Research Article The Effect of Early Initiation of...

Research ArticleThe Effect of Early Initiation of Breastfeeding on NeonatalMortality among Low Birth Weight in Aceh Province IndonesiaAn Unmatched Case Control Study

Satrinawati Berkat and Rosnah Sutan

Department of Community Health University Kebangsaan Malaysia Malaysia

Correspondence should be addressed to Satrinawati Berkat satrin acehyahoocom

Received 30 April 2014 Revised 3 October 2014 Accepted 8 October 2014 Published 11 November 2014

Academic Editor Peng Bi

Copyright copy 2014 S Berkat and R Sutan This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

Background Early initiation of breastfeeding is the breastfeed that is received by the baby within the first hour of birth It isrecommended to reduce infant mortality and illness Objective To assess the effect of early initiation of breastfeeding on neonatalmortality for low birth weight in Aceh province IndonesiaMethod In this qualitative study unmatched case controls were used asthe design Data was collected in 8 districts in Aceh province Indonesia between January and December 2012The total sample forthis studywas 500 LBWwhowere born between 2010 and 2012 subdivided into 250 LBWwhodied in neonatal period and 250 LBWwho survived during neonatal period Result Thermal care and hygienic practice were not significantly associated with neonatalmortality among LBW Feeding and early initiation of breastfeeding were associated Discussion Early initiation of breastfeedinghad an effect on neonatal mortality for the low birth weight in Aceh province Indonesia The risk of mortality was decreased forthose neonates who accepted breast milk within the first hour after birth Therefore it is concluded that a new strategy to promoteand improve the coverage of the initiation of breastfeeding is needed

1 Introduction

Breastfeeding has many health benefits for both the motherand infant To reduce infant mortality and ill health themother first provides breast milk to her infant within onehour of birthmdashreferred to as ldquoearly initiation of breastfeed-ingrdquo [1] This ensures that the infant receives the colostrum(ldquofirst milkrdquo) [1] Colostrums there are ninety known com-ponents of the colostrum and two primary benefits The twoprimary benefits are immune factors and growth factorsColostrum also contains vitamins minerals and amino acidsneeded by the neonates [2]

There is growing evidence of the significant impact ofearly initiation of breastfeeding preferably within the firsthour after birth on reducing overall neonatal mortality [3]It ensures that skin-to-skin contact is made early on animportant factor in preventing hypothermia and establishingthe bond between mother and child Early initiation ofbreastfeeding also reduces a motherrsquos risk of postpartum

hemorrhage one of the leading causes of maternal mortality[3] Colostrum themotherrsquosmilk during the first postpartumdays provides protective antibodies and indispensable nutri-ents essentially acting as a first immunization for newbornsstrengthening their immune system and reducing the chancesof death in the neonatal period [3]

Optimally the baby should start to breastfeed before anyroutine procedure (such as bathing weighing umbilical cordcare and administration of eye medications) is performed[4] Early breastfeeding and skin-to-skin contact helps withbetter temperature control of the new-born baby enhancesbonding between themother and the baby and also increasesthe chances of establishing exclusive breastfeeding early andof its success [4]These treatments should bemore rigorouslyadhered to infants with low birth weight because they aremore vulnerable to diseases than those of normal weight [4]

LBW (low birth weight) is defined as a birth weight of lessthan 2500 grams [5] The LBW are categorized into pretermbirths intrauterine growth restriction (IUGR) and neonates

Hindawi Publishing CorporationAdvances in EpidemiologyVolume 2014 Article ID 358692 7 pageshttpdxdoiorg1011552014358692

2 Advances in Epidemiology

Indonesia

N

0 200 400 600 800(km)

Figure 1 Aceh province in the western end of Indonesia

4∘09984000998400998400N

Figure 2 Districts in Aceh Province and 8 of 23 districts as the study site

who are both preterm and growth restricted [6] LBW willgreatly affect the growth and development of the child Theeffect does not only influence the childrsquos younger years butit will continue for its whole life cycle [6] LBW especiallypreterm birth complications is the major cause of neonatalmortality in the world (35 of all neonatal mortality) [7]Prevalence rate for the LBW worldwide between 2007 and2011 was 15 of all live births and the percentage of LBW inIndonesia (Figure 1) in 2011 was 9 of 43 million live births[8] The Indonesia Ministry of Health reported that prema-ture births were the second highest cause of early neonatalmortality in Indonesia (324 of all neonatal mortality) [9]

Even though the early initiation of breastfeeding is rec-ommended and there is some evidence to show the relation-ship between early initiation of breastfeeding and neonatalsurvival [10 11] the percentage of early of breastfeeding in

Indonesia is still low [12] Overall the percentage of earlyinitiation of breastfeeding in Indonesia between 2007 and2012 was 493 of all live births and lower in some provincesincluding Aceh Province (Figure 2) [12]

Aceh province is located in the most western part ofIndonesia directly adjacent to the Indian Ocean AndamanSea and Malacca strait [13] The weather in Aceh is the sameas in Indonesia it is a tropical climate with two seasons rainyand dry and the average temperature is 25ndash32∘C [13] Thetotal area of the Aceh province is 58377 km2 and divided into23 districts 286 subdistricts and 6489 villages with a totalpopulation in 2012 of around 47 million people [13]

The percentage of early initiation of breastfeeding inAceh province between 2007 and 2012 was 464 of all livebirths this is lower than the national percentage (493) [13]The data from the Indonesian Ministry of health gave the

Advances in Epidemiology 3

percentage of LBW in Aceh province in 2010 as 111 of alllive births [14] which was higher than the national percentageof 9 [8] Accordingly the data indicated a higher risk ofmortality in Aceh than in other provinces in Indonesia Sincethe percentage of LBW is higher it greatly increases a childrsquosrisk of dying during their early month and years of life andearly initiation of breastfeeding is expected to decrease theneonatal mortality especially for the LBW [3]

The high risk of neonatal mortality due to LBW and thelower number of newborns who accept early initiation ofbreastfeedingwere the reasons why the study conductedThisstudy was a part of a study that determines factors related toneonatal mortality among LBW in Aceh province IndonesiaThe objective of this study was to assess the effects of earlyinitiation of breastfeeding on neonatal mortality among theLBW in Aceh province Indonesia

2 Methods

21 Study Design This is a population study based onretrospective unmatched case control study The reason forthe choice of unmatched case control was the difficulty infinding individuals of matching case and control due to thelarge area of the study the limited number of cases and thelack of data or documentation related to this study within thehealth facility

22 Population The low birth weight babies who were bornbetween 2010ndash2012 in Aceh Province Indonesia

23 Inclusion and Exclusion Criteria Inclusion and exclusioncriteria for recruitment in the sample in the quantitative studyare shown in Table 1

24 Sample Size Total number of neonatal death due toLBW between 2009-2010 in Aceh province was 399 casesincluding multiple birth and birth weight lt1000 grams (from23 districts) that is 399 cases including multiple birth andbirth weight lt1000 grams Based on the number of casesthe sample size calculated with formula from Fleiss (2003)and the sample size required for this study was 454 Afteradded 10 to compensate for missing or incomplete data thetotal sample size this study was 500 The total sample wasdivided into two groups consist of 250 cases (LBWwho diedin neonatal period) and 250 control (LBW who alive duringthe neonatal period)

25 Study Instrument The study instruments were ques-tionnaire and medical records The questionnaire consists ofcharacteristics of the LBW and family and how the familytook care of the neonate at home during the neonatal periodincluding feed thermal care and hygienic practice Thequestionnaire was created by the researcher and had beentested for validity and reliability on 30 mothers who hadLBW infant in the Banda Aceh (one of the districts in Acehprovince and is not included as study site) The result ofthe test was that the questionnaire was valid and reliable

as an instrument in this study The tests were conducted inNovember 2011

26 Operational Definition of Variables and the ClassificationThere were 5 variables used in this study there were neonatalmortality early initiation of breast feeding feeding thermalcare and hygienic practice

261 Neonatal Mortality A live birth with birth weightlt2500 grams and dying during the first 28 completed daysof life

Classification 0 = alive A live birth with birth weight lt2500grams and survive during the first 28 completed days of life 1= died A live birth with birth weight lt2500 grams and dyingduring the first 28 completed days of life

262 Early Initiation of Breastfeeding The time of initiationof breastfeeding accepted by the baby after birthThe data wastaken from the MCH (Maternal and Child Health) book andcohort book in the health facility

Classification 0 = accepted of breastfeeding within an hourafter birth and 1 = Did not accept the breastfeeding withinan hour after birth

263 Feeding Food given to neonates for the first 28 daysof life or before the neonate died Classification 0 = only fedbreastfed 1 = breastfed and some other foods or other foodswithout breastfed

264 Thermal Care The methods used by the family toprovide warmth for the neonates were categorized into eightactions whichwere delay of the first bath untilgt12 hours afterbirth provision of warm clothes not bathing neonates twicea day always using blankets performing kangaroo mothercare (KMC) using warm bottles for a minimum period of1 week or before the neonate died using bulb lamp for aminimum period of 1 week or before the neonate died andusing fireplace twice a day and for a minimum period of oneweek Each action implemented by parentfamily was given1 score Classification 0 = Adequate care (if the total score ofthermal care between 5ndash8) 1 = inadequate care (if the totalscore of thermal care between 0ndash4)

265 Hygienic Practice The attempts to maintain neonatalhygiene were categorized into five actions which were Didnot apply traditionalalcohol ingredients on umbilical cordstump always put neonate in the clean place (baby cribmattress or bed) always changed immediately the clothedif were wet or dirty always boiled the equipment to feedbefore being used and always wash hands with soap beforegiving feeding to the neonate (such as after using thetoilet after cleaning the baby after doing housework afterreturning home from outside or after doing dirty work)Each action implemented by parentfamily was given 1 scoreClassification 0 =Adequate care (if the total score for hygiene


Table 1 Inclusion and exclusion criteria

Criteria Cases Control

Inclusion

(1) Born alive with birth weight between1001 and 2499 grams(2) Born between 2010 and 2012 on thestudy site(3) Dying during the first 28 completeddays of life

(1) Born alive with birth weight between1001 and 2499 grams(2) Born between 2010 and 2012 on thestudy site(3) Survived during the first 28 completeddays of life

Exclusion

(1) Moved from study site before orduring data collection(2) Presence of congenital abnormalities(3) Multiple births(4) Hospitalized during neonatal periods(5) The neonate was adopted in theneonatal period


practice between 3 to 5) 1 = Inadequate care (if the total scorefor hygiene practice between 0 to 2)

27 Study Site The study was conducted in 8 of 23 districtsin Aceh province The districts were Aceh Besar Pidie AcehUtara Lhoksumawe Aceh Timur Aceh Tamiang BenerMeriah and Aceh Tengah There were several reasons andconsiderations for selecting these districts which were highnumber of neonatal mortality due to LBW ease of access tothe geographical location of the study site and availability oftransportation and accommodation

28 Data Collection and Procedure The data about thenumber of cases in Aceh province was sourced from the Acehprovince health office and the researcher determined thedistricts to use as the study sites After receiving permissionfrom the head of Aceh province health office to collectdata the researcher approached the district officials to getinformation about possible cases for the study In the districthealth office the researcher found the addresses of LBWwho dying in the neonatal period (case) Furthermore theresearcher came to sub district through community healthcenter (Puskesmas) to trace the case In the Puskesmas theresearcher decided on the data to be used as case and controland then recruited enumerators for the home survey Theresearcher was assisted by from 1 to 4 enumerators in eachsubdistrict that had cases and most of the controls werefound in the same subdistrict If the control was not foundin the same subdistrict the researcher would be looking inanother subdistrict in that same districtThe enumerator wasa midwife who was working in the community health centeror village Before collecting data the researcher explainedabout the study to the enumerators and how they should fillin the questionnaire The data was collected from January toDecember 2012

29 Data Analysis Thedata was analyzed in three steps usingStatistical Package for Services Solutions (SPSS) 200 Thosesteps were descriptive analysis simple logistic regressionanalysis and multiple logistic regression analysis (Tables 4and 5)

Table 2 Characteristics of neonates

Characteristics Case (250) Control (250)119899 119899

SexFemale 101 404 140 56Male 149 596 110 44

Birth weight1500ndash2499 grams 171 684 243 9721001ndash1499 grams 79 316 7 28

Gestational ageFull term (ge37 weeks) 44 176 103 412Preterm (lt37 weeks) 206 824 147 588

3 Results

Table 2 shows the characteristics of neonates in the studysample The characteristics were divided into sex birthweight and gestational age when they were born In thesex characteristic 149 (596) neonates in the case groupwere male and 140 (56) neonates in the control group werefemale Most neonates in the control group (243 neonates or972) and 171 neonates (684) in the case group were bornat a weight between 1500 and 2499 gramsThe gestational agecharacteristic indicated that 206 or 824 neonates in casegroup and 147 neonates (588) in the control group wereborn lt37 weeks of gestational age

Table 3 shows the characteristic of the parents It can beseen that 2 of 500 mothers who gave birth in the sample ofthis study died during the neonatal period 211 or 844 of themothers in the control group who gave birth to LBW babieswere aged between 20 and 35 years as were 182 or 728 ofmothers in the case group n the birth interval characteristic201 (804) mothers in the control group and 165 (66)mother in the case group giving birth the LBWneonates after2ndash5 years from the previous child 147 (588) mothers inthe control group and 134 (536) mothers in the case grouphad been giving birth 2ndash4 times before give birth the LBWneonates who as the sample this study Amajority of mothersin the case group (221 or 884) and 214 or 856 mothersin the control group have a formal education in the low level


Table 3 Characteristics of family

VariablesGroup

Case (250) Control (250)() ()

Maternal deathMother dead 0 (0) 2 (08)Mother alive 250 (1000) 248 (992)

Age of motherlt20 or gt35 years old 68 (272) 39 (156)20ndash35 years old 182 (728) 211 (844)

Birth intervallt2 or gt5 years 85 (340) 49 (196)2ndash5 years 165 (660) 201 (804)

Parity1 or gt5 times 116 (464) 103 (412)2ndash4 times 134 (536) 147 (588)

Maternal education levelElementary school-high

school 221 (884) 214 (856)

Diploma-masterrsquos 29 (136) 36 (144)Paternal education level

Elementary school-seniorhigh school 228 (912) 216 (864)

Diploma and above 22 (88) 34 (136)Paternal smoking

Smoker and smoke aroundthe mother when she is pregnant 219 (876) 195 (78)

Not smoker or smoker but didnot smoke around the motherwhen she is pregnant

31 (124) 55 (22)

Family incomeLow income 107 (428) 75 (30)High income 143 (572) 175 (70)

Median IDR 150000000

(elementary school to high school) when they gave birth toLBW babies

Most of the fathers had a low level of education when theLBW babies were born that is 228 (912) in the case groupand 216 (864) in the control group 219 or 876 of fathersin case group and 195 (78) of fathers in the control groupwere smokers and smoked around themothers when they arepregnant with the LBW babies Based on the median incomefrom all the families in this study it was found that 175 (70)of the families in control group and 143 or 572 of familiesin the case group had a high income level

The results of simple logistic regression from 4 of thevariables early initiation of breastfeeding feeding thermalcare and hygiene practice showed that early initiation ofbreastfeeding and feeding were significantly associated withmortality among LBW (119875 lt 001) Meanwhile thermalcare and hygiene practice were not associated with neonatalmortality for LBW (119875 gt 005)

To determine the factors for neonatal mortality for thelow birth weight multiple logistic regressions was used Alikelihood ratio test was used for analysis because this studyinvolved unmatched case control In the multiple logisticregressions 2 variables had significance in simple logisticregression analysis The results indicate that early initiationof breastfeeding and feeding were determinant factors ofneonatal mortality among LBW neonates in Aceh provinceIndonesia Neonates who were not breastfed within the firsthour after birth had around 3 times greater risk of deathcompared to neonates who were breastfed within the firsthour (OR 29 CI 95 17ndash48) Neonates who obtain not onlybreast milk during neonatal period (or before death) as thefeeding had 85 times greater risk of death than neonates whoobtained only breast milk (OR 85 CI 95 289ndash1076)

4 Discussion

The study showed that feeding was the overwhelmingdeterminant factor of neonatal mortality for the LBW Theneonates who were fed not only breast milk but other foodas well had 85 times greater risk of death than neonates whoreceived only breast milk in the neonatal period There weresome previous studies in which the findings were in line withthis study [11 15]

The results of this study found that the early initiation ofbreastfeeding was one of determinant factors in the mortalityof LBW neonates Those LBW neonates who did not acceptbreastfeeding within an hour after birth had 29 times greaterrisk of death than those neonates who received breastfeedingwithin that hourThis result was similar to a study conductedin rural Ghana [11] That study concluded that 22 ofneonatal deaths could have been averted if all neonates hadbeen breastfed within the first hours of birth Around 16 ofneonatal deaths could be averted if all neonates got breastfedfrom the first day The subjects of the study included theneonates weighing gt3500 grams who had better chances ofsurvival than the LBW neonates That could be the reasonthe ratio was higher than in the present study The otherstudy conducted in Nepal also came to a similar conclusion[10] Those LBW neonates who did not receive breastfeedingwithin the first hour of birth had 4 times greater risk ofdeath than those LBW neonates who received it [10]The lowpercentage of LBW as the samples in that study (298 of allsamples) could be the reason the results were slightly lowerthan in the present study

A qualitative study that was conducted in Aceh provinceto explore the motherrsquos and family experience related toneonatal care of the LBWneonates found several reasons whymothers did not provide early breastfeeding to their neonatesand the reasons why some mothers gave early breastfeedingMost mothers who did not give early breastfeeding said theydid not know that the neonates should be breastfed within anhour and also because it was not in the culture or awidespreadcustom in their community other mothers said they did notgive early breastfeeding because the condition of the neonatesor their mothers (grandmother of the neonate) prohibit forgave breastfed early because of culture and customs All


Table 4 Simple logistic regression analysis of risk factors the neonatal mortality among low birth weight in Aceh Province

VariablesGroup

119875Case (250) Control (250) OR119891 () 119891 () 95 CI

Initiation of breastfeedingDid not accept early initiation of breastfeeding 219 (876) 131 (524) 641

lt0001lowastAccepted early initiation of breastfeeding 31 (124) 119 (476) (40ndash100)

FeedingInappropriate care 230 (92) 117 (468) 137

lt0001lowastAppropriate care 20 (08) 133 (532)

Thermal careInadequate care 109 (436) 116 (464) 089 0529Adequate care 141 (564) 134 (536) (062ndash127)

Hygienic practiceInadequate care 6 (24) 9 (36) 065 0435Adequate care 244 (976) 241 (964) (023ndash187)

lowastSignificant variable P lt 005

Table 5 Multiple logistic regression analysis of risk factors the neonatal mortality among low birth weight in Aceh Province

VariablesGroup





lt0001lowastAppropriate care 20 (08) 133 (532) (49ndash148)


mothers who gave early breastfeeding within an hour afterbirth did so because it was suggested by the midwife and wasnot because of their initiative [16]

This study indicated that there was no significant associa-tion between thermal care and hygiene practice with neonatalmortality for the LBW It contrasts with results from someprevious studies [17ndash19]The study method and study site arepossibilities for the different results Some factors that givestrength to this study are total sample number of districtsas study sites and the data being collected over 3 years Thestudy was limited by the lack of complete data in healthfacility for the cases that were used and having no referenceto similar studies in Indonesia

5 Conclusion

This study found that breast milk and the early initiation ofbreastfeeding were determinant factor of neonatal mortalityfor the LBW in Aceh Province Indonesia A new strategy topromote and improve the number of LBW that accept ini-tiation of breastfeeding and exclusive breastfeeding neededOne of the attempt is organize the annual LBW contest ineach sub-district where the judgment will be based on theacceptance of initiation of breastfeeding and exclusiveness of

breastfeeding by the infant and the growth and developmentof the infant

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

Acknowledgments

Theauthors would like to thank themidwives of the eight dis-tricts in Aceh province Indonesia for their help in collectingdata as enumerators in the field Also their appreciation goesto Aceh province health office and the eight district healthoffices inAceh province in giving their permission to conductthis study in their territory

References

[1] World Health Organization e-Library of Evidence for NutritionActions (eLENA) Early Initiation of Breastfeeding WHO 2014httpwwwwhointelenatitlesearly breastfeedingen

[2] B R Thapa ldquoHealth factors in colostrumrdquo Indian Journal ofPediatric vol 72 no 7 pp 579ndash581 2005


[3] United Nations Childrenrsquos Fund Child Info Monitoring theSituation of Children and Women Statistic by AreaChildNutrition httpwwwchildinfoorgbreastfeedinghtml

[4] The Global Breastfeeding Initiative for Child Survival( GBICS)The State of Breastfeeding in 33 Countries 2010 IBFAN-ASIADelhi India 2010

[5] World Health Organization and United Nations ChildrenrsquosFund Low Birth Weight Country Regional Global EstimatesWHO amp UNICEF New York NY USA 2004

[6] J Lawn B J McCarthyand and S R Ross The Healthy New-born A Reference Manual for ProgramManagers World HealthOrganization (WHO) Center forDisease Control amp Prevention(CDC) California Children Health Initiative (CCHI) and Care2005

[7] United Nations Childrenrsquos Fund Level amp Trends in Child Mor-tality httpwwwchildinfoorgfilesChild Mortality Report2012pdf

[8] United Nations Childrenrsquos Fund Improving Child Nutri-tion The Achievable Imperative for Global Progress 2013httpwwwuniceforgnutritionindex 68661html

[9] Departemen Kesehatan Republik Indonesia Report on Resultof National Basic Health Research (RISKESDAS) 2007 Departe-men Kesehatan Republik Indonesia Jakarta Indonesia 2008

[10] L C Mullany J Katz Y M Li et al ldquoBreast-feeding patternstime to initiation and mortality risk among newborns inSouthern Nepalrdquo Journal of Nutrition vol 138 no 3 pp 599ndash603 2008

[11] K M Edmond C Zandoh M A Quigley S Amenga-EtegoS Owusu-Agyei and B R Kirkwood ldquoDelayed breastfeedinginitiation increases risk of neonatal mortalityrdquo Pediatrics vol117 no 3 pp e380ndashe386 2006

[12] Statistics Indonesia National Population and Family PlanningBoard and Indonesia Ministry of Health and United StateAgency for International Development Indonesia Demographicand Health Survey 2012 Jakarta Indonesia 2013

[13] Dinas Kesehatan Provinsi Aceh Profil Kesehatan Provinsi AcehTahun 2012 Banda Aceh 2013

[14] Kementerian Kesehatan Republik Indonesia and Badan Peneli-tian dan Pengembangan Kesehatan Riset Kesehatan Dasar(Riskesdas) 2010 Kementerian Kesehatan Republik Indone-sia Badan Penelitian dan Pengembangan Kesehatan JakartaIndonesia 2010

[15] S LHuffman E R Zehner andCVictora ldquoCan improvementsin breast-feeding practices reduce neonatal mortality in devel-oping countriesrdquoMidwifery vol 17 no 2 pp 80ndash92 2001

[16] Satrinawati Determinant Factor of Neonatal MortalityamongLow Birth Weight Neonates in Aceh Province IndonesiaMedicine Faculty National University of Malaysia KualaLumpur Malaysia 2014

[17] A T Bang S B Baitule H M Reddy M D Deshmukh andR A Bang ldquoLow birth weight and preterm neonates can theybe managed at home by mother and a trained village healthworkerrdquo Journal of Perinatology vol 25 no 1 pp S72ndashS812005

[18] N L Sloan S Ahmed S N Mitra et al ldquoCommunity-basedkangaroomother care to prevent neonatal and infant mortalitya randomized controlled cluster trialrdquo Pediatrics vol 121 no 5pp e1047ndashe1059 2008

[19] V Rhee L C Mullany S K Khatry et al ldquoMaternal and birthattendant hand washing and neonatal mortality in southernNepalrdquo Archives of Pediatrics and Adolescent Medicine vol 162no 7 pp 603ndash608 2008

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Parkinsonrsquos Disease

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Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


Indonesia

N

0 200 400 600 800(km)

Figure 1 Aceh province in the western end of Indonesia

4∘09984000998400998400N

Figure 2 Districts in Aceh Province and 8 of 23 districts as the study site

who are both preterm and growth restricted [6] LBW willgreatly affect the growth and development of the child Theeffect does not only influence the childrsquos younger years butit will continue for its whole life cycle [6] LBW especiallypreterm birth complications is the major cause of neonatalmortality in the world (35 of all neonatal mortality) [7]Prevalence rate for the LBW worldwide between 2007 and2011 was 15 of all live births and the percentage of LBW inIndonesia (Figure 1) in 2011 was 9 of 43 million live births[8] The Indonesia Ministry of Health reported that prema-ture births were the second highest cause of early neonatalmortality in Indonesia (324 of all neonatal mortality) [9]

Even though the early initiation of breastfeeding is rec-ommended and there is some evidence to show the relation-ship between early initiation of breastfeeding and neonatalsurvival [10 11] the percentage of early of breastfeeding in

Indonesia is still low [12] Overall the percentage of earlyinitiation of breastfeeding in Indonesia between 2007 and2012 was 493 of all live births and lower in some provincesincluding Aceh Province (Figure 2) [12]

Aceh province is located in the most western part ofIndonesia directly adjacent to the Indian Ocean AndamanSea and Malacca strait [13] The weather in Aceh is the sameas in Indonesia it is a tropical climate with two seasons rainyand dry and the average temperature is 25ndash32∘C [13] Thetotal area of the Aceh province is 58377 km2 and divided into23 districts 286 subdistricts and 6489 villages with a totalpopulation in 2012 of around 47 million people [13]

The percentage of early initiation of breastfeeding inAceh province between 2007 and 2012 was 464 of all livebirths this is lower than the national percentage (493) [13]The data from the Indonesian Ministry of health gave the




2 Methods


















Inclusion



Exclusion









SexFemale 101 404 140 56Male 149 596 110 44



3 Results





VariablesGroup

Case (250) Control (250)() ()






school 221 (884) 214 (856)






31 (124) 55 (22)







4 Discussion






VariablesGroup










VariablesGroup









5 Conclusion





Acknowledgments


References


























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















2 Methods


















Inclusion



Exclusion









SexFemale 101 404 140 56Male 149 596 110 44



3 Results





VariablesGroup

Case (250) Control (250)() ()






school 221 (884) 214 (856)






31 (124) 55 (22)







4 Discussion






VariablesGroup










VariablesGroup









5 Conclusion





Acknowledgments


References


























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















Inclusion



Exclusion









SexFemale 101 404 140 56Male 149 596 110 44



3 Results





VariablesGroup

Case (250) Control (250)() ()






school 221 (884) 214 (856)






31 (124) 55 (22)







4 Discussion






VariablesGroup










VariablesGroup









5 Conclusion





Acknowledgments


References


























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















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Case (250) Control (250)() ()






school 221 (884) 214 (856)






31 (124) 55 (22)







4 Discussion






VariablesGroup










VariablesGroup









5 Conclusion





Acknowledgments


References


























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















VariablesGroup










VariablesGroup









5 Conclusion





Acknowledgments


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of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of







































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OncologyJournal of





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ObesityJournal of
















Research Article The Effect of Early Initiation of...

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