Timely Initiation of Breastfeeding and Associated Factors in 20 Sub-Saharan African Countries: Cross-Sectional Multilevel Analysis of Recent Demographic and Health Surveys

Introduction

Timely initiation of breastfeeding (TIBF) is defined as placing the newborn to the breast within the first hour of delivery. This practice is strongly recommended by the World Health Organization (WHO), as it plays a vital role in promoting optimal infant and young child feeding. This behavior is favorable for the provision of colostrum to the infant, which contains high concentrations of immunoglobulin and other bioactive constituents, including growth factors that are essential for optimal neonatal nutrition, growth, development, and the establishment of passive immunity [1,2]. During the first 6 months of life, breast milk is the primary and most appropriate source of nutrition for newborns. It should be initiated within the first hour after birth, ideally even before the placenta is delivered, in line with recommendations from the WHO [2-4]. TIBF has the following advantages for infants: it decreases upper respiratory tract infections, promotes the development of dentition, enhances cognitive development, and reduces childhood obesity [5]. TIBF helps to reduce the risk of postpartum hemorrhage by promoting uterine contraction and faster uterine involution, supports quicker physical recovery after delivery, and strengthens mother-infant bonding [3,5,6]. It stimulates breast milk production and helps transfer protective antibodies to the infant, strengthening early immunity. For mothers, it reduces the risk of postpartum hemorrhage and supports quicker uterine recovery. It also promotes emotional attachment and strengthens the mother-child bond [7].

The Baby-Friendly Hospital Initiative (BFHI), established by the WHO and United Nations Children’s Fund (UNICEF) in 1991, developed a platform of 10 steps to improve maternal and neonatal care in health care institutions and promote optimal breastfeeding practices, including TIBF [8].

Worldwide, the magnitude of TIBF ranged from 17.7% to 98.4%, with an average magnitude of 57.6%. A global study demonstrated that an estimated 78 million newborns were not put to the breast within the first hour of delivery, based on a joint report by the UNICEF and the WHO [3,8]. A pooled analysis of Economic Community of West African States countries found that the magnitude of TIBF was 43%, highlighting notable differences in breastfeeding practices across the region [9].

Delayed initiation of breastfeeding (DIBF) is highly practiced, and reports have highlighted that it is linked with increased neonatal morbidity and mortality, particularly in low- and middle-income countries [10]. The 2019 mini-demography health survey of Ethiopia revealed that the prevalence of TIBF was 73.6% [11]. Evidence from sub-Saharan African countries from the 2013 Demographic and Health Survey (DHS) revealed that the prevalence of TIBF was 57% [12] and 34.7% [13], which were below the recommendations.

Maternal complications during pregnancy and cesarean delivery were associated with DIBF. Health facility deliveries that adhered to postnatal care protocols promoted TIBF among mothers [8,9,12]. Antenatal care attendance, having female infants, urban residence, multiparity, larger birth size, maternal unemployment status, and belonging to wealthier households were significantly associated with TIBF [9,11,12].

Although there are different recommendations by the WHO and UNICEF about the importance of TIBF within 1 hour, many newborns are not put to the breast within the recommended time [14]. Nowadays, different evidence demonstrates that TIBF reduces infant mortality by 22% [15]. Countries in sub-Saharan Africa had an infant mortality rate of 52 per 100 live births, which is higher than the global level, and this could be reduced by TIBF [12].

While the national policies and recommendations in Africa advocate and promote timely breastfeeding initiation, countries are not adhering to these recommendations [6,7,13,16]. There are other programs that promote TIBF in African countries, such as the national policy on infant and young child feeding, the WHO, and the Community-Integrated Management of Childhood Illness [2,17].

Reports from previous studies on the continent demonstrated that TIBF is complex and shaped by many factors, notably maternal sociodemographic characteristics like age, education, and residence, as well as use of maternal health services, including antenatal care visits and place of delivery [18].

Countries in sub-Saharan Africa continue to face high neonatal and infant mortality rates, and one contributing factor could be the DIBF after birth. There is a need to determine the updated pooled estimate level of TIBF and its key determinants at the continent level. Recent DHS data from 20 sub-Saharan countries can provide important information to estimate the magnitude and identify factors. Therefore, the aim of this study was to assess the prevalence of TIBF and to identify factors associated with this among women who delivered in the last 5 years preceding the survey in the selected countries, using data from the recent DHS.

Methods

Study Design and Setting

The study included 20 countries in sub-Saharan Africa that had recent Demographic and Health Survey data available. The countries were selected based on the availability of recent DHS datasets and included Angola, Burkina Faso, the Democratic Republic of the Congo, Côte d'Ivoire, Gabon, Ghana, The Gambia, Kenya, Liberia, Lesotho, Madagascar, Mali, Mauritania, Mozambique, Nigeria, Rwanda, Sierra Leone, Senegal, Tanzania, and Zambia.

Data Source and Extraction

We obtained the required authorization to access the dataset online after submitting a request for the data via the DHS online platform, accompanied by a detailed explanation of the study’s objectives and research methodology. The data were accessed using the following login link [19].

Populations

The study population comprised children aged 6 to 59 months from 20 sub-Saharan African countries with available DHS data conducted between 2019 and 2024. We used the DHS Kids’ Recode files for the analysis. The countries included in the study, their respective regions, DHS survey periods, and sample sizes are presented in Table 1. Countries were eligible for inclusion if they had a DHS conducted from 2019 onward and the available dataset contained the variables required for the present analysis. Countries without an eligible DHS conducted during the study period, including those whose most recent DHS was conducted before 2019, were excluded.

Sample Size Determination and Sampling Procedure

Sample Size Determination

The sample size for this study included all children who were born within the last 5 years preceding the survey and were documented in the dataset. After eliminating and adjusting for relevant variables and applying sampling weights, a total weighted sample of 177,988 was extracted and included in the analysis.

Sampling Procedure

The DHS used a stratified 2-stage sample design. Stratification was achieved by separating each of the countries’ states and the Federal Capital Territory into urban and rural areas. Samples were selected independently in every stratum via a 2-stage selection. The first stage involved selecting sample points (clusters) consisting of enumeration areas. Enumeration areas were drawn with probability proportional to their size within each sampling stratum.

Variables of the Study

Dependent Variable

The primary outcome variable of the study is the magnitude of TIBF in 20 sub-Saharan African countries.

Independent Variables

These were categorized as individual-level factors and community-level factors, as described below:

• Individual-level factors: maternal age, educational level of the mother, media exposure (mass media and print), parity, wanted the last child, sex of household head, ever had died children, wanted pregnancy, getting permission to visit a medical health facility, transport cost, respondent’s occupation.
• Health sector–related factors: mode of delivery (delivered by cesarean section or vaginal birth), ever had history of terminated pregnancy (abortion)
• Community-level factors: residence, distance from health facility, and wealth index

Operational Definition

TIBF

It was defined as the proportion of children aged 0 to 59 months who were put to the breast within the first hour of delivery [20].

Parity

This is the total number of live births that a woman has given birth to. It was classified as primiparous (1 birth), multiparous (2‐5 births), and grand multiparous (>5 births), consistent with prior DHS analyses [21].

Media Exposure

If a woman reads, listens to, or watches mass media (radio, TV, and newspaper) at least once a week, she is considered to have media exposure [22].

Data Management, Processing, and Analysis Methods

Secondary data obtained from the DHS survey were used, and the extracted dataset was analyzed. The data were obtained from an online source. They were cleaned, recoded, and analyzed using Stata (version 17; StataCorp). In line with DHS survey recommendations, sampling weights were applied to adjust for sampling probabilities and nonresponse, ensuring nationally representative and statistically reliable estimates before analysis.

Bivariable logistic regression followed by multivariable logistic regression analyses was conducted. Variables with a P value less than .25 in the bivariable regression were considered for inclusion in the multivariable logistic regression model. Both crude odds ratios and adjusted odds ratios (AORs) with 95% CIs were calculated. Variables with P values less than .05 were considered statistically significant. Three models were constructed: Model I included individual-level variables, Model II included community-level variables, and Model III (final model) included both individual- and community-level variables simultaneously. Multicollinearity among independent variables was assessed using the variance inflation factor (VIF). A VIF value greater than 10 was considered evidence of multicollinearity. To obtain statistically valid regression coefficient estimates, clustering information was used.

A multilevel analysis was employed to account for both person-level and community-level predictors, with a random effect for variations between clusters. Model I included individual-level factors, Model II included community-level factors, and Model III included both individual- and community-level factors. The significance of the random intercept variation was assessed using the likelihood ratio test. Measures of variation for the random effect between clusters were determined using the intraclass correlation coefficient (ICC), proportional change in variance, and median odds ratio (MOR).

Ethical Considerations

Ethical approval for data collection was obtained from the relevant institutional review boards overseeing the DHS Program in each participating country. Permission to use the dataset was requested from the DHS Program, and approval was obtained. The institutional review board–approved procedures for DHS public-use datasets do not in any way allow respondents, households, or sample communities to be identified. There are no names of individuals or household addresses in the data files. This study analyzed publicly available, deidentified secondary data and was therefore exempt from further ethical review. All analyses were conducted in accordance with established ethical standards of the Declaration of Helsinki.

Results

Sociodemographic and Other Factors

A total of 177,988 weighted samples were extracted and included from the DHS Kids’ Record dataset. The mean age of the respondents was 28.90 (95% CI 28.86‐28.93) years. Among the study participants, 64,260 (36.1%) were from urban residences. The majority of households were male-headed (n=140,983, 79.21%), and regarding age distribution, 70.59% (n=125,642) of women were in the age group of 20 to 34 years. Concerning media exposure, more than half (n=90,233, 50.7%) had media exposure (Table 1).

The largest contribution to the pooled sample came from Nigeria (NG8), accounting for 12.66% (22,542/177,988) of the total population, with 14,106 late initiations and 8436 timely initiations. This was followed by the Democratic Republic of the Congo (CD8), which contributed 9.65% (17,173/177,988) of the sample, including 7387 late and 9786 timely initiations. In contrast, Lesotho (LS8) contributed the smallest proportion (1548/177,988, 0.87%) with 442 late initiations and 1106 timely initiations (Table 2).

The Magnitude of TIBF Among Sub-Saharan African Countries

The magnitude of TIBF was 59.05% (95% CI 58.82%‐59.28%) within 1 hour of delivery.

Factors Associated With the TIBF

All included individual- and community-level variables were candidates for multivariable logistic regression as they had a P value less than .25. Individual-level and community-level factors were entered into separate regression models initially, followed by a final model (Model III) in which both sets of factors were included simultaneously. The analysis identified several factors associated with the TIBF. In the final model (Model III), type of place of residence, sex of head of household, sex of the child, women’s educational level, media exposure, respondents’ occupation, respondents’ age, place of delivery, getting permission to seek medical help, distance to a health facility, initiation of first antenatal care, parity, twin status of the child, delivery by cesarean section, and history of child death were significantly associated with TIBF (P<.05).

Mothers living in rural areas had higher odds of TIBF compared with urban residents (AOR 1.25, 95% CI 1.21‐1.28). Maternal education showed a positive association, where women with primary education had 48% (AOR 1.48, 95% CI 1.45‐1.52) compared to no education, secondary education has 22% (AOR 1.22, 95% CI 1.19‐1.26), and higher education and above had 22% (AOR 1.22, 95% CI 1.15‐1.28) more likely to initiate breastfeeding timely compared with women with no education. Mothers who delivered by cesarean section had reduced odds of TIBF (AOR 0.31, 95% CI 0.30‐0.33). Similarly, mothers of twin births had significantly lower odds of TIBF compared with singleton births (AOR 0.87, 95% CI 0.82‐0.92). Multiparous and grand multiparous mothers were more likely to timely initiate breastfeeding (AOR 1.19, 95% CI 1.15‐1.23 and AOR 1.10, 95% CI 1.05‐1.14, respectively). Mothers who initiated their first ANC visit late had lower odds of TIBF (AOR 0.84, 95% CI 0.82‐0.85), while mothers who delivered at a health institution had higher odds of TIBF (AOR 1.40, 95% CI 1.36‐1.43) (Table 3).

Random Effects and Model Comparisons

In the empty (null) model, the ICC revealed that variations between cluster areas accounted for 8.3% (ICC 0.083) of the overall variation in TIBF after delivery, while individual differences accounted for the remaining 91.7% of the variability (Table 4). In the null model, the odds of TIBF differed between higher- and lower-risk clusters by a factor of 1.68 (MOR 1.68).

Model fitness was assessed using the Akaike information criterion, Bayesian information criterion, and deviance statistics. The model with the lowest deviance value was considered the best-fitting model. Accordingly, the final model (Model III) had the lowest deviance (230,786.96) compared with the null model (236,767.84), Model I (231,114.1), and Model II (236,494.74), indicating better model fitness for identifying factors significantly associated with TIBF among children born within the 5 years preceding the DHS survey. Similarly, Model III had the lowest Akaike information criterion (230,833) and a relatively lower Bayesian information criterion (231,065.8) compared with the other fitted models.

In the final model (Model III), the cluster-level variation in TIBF remained at 8.3% (ICC 0.083), suggesting the presence of unobserved community-level factors influencing breastfeeding initiation practices. The MOR slightly decreased from 1.69 in Model I to 1.68 in Model III, indicating persistent but relatively stable cluster-level heterogeneity after controlling for both individual- and community-level factors. The proportional change in variance indicated that the variables included in the final model explained only a minimal proportion of the variation (−0.01%) in TIBF compared with the null model. In addition, the mean VIF (1.74) in Model III suggested no evidence of problematic multicollinearity among explanatory variables (Table 5).

Discussion

Pirncipal Findings

The analysis in these 20 sub-Saharan African countries showed that 59.05% (95% CI 58.82%‐59.28%) of children initiated breastfeeding within the first hour of delivery, indicating suboptimal TIBF. This finding was slightly higher than the pooled estimate of 58.3% reported from 35 sub-Saharan African countries between 2008 and 2019 [23]. This similarity could reflect persistent regional barriers, including inadequate breastfeeding counseling [24], limited access to maternal health care services [25], and sociocultural practices that delay timely breastfeeding initiation [26]. This increment might also be attributed to gradual improvements in maternal and child health services and breastfeeding promotion programs across the region, including BFHI programs, increased antenatal counseling, and expanded awareness campaigns emphasizing the importance of initiating breastfeeding within 1 hour of birth. These initiatives are known to improve mothers’ knowledge and attitudes toward timely breastfeeding [8,16,17].

The finding from the analysis in the included countries revealed that the magnitude of TIBF is lower than that reported in studies conducted in many sub-Saharan African countries. Higher magnitudes were reported in Ethiopia (73.6% from Mini DHS 2019), Burundi (85%), Uganda (71.6%), Malawi (76.9%), and Mozambique (75.03%) [11,13,27-29]. This variation may be attributed to the inclusion of pooled data from 20 sub-Saharan African countries with differences in health care systems, socioeconomic contexts, and breastfeeding promotion strategies, which could influence the overall estimate. Conversely, findings from individual countries may reflect more favorable maternal health services and country-specific progress in breastfeeding practices [13,30]. Higher rates of TIBF in some countries could be attributed to better implementation of maternal health care services, particularly skilled birth attendance and institutional delivery care [8]. Effective integration of breastfeeding promotion into antenatal care and immediate postpartum support, particularly early skin-to-skin contact and adherence to BFHI guidelines, contributed to significant improvements in the initiation of breastfeeding within 1 hour of delivery [10,31]. In settings where health facilities provide consistent postpartum breastfeeding support within the first hour of birth, higher rates of TIBF have been reported, highlighting the importance of strengthening immediate postnatal care practices across health facilities [32].

Community-based health promotion activities may explain the differences. Countries with strong community health worker programs that deliver breastfeeding counseling after delivery tend to achieve a higher magnitude of TIBF [33,34]. In contrast, poor counseling quality, shortages of trained health professionals in breastfeeding counseling, and absence of postnatal care can delay its initiation.

In contrast, the magnitude in the current study is higher than that in Guinea (16.6%), Congo-Brazzaville (24%), and Chad (23%) [13]. Such variations have also been documented in previous sub-Saharan African analyses, which show substantial between-country differences in TIBF, largely due to disparities in maternal health care access, socioeconomic status, and cultural practices influencing newborn feeding behaviors. Differences in study design, sample size, and sociodemographic composition may also contribute to these inconsistencies [17,30].

In this study, women from rural residences had higher odds of TIBF (AOR 1.25) compared with their counterparts. The higher odds of timely breastfeeding initiation among rural women may be attributed to urban health facilities, which may also have greater formula exposure and weaker adherence to Baby-Friendly practices. In addition, urban mothers are more likely to be influenced by modern feeding beliefs, face employment-related constraints, and experience inconsistent breastfeeding counseling despite better access to health services [17].

The present study findings reported that women with higher educational levels were more likely to initiate breastfeeding in a timely manner. This is supported by evidence from Ethiopia Demographic and Health Survey analyses, which show that mothers with secondary or higher education have significantly increased odds of timely breastfeeding initiation compared with uneducated women [25].

Women with media exposure demonstrated significantly decreased odds of TIBF in the current study. This finding is inconsistent with the study conducted in pooled sub-Saharan African countries using DHS data, which identified media exposure as a strong enabler of early initiation of breastfeeding [9,13]. This inconsistency may be due to differences in the type of media content accessed in the study setting, where exposure may include formula marketing or mixed infant feeding messages that discourage immediate breastfeeding. In contrast, in settings covered by DHS analyses, mass media often delivers coordinated public health campaigns promoting TIBF. Variations in media regulation and the effectiveness of breastfeeding promotion messages may therefore explain the differing associations [35].

Age of the mother was also a significant factor in TIBF. Women aged 20 to 34 years and 35 to 49 years had higher odds (AOR 1.07 and 1.26, respectively) compared with those aged 15 to 19 years, indicating an age-related disparity in TIBF. The possible reason for this is that young women could have relatively poor knowledge of the importance of timely breastfeeding and may not have received antenatal care or institutional delivery, which have a direct or indirect effect on TIBF [36]. This finding is similar to that of a study conducted in Nigeria [37]. Additionally, older women, particularly multiparous mothers, may rely on previous childbirth experience and perceived knowledge, which may positively influence TIBF. However, this pattern contrasts with studies reporting that younger mothers demonstrate higher timely breastfeeding behavior, possibly due to targeted maternal health programs, perceived vulnerability, and stronger exposure to health promotion messages [38].

Women who reported difficulty obtaining permission to seek medical care had lower odds of TIBF. This may be because restricted autonomy limits access to antenatal care, institutional delivery, and postnatal breastfeeding counseling, all of which positively influence timely breastfeeding initiation.

Women who delivered in health facilities were more likely to initiate breastfeeding timely than those who delivered at home. This finding is consistent with a study conducted in Ethiopia [39], which reported that institutionally delivered women had about 2 times higher odds of TIBF. This may be because health facility delivery provides access to skilled birth attendants, immediate breastfeeding counseling, and postpartum support, including early skin-to-skin contact, which facilitates breastfeeding within the first hour after birth [40].

The findings of this study indicated that multiparous and grand multiparous women were more likely to initiate breastfeeding within 1 hour of delivery compared with nulliparous mothers. This may be because first-time mothers often have limited experience and knowledge regarding breastfeeding, may feel uncertain about proper positioning of the baby, lack confidence to initiate breastfeeding immediately after birth, and require more guidance on breastfeeding techniques. They also experience stress and anxiety during labor and can delay skin-to-skin contact and breastfeeding initiation within the recommended hour. Nulliparous women may rely heavily on family advice, which is not always supportive of immediate breastfeeding. Elders may prioritize other newborn practices before breastfeeding, and misconceptions about colostrum may delay initiation of breastfeeding. This evidence is similar to that from studies conducted in Nepal, Bangladesh [41], Ghana, and Ethiopia [13]. This similar report could be because of the similarity in cultural perceptions and sociodemographic factors.

In this study, twin children had DIBF compared with singletons. This is because twin pregnancies are more likely to have preterm birth, low birth weight, and high fetal complications, more likely to have an elective cesarean section. These mentioned unfavorable outcomes lead for the DIBF [42,43].

Employed women had lower odds of TIBF compared with unemployed women. This may be related to work-related stress, fatigue, and competing responsibilities, which may reduce preparedness for immediate breastfeeding. Employed mothers may also be more exposed to formula-feeding alternatives and concerns about balancing breastfeeding with future work demands.

Women with a history of child death had lower odds of TIBF. This may reflect previous adverse birth experiences, maternal psychological distress, or underlying health and socioeconomic vulnerabilities that negatively influence maternal care practices, including timely breastfeeding initiation.

Limitations

Some subnational areas had relatively small sample sizes, requiring cautious interpretation of findings. As a secondary analysis of DHS data, important factors such as cultural beliefs, psychosocial influences, partner preferences, and qualitative maternal perspectives were unavailable. In addition, breastfeeding initiation was self-reported for births occurring within the 5 years preceding the survey, which may introduce recall bias. Finally, the cross-sectional nature of the data limits causal inference between explanatory variables and TIBF.

Conclusion and Recommendations

The TIBF according to the DHS survey in sub-Saharan African countries remains suboptimal. Although this reflects a modest improvement compared with previous surveys, it demonstrates inconsistent national progress toward global breastfeeding targets recommended by the WHO and United Nations Children’s Fund. Individual-level and community-level factors were regressed together in the final model, and place of residence, women’s educational level, media exposure, wealth index, age of the respondent, mode of delivery, wanted child, getting permission to go to a health facility, parity, and type of pregnancy were significantly associated with TIBF.

The substantial cluster-level variation suggests the influence of contextual and health system factors. Strengthening implementation of the BFHI, improving access to skilled delivery and postnatal counseling, particularly in rural areas, and promoting maternal education and social protection mechanisms are critical to enhancing timely breastfeeding practices in the country.

Rural-urban disparities highlight the need for expanded access to skilled birth attendance, quality antenatal counseling, and timely postnatal support in rural settings.

Educational and socioeconomic disparities observed in this study suggest that policies promoting female education, male partner involvement, media-based health promotion, and financial risk protection (including health insurance coverage) may enhance timely initiation practices. Strengthening family planning services may further contribute by reducing unintended pregnancies, which were associated with DIBF.