, and over 80% were still exclusively breastfeeding by 6 weeks, showing that most mothers are committed to breastfeeding in the first weeks following delivery. However, the drastic drop in the number of neonates exclusively breastfed by almost 18% over just 1 month (6th to 10th ) is a cause of great concern.

A similar rate of inadequate breastfeeding practices was reported in Cameroon; 61.2% of mothers had inadequate breastfeeding practices (Hermann & Moyo, 2020)

Our findings regarding the timing of initiation of breastfeeding were similar to findings in Ethiopia, timely initiation of breastfeeding was 77.8% (8), Namibia 74.9%(9), Malawi 76.9% (10), Turkey 70.7% (11), and Ghana 76.2% (12),

However, the proportion of mothers who did early initiation in this study was higher than that reported in Fort Portal, where 68% of mothers had initiated breastfeeding in the first hour (13), in eastern Uganda, where the rate of early initiation of breastfeeding was 30% (14), Analysis of data from Uganda demographic health survey 2014, revealed that on average, 56% initiated breastfeeding in the first hour (15), in Nigeria, where 61% of mothers breastfeed their newborns within 1 hour of birth (16), in India, where breastfeeding initiation within 1 hour of delivery was only 61% (17), in Morocco, where only 37% of mothers initiated breastfeeding with in the first hour (1) and in chad the prevalence of early initiation of breastfeeding 23.8% (18).

A possible explanation for the high rate of early initiation of breastfeeding in this study is that mothers who give birth in health facilities are often required to initiate breastfeeding within the first hour under the direct supervision of healthcare providers. This proactive support ensures that early initiation is practiced as part of routine postnatal care. Additionally, unlike previous studies that have primarily employed cross-sectional designs where the timing of breastfeeding initiation was often estimated, this prospective cohort design allowed for more accurate and timely documentation of breastfeeding practices. Therefore, it is essential to consistently remind and support mothers about the importance of initiating breastfeeding immediately after delivery to further improve neonatal health outcomes.

Regarding the rate of exclusive breastfeeding, the percentage of children exclusively breastfed at 10 weeks was higher than in Mbarara 31.2% was exclusive breastfeeding (19), Uganda Demographic and Health Survey (UDHS) 2014, 46% of infants under six months of age were exclusively breastfed, Only about 43% of mothers in Kampala's informal sector reported exclusively Breastfeeding (3), in Italy where 27% of the children were exclusively breastfed (20), in Vietnam where 14.2% were exclusively breast fed (4), in Egypt, the percentage of mothers who did not practice exclusive breastfeeding (EBF) was 43.5%(21), in low- and middle-income countries, it was 35.2% (22) in Pakistan exclusive breastfeeding (EBF) was 41.5% (23) and in Indian infants exclusively breastfeeding was 43%(24)

The possible reason for having a higher prevalence in our study could be because our follow-up stopped at 10 weeks, yet some of these studies did a longer follow-up, and hence, given the trend in which more children stop exclusive breastfeeding as time goes by, our rates would become much lower with time.

Regarding the risk factors, the risk for inadequate breastfeeding was increased for mothers with no tertiary education, the preterm, those with low birth weight, firstborns and those with a prolonged labour duration. Mothers with lower education, are less likely to have access to accurate information in regard to the importance of exclusive breastfeeding and therefore may not be fully aware about its benefits to the baby nor the dangers associated with not breastfeeding exclusively (25). Also, due to limited access to accurate information, mothers with low education are susceptible to misconceptions and myths and are unlikely to have answers when they experience challenges during breastfeeding. This was in agreement with findings by (25) in Ghana and (1) in Morocco who both reported that education level affected breastfeeding practice.

Babies who are preterm or born with a low birth weight often have difficulties in latching in addition to challenges with coordinated suckling, swallowing, and breathing (26). In addition to the above, they may have medical complications such as respiratory distress syndrome and other gastrointestinal pathologies that may make breastfeeding difficult (26). Also, the fact that some of these preterm neonates require admission results in separation from the mother, which can interfere with breastfeeding. At times, the mother may be overwhelmed by the challenges of breastfeeding a preterm and, hence, opt for other feeds if not given adequate support (27). This was in agreement with findings by (11) in Turkey, in addition to the reviews by (27) and (26).

The firstborn is less likely to be breastfed adequately because first-time mothers are usually more anxious and insecure about breastfeeding, which may lead to an increased risk of latching issues, milk supply concerns, and difficulties in management of feeding and at times leading to premature termination of breastfeeding compared to subsequent children of more confident and experienced mothers. This is due mainly to a lack of previous breastfeeding experience and heightened perceived pressure associated with feeding a first baby (28). This was in agreement with findings in the USA by (29) who reported that first time mothers were more likely to experience difficulties in breastfeeding compared to other mothers and (30) in Ethiopia who observed a significant association between parity and timely initiation of breast feeding.

Physical and emotional exhaustion from a long labor can cause a delay in the onset of lactation (31). Also, administration of Pitocin negatively affects maternal endogenous production and release of oxytocin postpartum. This in turn delays milk production. A baby born after a long labor can be less alert and may not be able to coordinate suckling well due to possible oxygen deprivation during delivery (32). Interventions associated with long labors, such as epidurals and assisted deliveries, can also complicate the start of breastfeeding (33). If a prolonged labor requires more medical interventions or recovery time, it may involve separation from the baby, disrupting early attempts at breastfeeding (34). This was in agreement with findings by (35), who noted that prolonged labour interventions, such as administration of oxytocin, affected breastfeeding practices, as well as in Eastern Uganda, who noted that difficult labour had a significant association with breastfeeding practices (14).

The rates of diarrhea and respiratory tract infections were more common in neonates who had inadequate breastfeeding. Rates of underweight and wasting were also higher among infants who had inadequate breastfeeding. This was in agreement with the findings in Bangladesh, where 27.37% of diarrhea cases and 8.94% of acute respiratory infection cases could have been prevented if exclusive breastfeeding had not been discontinued. Also, in Bangladesh, if EBF was terminated during 0–2 months, the odds of becoming underweight were 2.16 times higher than babies for whom EBF was not terminated (36).

the findings of our study align with those of the study conducted in India by (37), which reported that infants who were not exclusively breastfed had higher rates of malnutrition, particularly with significant differences in underweight and wasting beyond six weeks. Similarly, this study found that while underweight and wasting did not show a statistically significant difference at six weeks, the difference became significant at ten weeks, indicating that the negative effects of inadequate breastfeeding on nutritional status become more pronounced over time. Additionally, both studies observed a strong association between early discontinuation of exclusive breastfeeding (EBF) and increased risk of infections. In my study, the inadequate breastfeeding group had significantly higher rates of diarrhea and respiratory tract infections at both six and ten weeks, reinforcing the protective role of breast milk against infectious diseases. The consistency of these findings across different settings highlights the universal importance of adequate breastfeeding in reducing infant morbidity and malnutrition, emphasizing the need for sustained breastfeeding promotion and support interventions. Similar to my findings, the study in Bangladesh.(38) demonstrated that inadequate breastfeeding significantly increases the risk of diarrhea and acute respiratory infections, highlighting the protective role of exclusive breastfeeding in reducing infant morbidity and mortality

In line with my findings, the study conducted in Mexico by(39) emphasized the significant health costs of inadequate breastfeeding, with increased risks of infections and malnutrition, particularly underweight and wasting, among infants not exclusively breastfed. Both studies highlight the adverse impact of inadequate breastfeeding on infant health, underscoring the need for improved breastfeeding practices to prevent these negative outcomes

The findings are consistent with the study by Saldana Hossain and Mihrshahi (2022), which highlighted the protective role of exclusive breastfeeding (EBF) against gastrointestinal and respiratory infections. Both studies found that inadequate breastfeeding significantly increased the risk of infections, such as diarrhea and respiratory tract infections. Their review emphasized the benefits of EBF in reducing childhood morbidity and mortality, particularly when breastfeeding is sustained for longer durations(40).

In a study by (41).it was found that inadequate breastfeeding practices were linked to a significant portion of childhood diseases, including gastrointestinal infections and respiratory illnesses. This finding aligns with our study, where we observed that inadequate breastfeeding was associated with significantly higher rates of infections, particularly diarrhea and respiratory tract infections. Both studies emphasize the critical role of exclusive breastfeeding in reducing childhood morbidity and highlight the need for improved breastfeeding practices to prevent the spread of infectious diseases among infants

Breast milk directly helps fight infections that cause diarrhea with immunoglobulin. The sugars in human milk also promote bacterial growth in the gut, thereby protecting against some pathogenic microorganisms. Additionally, it contains enzymes and a number of additional factors that tend to make it prevent infections in the intestinal tract (42). Exclusive breastfeeding protects an infant from diarrhea by giving them antibodies and the immune factors contained in breast milk, which work actively against gastrointestinal pathogens. It also limits the contact of the infant to food and water that could contain pathogens since their digestive systems are not quite developed yet; in other words, breast milk becomes a sort of natural defense from bacteria causing diarrhea (42).

Human milk naturally contains all the vitamins, minerals, and macronutrients that an infant requires in the early stages of life (36).Human milk contains a host of antibodies that help to protect infants from infection, such as from diarrhea and respiratory diseases, the consequences of which can cause malnutrition. Human milk is easily digested by an infant's immature digestive system, promoting efficient nutrient absorption. Essentially, breast milk acts as a complete food for infants, thereby eliminating the risk of poor nutrition from other feeding methods (36).

Over half of the infants had inadequate breastfeeding by the 10th week.

The risk for inadequate breastfeeding was increased for mothers with no tertiary education, the preterm, those with low birth weight, firstborns, and those with a prolonged labour duration.

The rates of diarrhea, respiratory tract infections, underweight, and wasting were significantly higher among infants who had inadequate breastfeeding.