Open access
BMJ Open: first published as 10.1136/bmjopen-2023-072849 on 5 October 2023. Downloaded from http://bmjopen.bmj.com/ on February 17, 2024 by guest. Protected by copyright.
To cite: Oyedele OK.
Effect of caesarian section
delivery on breastfeeding
initiation in Nigeria: logit-­
based decomposition and
subnational analysis of cross-­
sectional survey. BMJ Open
2023;13:e072849. doi:10.1136/
bmjopen-2023-072849
► Prepublication history and
additional supplemental material
for this paper are available
online. To view these files,
please visit the journal online
(http://dx.doi.org/10.1136/​
bmjopen-2023-072849).
Received 15 February 2023
Accepted 20 September 2023
© Author(s) (or their
employer(s)) 2023. Re-­use
permitted under CC BY-­NC. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
1
International Research Center
of Excellence, Institute of Human
Virology Nigeria, Abuja, Nigeria
2 in Taraba (0.02%) with topmost impact in Bayelsa state
Epidemiology and Medical
Statistics, University of Ibadan,
College of Medicine, Ibadan,
Nigeria
Correspondence to
Oyewole K Oyedele;
​mrokoyedele@​gmail.​com
Effect of caesarian section delivery on
breastfeeding initiation in Nigeria: logit-­
based decomposition and subnational
analysis of cross-­sectional survey
Oyewole K Oyedele ‍ ‍1,2
ABSTRACT
Objectives This study investigates caesarian section (CS)
and vaginal delivery disparity, impact and contributions to
timely initiation of breastfeeding (TIBF) to guide evidence-­
based strategy for improved breastfeeding practice.
Design and settings A cross-­sectional (population-­
based) analysis of 19 101 non-­missing breastfeeding
data from the 2018 Nigerian Demographic Health Survey
collected via a two-­stage stratified-­random sampling
across the 37 states in the 6 geopolitical-­zones of
Nigeria.
Participants Complete responses from reproductive-­age
women (15–49 years) who had at least a childbirth in the
last 5 years prior to the 2018 survey.
Main outcome measures TIBF, that is, breastfeeding
initiation within the first hour of newborn life is the
outcome, CS is the exposure variable and explanatory
factors were classified as; socio-­demographic and
obstetrics.
Methods Descriptive statistics were reported and
graphically presented. Bivariate χ2 analysis initially
assessed the relationship. Crude and adjusted logistic
regression evaluated the likelihood and significance of
multivariable association. Multivariate decomposition
further quantified predictors’ contribution and importance.
Statistical analysis was performed at a 95% confidence
level in Stata V.17.
Results 44.1% and 20.2% of women with vaginal and
CS delivery observed TIBF, respectively. Odds of TIBF were
five times lower in women with CS delivery (adjusted OR
‘AOR’=0.21: 95% CI=0.16 to 0.26). TIBF odds increase
among women who used skilled prenatal provider
(AOR=1.29: 95% CI=1.15 to 1.45), had hospital delivery
(AOR=1.34: 95% CI=1.18 to 1.52) and in rich wealth
class (AOR=1.44: 95% CI=1.29 to 1.60), respectively.
Rural residency, unwanted pregnancy and large child
size at birth however reduces the odds. Partial skin-­to-­
skin contacts contributed to about 54% (p<0.05) of the
negative effect. TIBF is highest in Kano (3.4%) and lowest
(crude OR ‘COR’=63.9: 95% CI=28.2 to 144.9).
Conclusions CS exposure reduced the odds of TIBF by
fivefolds. Hence, the adverse effect of CS exposure on TIBF.
Skin-­to-­skin contact can reduce the negative effect of CS
on TIBF. Early mother−child contact peculiar to CS women
is critical for improved breastfeeding practice.
Oyedele OK. BMJ Open 2023;13:e072849. doi:10.1136/bmjopen-2023-072849
Original research
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒ This study was subjected to the operationalised
variable measured in the Demographic and Health
Survey and thus the type of health facility (prima-
ry or secondary or tertiary) where caesarian and
vaginal delivery took place, which could influence
breastfeeding initiation was not assessed.
⇒ The study might have also suffered from responder
bias mainly associated with cross-­sectional designs
due to possible bias in retention (recall) of breast-
feeding initiation timing.
⇒ The study is not free from social desirability bias as
respondent has the tendency to provide desired re-
sponse to breastfeeding questions rather than what
was practiced or experienced.
⇒ However, study strength can be found in gener-
alisability of the nationally representative survey
and the reliability of the weighted sample estimate
which support external validity.
⇒ The uniqueness of the study in decomposing the ef-
fect of caesarian section delivery on breastfeeding
with the application of multivariate decomposition
analysis is also a strength.
INTRODUCTION
WHO and UNICEF jointly developed the
global strategy that recommends timely
(early) initiation of breastfeeding (TIBF)
within the first hour of life.1 To ensure
newborns received in addition to the breast-
milk nutrient for growth and development,
the required colostrum that helps build anti-
body to prevent diseases.2–5 These recommen-
dations further extend to practice of exclusive
breastfeeding (EBF) for the first 6 months of
life, that is, feeding with breastmilk only and
without infant formula other than minerals or
vitamins for newborn survival, supplementary
feeding after 6 months and continue breast-
feeding for 24 months.1 6 Mother benefit from
the cost-­effectiveness, pregnancy spacing, low
risk of cancer and cardiovascular disease like
obesity and diabetes.6 7
1
 Open access
However, only 39% of newborn in 57 lower-­middle-­
income countries were early breastfed between 2010
and 2013.8 The prevalence has gone on to increase to
about 50% in 2017.9 TIBF prevalence in 29 sub-­Saharan
Africa (SSA) countries varied between 37.8% (24.6%–
51.1%) in Central Africa and 69.3% (67.6%–70.9%) in
Southern Africa between 2010 and 2015 while a pooled
prevalence of 58.3% (58.0%–58.6%) ranging between
24% in Chad and 86% in Burundi was reported in
2021.10 11 Studies have added that about 20% of neonate
and 13% of under 5 deaths could be prevented if
optimal breastfeeding practice is sustained, and the
impact of breastfeeding in reducing under 5 mortali-
ties from 12.7 million in 1990 to 5.9 million in 2015 has
been established.12–14
In Nigeria, the prevalence of TIBF is below average
despite recent increase. According to the Nigerian demo-
graphic and health survey, TIBF and EBF prevalence has
increased from 33% and 17% in 2013 to 42% and 29%
in 2018 respectively, while neonatal (NMR), infant and
under 5 mortality rate is currently 39/1000, 67/1000 and
132/1000 live births, respectively.15 16 The low prevalence
in Nigeria undermines the WHO target of 50% TIBF by
2025 and the Sustainable Development Goal target of
reducing NMR to 12/1000 live births by 2030.10 17
Literatures have revealed that the ideal childbirth
process from optimal antenatal care (ANC) uptake to
delivery in a health facility using skilled birth atten-
dants (SBA) and subsequently having normal vaginal
delivery positively influence timely initiation of breast-
feeding.2 11 18–24 Demographic, maternal and childbirth
characteristics that encourages TIBF includes; maternal
age,2 11 22 25 residence,2 19–23 education,2 11 26 household
wealth,11 19 22 24 singleton birth,2 11 18 child size,11 19 22 as well
as skin-­to-­skin contact (SSC) of mother and newborn.27–29
However, prelacteal feeding discourages early breast-
feeding initiation.9 30 31 Also, studies have identified
caesarian delivery as a negative predictor of early breast-
feeding initiation.23–25 31 However, there is paucity of
evidence on the impact and quantifiable contribution of
exposure to caesarian section (CS) delivery on/to breast-
feeding initiation in Nigeria.
Furthermore, literatures freely flourish in assessing
normal vaginal and CS delivery in Nigeria.32–35 None-
theless, the clustered effect of the CS delivery on breast-
feeding initiation is yet to be determined. Particularly,
with Nigeria being the host to the highest burden of
neonatal deaths in SSA and the top five worldwide.14
Hence, the need to understand the contribution of vagi-
nal-­CS delivery gap to TIBF. Also, the subnational distri-
bution of TIBF by mode of delivery in Nigeria is yet to
be studied. Thus, this study decomposed the effect of
CS delivery on TIBF and provided the subnational prev-
alence to respond to the following research questions:
Is there any difference in the prevalence of TIBF in CS
and vaginal delivery in Nigeria? What is the effect of CS
delivery on TIBF for newborns in Nigeria? What factor
contribute to the CS effect on TIBF in Nigeria? Findings
2 Oyedele OK. BMJ Open 2023;13:e072849. doi:10.1136/bmjopen-2023-072849
BMJ Open: first published as 10.1136/bmjopen-2023-072849 on 5 October 2023. Downloaded from http://bmjopen.bmj.com/ on February 17, 2024 by guest. Protected by copyright.
from this study will inform intervention strategy to opti-
mise the TIBF in women who had CS delivery.
METHODOLOGY
Study design, data and area
The study is a secondary analysis of cross-­sectional data
from the 2018 Nigerian Demographic and Health Survey
(NDHS). NDHS is a nationally representative population-­
based survey usually collected every 5 years. The survey
was first conducted in 1990 and then 2003, 2008, 2013
and recently in 2018 which is the fifth of the series. NDHS
is collected across all the 6 geopolitical zones of Nigeria
(Northcentral, Northeast, Northwest, South-­south, South-
east and Southwest) covering a total of 36 states and the
federal capital territory (FCT). Nigeria is the most popu-
lated country in Africa with an estimated over 218 million
people and a land mass of 923 768 km2.36
Sampling procedure and participants
The 2018 NDHS used the two-­stage stratified random
sampling technique for data collection that span across
the states, based on the National Population and
Housing Census sampling frame. The states are divided
into local government areas referred to as the adminis-
trative units in the first stage of sampling (74 strata) and
these units are further subdivided into rural and urban
enumeration areas at the second stage which made up
the primary sampling units (1400 urban and rural clus-
ters). Based on equal probability systematic sampling,
30 households were selected per cluster and a total of
42 000 households were selected. Among which women
of reproductive age (15–49 years) who had at least one
birth in the last 5 years preceding the survey were inter-
viewed regarding breastfeeding practice that includes
initiation and other related obstetrics and demographics
characteristics (figure 1). A complete 19 101 weighted
women respondents made up the study sample size for
data analysis (figure 1). The sampling methodology of
the 2018 NDHS that achieves a response rate of 99% has
been documented.15 16
Ethical consideration
This study used secondary data from the NDHS which
obtained ethical approval from the Institutional Review
Board (IRB) of Inner City Fund International Macro at
Fairfax, Virginia, USA, and the IRB (National Health
Research Ethics Committee) in Nigeria. The author was
granted access to the data following request. Written
informed consent was obtained from participants prior to
data collection per IRB ethical guidelines for conduct of
research. All methods were implemented in accordance
with the relevant guidelines and regulations. Author
adheres to the Strengthening the Reporting of Observa-
tional Studies in Epidemiology reporting guidelines for
cross-­sectional studies.37

Figure 1 Data flow schema of weighted sample included and excluded in the study analysis of the 2018 NDHS. NDHS,
Nigerian Demographic and Health Survey.
Patient and public involvement
Neither the patient nor the public were involved in the
design, conduct, analysis and reporting of the study.
Outcome variable
The outcome variable ‘timely initiation of breastfeeding
(TIBF)’ was assessed from the response to the question;
How long after birth did you first put (child) to the breast?
This was classified according to the WHO and UNICEF
standards as; ‘early’, that is, ‘timely’ if it is within the first
hour of birth and ‘late’ if it is beyond the first hour of
birth as illustrated below.1
{
1, Early i.e. within the first hour of birth
TIBF=
‍ 0, Otherwise late i.e. beyond the first hour ‍
Exposure variable
The exposure variable is the ‘mode of delivery’ vaginal or
CS.19 25 38 Women who had at least the last singleton birth
via the CS delivery mode are the exposed group while
those who had the last childbirth via the vaginal delivery
mode are the unexposed group.
Explanatory variables
Socio-demographic characteristics
These are; age in group (15–24, 25–34, 35–49 years),2 11 25
place of residence (urban, rural),19 23 education (no formal
education, primary, secondary, tertiary),2 11 marital status
Oyedele OK. BMJ Open 2023;13:e072849. doi:10.1136/bmjopen-2023-072849
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(married, unmarried), partner education (no formal
education, primary, secondary, tertiary), religion (Chris-
tian, Muslim, traditional/other), ethnicity (Hausa/
Fulani, Igbo, Yoruba, other), occupation (unemployed,
employed), wealth (poor, average, rich),19 22 24 media
exposure (no, yes),11 region (Northcentral, Northeast,
Northwest, Southeast, South-­south, Southwest).
Obstetrics and reproductive health factors
This includes; pregnancy desire (then, later, no more),11 25
ANC visit (none, <4 visits, 4–7 visits, 8+ visits),2 22 23 prenatal
provider (unskilled, skilled),18 skilled birth attendant
use (no, yes)8 9 22 birth order (1, 2, 3, 4+),22 24 place of
delivery (home, hospital),2 11 19 39 birth type (single birth,
twin/multiple birth),2 11 18 sex of child (male, female),
child size (small, average, large),11 19 22 SSC (put to chest
touching bare skin, put to chest not touching bare skin,
not put to chest).27 29
Statistical analysis
Descriptive statistics described the socio-­demographic
and obstetrics and health-­ related factors. Numer-
ical variable like age was summarised by mean (±SD).
Frequency and percentages of categorical variables were
reported. TIBF was classified as early breastfeeding initi-
ation (coded 1) and late breastfeeding initiation (coded
0) and summarised in proportion. Summary statistics
3
Open access
(proportion) of the exposure variable (CS delivery) was
similarly reported based on the classified group; caesarian
delivery (coded 1) and vaginal delivery (coded 0).
Bivariate χ2 analysis was performed to identify the socio-­
demographic and obstetrics and other health-­ related
characteristics associated with TIBF by setting the level
of significance at 10% (p<0.10) and to allow for more
variable inclusion in the multivariable analysis and since
TIBF is not a rare outcome. The Pearson χ2 statistic was
reported throughout as none of the 20% expected cell
count was less than 5. All the women characteristics asso-
ciated with early breastfeeding initiation were included in
the subsequent multivariable logistic regression analysis.
The multivariable binary logistic regression analysis was
performed for the association between TIBF, and women
factors identified under the bivariate analysis. This is to
assess the likelihood (in terms of odds) and significance
of the predictors at p<0.05. The crude OR (COR) was
reported when individual factors were assessed without
controlling for other variables while adjusted OR (AOR)
was reported when other independent variables were
controlled in the model.
Multivariate decomposition analysis was then performed
to determine factors contributing to the exposure (CS
delivery) effect on the outcome (TIBF). The reported
statistics breakdown the characteristics and coefficient
component effect and, the percentage (%) and signifi-
cant (p<0.05) of the factors were also reported. Women
use of SBA and place of delivery were not included in the
decomposition analysis due to the confounding effect as
these factors were associated with the exposure variable as
well as the outcome. The women weight indices included
in the NDHS were applied to account for clustering effect
due to a disproportionate sample of the complex survey
design. svyset command was used to adjust for sample
weight, strata and cluster. All analysis was performed
using Stata (V.17.0) at 5% level of significant (95% CI).
Multivariable logistic regression
The binary logistic regression (P(Y‍ i = 0)‍ , P(Y‍ i = 1)‍ )
modelled the binary response (TIBF = ‘0’ if late and ‘1’
if early) such that the regression coefficients and OR
(exponent of the regression coefficients) are estimable.40
The multivariable logistic regression model equation is
illustrated below as the linear function of the regression
outcome ‘Y’ and predictors ‘X’.
π ) = β + β X + . . . + β X + ϵ(1)
Y‍ i = ln( 1−π 0 1 1i k ki ‍
exp(β +β x +...+β x )
E(Y ) = ki = (1+exp(β 0 1 1i k ki
(2)
‍ i ( ) 0 +β1 x1i +...+βk xki ) ‍
π in Imo and Abia were after CS delivery compared with
Where: ln 1−π is the log odds (π is the probability of
‍ ‍
success (ie, early initiation of breastfeeding) and 1-π is the
failure probability (ie, late initiation of breastfeeding)).
‍β0‍is the logistic regression constant or intercept.
‍β1 + · · · + βk ‍are the k×1 vector of regression coefficient
or slopes.
‍ i1 + · · · + Xik ‍ are the n×k matrix of explanatory vari-
X The descriptive analysis of women socio-­demographics
ables predicting the log odds in the model.
4 Oyedele OK. BMJ Open 2023;13:e072849. doi:10.1136/bmjopen-2023-072849
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DECOMPOSITION ANALYSIS
The multivariate decomposition analysis (MDA) tech-
nique was adopted to determine the contributing factors
partition into characteristics and coefficients effect.41
MDA is a non-­linear model for splitting the difference
in group statistics ‘mean (linear), proportion (logit) and
count (Poisson)’ or change in outcome distribution over
time into compositional and coefficient effect.41–43 In this
study, the decomposition of the differences in group (CS
and vaginal birth) proportion of TIBF was based on the
logit model which is a function of the linear combination
of the logistic regression coefficients and the TIBF predic-
tors. The non-­linear regression can be additively decom-
posed into:
Y‍ = F(Xβ)(‍ 3)
Y‍ k − Y1−k {
= F(Xk βk )F(X1−k β1−k )(4)‍ }
Y‍ k − Y1−k F(Xk βk )F(X1−k βk ) + F(X1−k βk )F(X1−k β1−k ) (5)
‍
Where Y is the n×1 vector of the dependent variable
0≤k≤1, X is the n×k matrices of the independent variables
and β is the k×1 vector of the regression coefficients in
(1). The difference in the proportion of TIBF was decom-
posed by delivery mode (exposure group) in (2). The
component (F (X ‍ k βk )‍ – F (X
‍ 1−k βk ))
‍ in (3) refers to the
differential in endowment (explained component) while
(F (X ‍ 1−k βk )‍ – F (X ‍ 1−k β1−k ))
‍ refers to the differential
attributable to coefficients effect (unexplained compo-
nent). Y‍ k ‍denotes the proportion initiating breastfeeding
early while Y‍ 1−k ‍ denotes the proportion delaying breast-
feeding initiation.
RESULTS
Prevalence of breastfeeding initiation by mode of delivery
The distribution of breastfeeding initiation disaggre-
gated by caesarian and vaginal delivery is shown in online
supplemental figure 1. About 44% (8168/18 508) of
women who had vaginal birth initiated breast feeding
early while only 20.2% (120/593) of women who had
CS deliveries initiated breast feeding early. Prevalence of
early breast feeding in all modes of deliveries was 43.4%.
Subnational prevalence of timely initiation of breast feeding
by delivery mode
Figure 2 shows the state-­ level distribution of TIBF by
virginal and caesarian birth. TIBF from CS was highest
in Lagos (20/441 ‘4.5%’) and Oyo (16/479 ‘3.3%’) and
lowest in Sokoto (0%), Gombe (0%), Ondo (0%), Bauchi
(0%), Kebbi (0%), Kwara (0%), Borno (0%), Zamfara
(0%) and Katsina (0%) (figure 2). About 5.5% of TIBF
94.5% of TIBF after virginal birth (figure 2). TIBF prev-
alence due to CS delivery were 3.5%, 3.2% and 3.0% in
cross-­rivers, rivers and Enugu, respectively (figure 2).
Descriptive statistics of women socio-demographic and
obstetrical characteristics
and obstetrics characteristics are shown in table 1. The

Figure 2 subnational prevalence of timely initiation of breastfeeding by mode of delivery.
mean age of the women is 29.84 (±7.14) with 48.5%
(9262) in the mean age group (24–34 years). 61.3% (11
715) reside in the rural and 97.0% (18 528) are married
(table 1). Around 46.4% (8870) and 36.9% (7051) of
the women and their partners have no formal educa-
tion while 8.7% (1664) and 15.3% (2927) have tertiary
education, respectively. About 45% (8550) are poor while
35.3% (6740) belong to the rich quintiles, 39.6% (7574)
Oyedele OK. BMJ Open 2023;13:e072849. doi:10.1136/bmjopen-2023-072849
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are exposed to mass media while 60.4% (11 527) are not
(table 1). Around 3.2% and 7.3%, respectively, wanted the
pregnancy later and no more compared with the 89.5%
that wanted the pregnancy (table 1). Around 24.5% do
not attend ANC while a combined 57.7% attended ANC
at least four times. 64.7% of the women ANC was provided
by skilled attendants and 41.4% use skilled attendants at
births (table 1). Sixty per cent of deliveries are at home
5
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Table 1 Bivariate χ2 test of association between women characteristics and TIBF
TIBF status
Complete sample N=19 101 Early N=8288 Late N=10 813
Factors n (%) n (%) n (%) Χ2 P value*
Age group 75.43 <0.001
 15–24 4569 (23.9) 1754 (21.2) 2815 (26.0)
 25–34 9263 (48.5) 4147 (50.0) 5116 (47.3)
 35–49 5270 (27.6) 2388 (28.8) 2882 (26.7)
Place of residence 172.64 <0.001
 Urban 7386 (38.7) 3708 (44.7) 3678 (34.0)
 Rural 11 715 (61.3) 4580 (55.3) 71 345 (66.0)
Education 450.50 <0.001
 No formal education 8870 (46.4) 3215 (38.8) 5655 (52.3)
 Primary 2779 (14.6) 1269 (15.3) 1510 (14.0)
 Secondary 5788 (30.3) 2934 (35.4) 2854 (26.4)
 Tertiary 1664 (8.7) 870 (10.5) 794 (7.3)
Marital status 25.54 <0.001
 Married 18 528 (97.0) 7972 (96.2) 10 556 (97.6)
 Unmarried 573 (3.0) 316 (3.8) 257 (2.4)
Partner education 258.57 <0.001
 No formal education 7051 (36.9) 2606 (31.4) 4445 (41.1)
 Primary 2623 (13.7) 1140 (13.7) 1483 (13.7)
 Secondary 6500 (34.1) 3121 (37.7) 3379 (31.3)
 Tertiary 2926 (15.3) 1421 (17.1) 1506 (13.9)
Religion 410.88 <0.001
 Christian 6835 (35.8) 3473 (41.9) 3362 (31.1)
 Muslim 12 170 (63.7) 4769 (57.5) 7401 (68.4)
 Traditional/other 95 (0.5) 46 (0.6) 50 (0.5)
Ethnicity 891.6 <0.001
 Hausa/Fulani 8807 (46.1) 2936 (35.4) 5871 (54.3)
 Igbo 2249 (11.7) 937 (11.3) 1312 (12.1)
 Yoruba 2305 (12.1) 1473 (17.8) 832 (7.7)
 Other 5740 (30.1) 2942 (35.5) 2798 (25.9)
Occupation 52.76 <0.001
 Unemployed 6140 (32.1) 2405 (29.0) 3735 (34.5)
 Employed 12 960 (67.9) 5883 (71.0) 7078 (65.5)
Wealth 461.02 <0.001
 Poor 8550 (44.7) 2998 (36.1) 5562 (51.4)
 Average 3811 (20.0) 1776 (21.4) 2035 (18.8)
 Rich 6740 (35.3) 3524 (42.5) 3216 (29.7)
Media exposure 61.70 <0.001
 No 11 526 (60.4) 4751 (57.3) 6775 (62.7)
 Yes 7575 (39.6) 3537 (42.7) 4038 (37.3)
Region 17 000.00 <0.001
 Northcentral 2667 (13.9) 1639 (19.8) 1028 (9.5)
 Northeast 3475 (18.2) 1032 (12.4) 2443 (22.6)
 Northwest 7017 (36.7) 2356 (28.4) 4661 (43.1)
 Southeast 1735 (9.1) 713 (8.6) 1022 (9.5)
Continued

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Table 1 Continued
TIBF status
Complete sample N=19 101 Early N=8288 Late N=10 813
Factors n (%) n (%) n (%) Χ2 P value*
 South-­south 1581 (8.2) 884 (10.7) 696 (6.4)
 Southwest 2625 (13.7) 1662 (20.1) 963 (8.9)
Wanted pregnancy 14.88 0.001
 Then 17 091 (89.5) 7344 (88.6) 9747 (90.1)
 Later 1398 (7.3) 641 (7.7) 757 (7.0)
 No more 612 (3.2) 303 (3.7) 309 (2.9)
ANC visit 210.54 <0.001
 None 4688 (24.5) 1836 (22.1) 2852 (26.4)
 <4 visits 3407 (17.8) 1262 (15.2) 2145 (19.8)
 4–7 visits 7173 (37.6) 3204 (38.7) 3969 (36.7)
 8+ visits 3833 (20.1) 1986 (23.9) 1847 (17.1)
Prenatal provider 126.12 <0.001
 Unskilled 6750 (35.3) 2559 (30.9) 4191 (38.8)
 Skilled 12 351 (64.7) 5729 (69.1) 6622 (61.2)
SBA use 346.62 <0.001
 No 11 200 (58.6) 4255 (51.3) 6945 (64.2)
 Yes 7901 (41.4) 4033 (48.7) 3868 (35.8)
Birth order 31.52 <0.001
 1 2961 (15.5) 1200 (14.5) 1761 (16.3)
 2 3461 (18.1) 1573 (18.9) 1888 (17.5)
 3 2947 (15.4) 1365 (16.5) 1582 (14.6)
 4+ 9732 (51.0) 4150 (50.1) 5582 (51.6)
Place of delivery 316.94 <0.001
 Home 11 469 (60.0) 4382 (52.9) 7087 (65.5)
 Hospital 7632 (40.0) 3906 (47.1) 3726 (34.5)
Delivery by CS 111.95 <0.001
 No 18 508 (96.9) 8168 (98.6) 10 340 (95.6)
 Yes 593 (3.1) 120 (1.4) 473 (4.4)
Birth type 0.43 0.511
 Single birth 18 747 (98.2) 8132 (98.1) 10 615 (98.7)
 Twin/multiple births 354 (1.8) 156 (1.9) 198 (1.8)
Sex of child 3.14 0.076
 Male 9788 (51.3) 4271 (51.5) 5517 (51.0)
 Female 9313 (48.7) 4017 (48.5) 5296 (49.0)
Child size 73.17 <0.001
 Small 6684 (35.0) 2979 (35.9) 3705 (34.3)
 Average 9844 (51.5) 4392 (53.0) 5452 (50.4)
 Large 2573 (13.5) 917 (11.1) 1656 (15.3)
Skin-­to-­skin contact 35.56 <0.001
 Put to chest touching bare skin 2273 (11.9) 1078 (13.0) 1195 (11.1)
 Put to chest no bare skin touch 534 (2.8) 153 (1.9) 381 (3.5)
 Not put to chest 16 294 (85.3) 7057 (85.1) 9237 (85.4)
2
*P value of Pearson χ test.
ANC, antenatal care; CS, caesarian section; SBA, skilled birth attendant; TIBF, timely initiation of breast feeding.

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Open access
with 1.9% twin or multiple births and only 11.9% put the
child to chest touching bare skin (table 1).
Bivariate χ2 test of association
Table 1 also shows the bivariate association of women
characteristic with early breastfeeding initiation at
p<0.10. Delivery by CS (χ2=111.95), place of delivery
(χ2=316.94), SBA use (χ2=346.62) prenatal provider
(χ2=126.12), residence (χ2=172.64), wealth (χ2=461.02),
women (χ2=258.57) and partner education (χ2=258.57)
among other characteristics are associated with early
breastfeeding initiation at p<0.001 (table 2). Except
for birth type (χ2=0.43) that is not associated (p>0.10),
pregnancy desire (χ2=14.88) is connected to early breast-
feeding initiation at p<0.01 while sex of child (χ2=3.14) is
associated at p<0.10 (table 1).
Crude and adjusted effect of CS birth and other maternal
characteristics on TIBF
Table 2 present the crude and adjusted association
between caesarian birth/maternal factors and early
breastfeeding initiation. Caesarian delivery is negatively
associated with early initiation of breastfeeding as women
who had CS delivery are three to five times less likely to
early initiate breastfeeding when other variables were
adjusted and unadjusted (AOR=0.21 95% CI=0.16 to
0.26; COR=0.32, 95% CI=0.26 to 0.39) (table 2). Rural
residency (AOR=0.85, 95% CI=0.78 to 0.92; COR=0.64,
95% CI=0.60 to 0.67), large child size at birth (AOR=0.72,
95% CI=0.65 to 0.81; COR=0.68, 95% CI=0.62 to 0.76)
and putting child to chest but not touching bare skin
(AOR=0.52, 95% CI=0.42 to 0.65; COR=0.45, 95% CI=0.36
to 0.55) are also negatively associated with early initia-
tion when other variables were adjusted and unadjusted,
respectively (table 2). Women with tertiary education
(AOR=1.20, 95% CI=1.01 to 1.19), average (AOR=1.37,
95% CI=1.25 to 1.51) and rich wealth status (AOR=1.44,
95% CI=1.29 to 1.60), Yoruba (AOR=1.22, 95% CI=1.02
to 1.47) and other ethnic group (AOR=1.54, 95% CI=1.37
to 1.71), having skilled prenatal provider (AOR=1.29,
95% CI=1.15 to 1.45) and hospital delivery (AOR=1.34,
95% CI=1.18 to 1.52) are however positively associated
with TIBF. Odds of early breastfeeding initiation increase
with increase in birth order and decrease with child size
and number of ANC visit (table 2).
Decomposing effect of caesarian birth on timely initiation of
breast feeding
Table 3 presented the decomposition effect of caesarian
delivery on early breastfeeding initiation. Overall, −24.4%
(p<0.05) of the effect are due to characteristics or endow-
ment component while 124.4% (p<0.001) are attributed
to coefficient effect (table 3). Tertiary education raised the
caesarian-­vaginal delivery gap in early breastfeeding initi-
ation by 22.2% (p value=0.028) and increased the effect
by 7.6% (p value=0.031). Women exposure to media simi-
larly increases the caesarian-­vaginal delivery differential
in TIBF by 8.4% (p value=0.025) and significantly raises
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the coefficient effect by 20.9% (p value=0.004) (table 3).
Birth order three contributed only 2.4% (p value=0.005)
to the overall characteristics effect but increased the coef-
ficient effect by 8.1%. Partial SSC (53.4%, p<0.01) signifi-
cantly contributed most to the negative caesarian effect
when compared with full SSC (table 3).
Impact of women subnational on timely breastfeeding
initiation
Online supplemental table 1 presents the influence
of women’s state of residence on TIBF. Kano women
(640/8288 ‘3.4%’) recorded the highest prevalence of
TIBF from all births, followed by Niger (3.0%), Kaduna
(2.6%), Oyo (2.5%), Katsina (2.5%) and Lagos (2.3%).
Whereas TIBF prevalence was lowest in Taraba (0.2%)
(online supplemental table 1). Compared with Kano,
the chance of initiating breastfeeding early is more
than 5 times likely in Oyo (COR=5.64: 95% CI=4.32 to
7.36), Kogi (COR=5.53: 95% CI=4.20 to 7.28) and Ogun
(COR=5.32: 95% CI=3.97 to 7.13) and about 64 times as
likely in Bayelsa (COR=63.97: 95% CI=28.23 to 144.97)
(online supplemental table 1). Women in Taraba, Bauchi,
Sokoto, Adamawa, Gombe, Nasarawa and Kebbi are about
two to five times less likely to initiate breastfeeding early
(online supplemental table 1).
DISCUSSION
The role of CS births on TIBF within the first hour of life
as recommended by WHO and UNICEF was investigated,
by decomposing the effect of caesarian delivery on TIBF
and evaluating the subnational prevalence. This is to
provide statistics and facts that will support interventional
strategy development targeting improved breastfeeding
practice.
Nearly half of women who had vaginal birth initiated
breastfeeding early while only one-­fifth of women who
had caesarian delivery initiated breastfeeding early.
Overall, 96.9% and 3.1% of women had vaginal and CS
birth, respectively, in Nigeria. Prevalence of early breast-
feeding initiation is 43.4% in Nigeria with nine-­ tenth
(42.8%) of the TIBF prevalence found in women who
had vaginal delivery compared with the one-­tenth (0.6%)
in CS delivery. Similar findings were reported in the
recent NDHS and the pooled TIBF prevalence in devel-
oping countries9 16
Women exposure to caesarian delivery along with other
obstetrics and reproductive health characteristics as
well as demographic factors were associated with timely
breastfeeding initiation as observed in the bivariate anal-
ysis. These factors include place of delivery, SBA use at
birth, SSC, parity, pregnancy desire, place of residence,
education, ethnicity, media exposure and so on. Which
is in agreement with factors identified in cross-­sectional
studies and systematic review.25 38 44 Single and multiple
birth types were however non-­related to TIBF.
Furthermore, exposure to caesarian birth negatively
influences early initiation of breast feeding as women
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Table 2 Crude and adjusted effect of CS birth and other maternal characteristics on TIBF
Factors Crude OR 95% CI Adjusted OR 95% CI
Delivery by CS
 No# Ref Ref
 Yes 0.32*** 0.26 to 0.39 0.21*** 0.16 to 0.26
Age group
 15–24# Ref Ref
***
 25–34 1.30 1.21 to 1.40 0.98 0.89 to 1.08
 35–49 1.33*** 1.22 to 1.44 1.01 0.90 to 1.14
Place of residence
 Urban# Ref Ref
***
 Rural 0.64 0.60 to 0.67 0.85*** 0.78 to 0.92
Education
 No formal education# Ref Ref
 Primary 1.47*** 1.35 to 1.61 0.99 0.89 to 1.11
***
 Secondary 1.81 1.69 to 1.93 1.07 0.95 to 1.20
 Tertiary 1.92*** 1.73 to 2.14 1.20* 1.01 to 1.19
Marital status
 Married# Ref Ref
***
 Unmarried 1.63 1.38 to 1.93 0.99 0.82 to 1.20
Partner education
 No formal education# Ref Ref
 Primary 1.31*** 1.19 to 1.44 0.92 0.82 to 1.03
*** ***
 Secondary 1.58 1.47 to 1.69 0.81 0.73 to 0.90
 Tertiary 1.61*** 1.47 to 1.75 0.83** 0.73 to 0.95
Religion
 Christian# Ref Ref
***
 Muslim 0.62 0.58 to 0.66 1.18** 1.06 to 1.32
 Traditional/other 0.89 0.59 to 1.34 1.01 0.65 to 1.55
Ethnicity
 Hausa/Fulani# Ref Ref
***
 Igbo 1.42 1.29 to 1.57 0.83 0.67 to 1.03
***
 Yoruba 3.54 3.21 to 3.89 1.22* 1.02 to 1.47
 Other 2.10*** 1.96 to 2.25 1.54*** 1.37 to 1.71
Occupation
 Unemployed# Ref Ref
***
 Employed 1.29 1.21 to 1.37 0.92* 0.86 to 0.99
Wealth
 Poor# Ref Ref
 Average 1.63*** 1.50 to 1.76 1.37*** 1.25 to 1.51
*** ***
 Rich 2.04 1.91 to 2.17 1.44 1.29 to 1.60
Media exposure
 No# Ref Ref
 Yes 1.25*** 1.17 to 1.32 0.83*** 0.77 to 0.89
Region
 Northcentral# Ref Ref
***
 Northeast 0.26 0.23 to 0.30 0.27*** 0.24 to 0.31
***
 Northwest 0.32 0.28 to 0.35 0.39*** 0.35 to 0.45
Continued

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Table 2 Continued
Factors Crude OR 95% CI Adjusted OR 95% CI
***
 Southeast 0.44 0.38 to 0.50 0.70** 0.56 to 0.87
 South-­south 0.80*** 0.70 to 0.90 0.95 0.81 to 1.10
 Southwest 1.08 0.96 to 1.21 1.34** 1.13 to 1.59
Wanted pregnancy
 Then# Ref Ref
 Later 1.12* 1.00 to 1.26 0.87* 0.77 to 0.98
 No more 1.30** 1.10 to 1.53 0.84* 0.70 to 0.99
ANC visit
 None# Ref Ref
 <4 visits 0.91 0.83 to 1.00 0.72*** 0.63 to 0.82
***
 4–7 visits 1.25 1.16 to 1.35 0.81** 0.71 to 0.91
 8+ visits 1.67*** 1.53 to 1.82 0.64*** 0.54 to 0.74
Prenatal provider
 Unskilled# Ref Ref
***
 Skilled 1.42 1.33 to 1.51 1.29*** 1.15 to 1.45
SBA use
 No# Ref Ref
 Yes 1.70*** 1.60 to 1.80 0.87* 0.76 to 0.99
Birth order
 1# Ref Ref
***
 2 1.22 1.10 to 1.35 1.18** 1.05 to 1.31
 3 1.26*** 1.14 to 1.40 1.31*** 1.16 to 1.47
***
 4+ 1.09* 1.00 to 1.19 1.36 1.20 to 1.53
Place of delivery
 Home# Ref Ref
***
 Hospital 1.70 1.59 to 1.80 1.34*** 1.18 to 1.52
Sex of child
 Male# Ref Ref
 Female 0.97 0.92 to 1.04 0.99 0.93 to 1.05
Child size
 Small# Ref Ref
 Average 1.00 0.94 to 1.07 0.93* 0.87 to 1.00
 Large 0.68*** 0.62 to 0.76 0.72*** 0.65 to 0.81
Skin-­to-­skin contact
 Put to chest touching bare skin# Ref Ref
***
 Put to chest no bare skin touch 0.45 0.36 to 0.55 0.52*** 0.42 to 0.65
***
 Not put to chest 0.85 0.77 to 0.93 0.97 0.88 to 1.08

***significant at p<0.001; **significant at p<0.01; *significant at p<0.05; #reference category.

.ANC, antenatal care; CS, caesarian section; SBA, skilled birth attendant; TIBA, timely initiation of breast feeding.

who had caesarian birth are about five times less likely
to initiate breastfeeding within the first hour of birth
compared with those who had virginal birth. This can be
attributed to the difference in recovery time as women
who had CS are likely to be unconscious in the first hour
of life of newborn birth due to the anaesthesia effect,
general body weakness and will require more clinical care
than those who had virginal delivery. This is in congruent
with findings of studies in SSA.25 45 Lack of mother–child
SSC after birth twice reduced the chance of early breast-
feeding initiation. Comparable findings were reported in
cross-­sectional and experimental studies assessing associ-
ation between SSC and breastfeeding practice.28 46 Simi-
larly, women who wanted pregnancy later or never and

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Table 3 Decomposition effect of caesarean birth on timely initiation of breast feeding
Effect due to characteristics (C) Effect due to co-­efficients (E)
Factors Coefficients P value Per cent Coefficients P value Per cent
Age group
 15–24* Ref Ref
 25–34 0.00025 0.601 0.10 0.01986 0.560 8.28
 35–49 0.00016 0.978 0.07 0.00025 0.990 0.10
Place of residence
 Urban* Ref Ref
 Rural 0.00123 0.895 0.51 0.01123 0.685 4.69
Education
 No formal education* Ref Ref
 Primary 0.00119 0.846 0.49 0.00409 0.835 1.71
 Secondary 0.01403 0.055 5.85 0.05862 0.057 24.45
 Tertiary 0.05330 0.028 22.24 0.01833 0.031 7.64
Marital status
 Married* Ref Ref
 Unmarried 0.00031 0.240 0.13 0.00430 0.239 1.79
Partner education
 No formal education Ref Ref
 Primary* 0.00065 0.730 0.27 0.00751 0.659 3.13
 Secondary 0.00001 0.997 0.01 0.00952 0.812 3.97
 Tertiary 0.00297 0.894 1.24 0.00121 0.945 0.50
Ethnicity
 Hausa/Fulani* Ref Ref
 Igbo 0.00103 0.937 0.43 0.00439 0.674 1.83
 Yoruba 0.00536 0.364 2.23 0.00715 0.520 2.98
 Other 0.00001 0.680 0.01 0.00567 0.822 2.36
Occupation
 Unemployed* Ref Ref
 Employed 0.00092 0.701 0.38 0.01788 0.514 7.46
Wealth
 Poor* Ref Ref
 Average 0.00090 0.840 0.38 0.01360 0.518 5.67
 Rich 0.02746 0.287 11.45 0.01470 0.647 6.13
Media exposure
 No* Ref Ref
 Yes 0.02019 0.025 8.42 0.05007 0.004 20.88
Region
 North central* Ref Ref
 Northeast 0.00924 0.008 8.03 0.01844 0.353 7.69
 Northwest 0.01158 0.418 4.83 0.02145 0.515 8.95
 Southeast 0.00382 0.364 1.59 0.00090 0.890 0.37
 South-­south 0.00253 0.402 1.06 0.00231 0.626 0.97
 Southwest 0.00612 0.443 2.55 0.01148 0.163 4.79
Wanted pregnancy
 Then* Ref Ref
 Later 0.00011 0.947 0.04 0.00188 0.602 0.78
Continued

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Table 3 Continued
Effect due to characteristics (C) Effect due to co-­efficients (E)
Factors Coefficients P value Per cent Coefficients P value Per cent
 No more 0.00064 0.439 0.27 0.00267 0.252 1.12
ANC visit
 None* Ref Ref
 <4 visits 0.00564 0.669 2.35 0.02191 0.503 9.14
 4–7 visits 0.00139 0.656 0.58 0.01961 0.765 8.18
 8+ visits 0.05227 0.211 21.80 0.03259 0.337 13.60
Prenatal provider
 Unskilled* Ref Ref
 Skilled 0.02459 0.283 10.26 0.10212 0.174 42.60
Birth order
 1* Ref Ref
 2 0.00008 0.966 0.03 0.00338 0.699 1.41
 3 0.00585 0.005 2.44 0.01944 0.012 8.11
 4+ 0.00670 0.392 2.80 0.00329 0.908 1.37
Sex of child
 Male* Ref Ref
 Female 0.00015 0.575 0.06 0.00963 0.533 4.02
Child size
 Small* Ref Ref
 Average 0.00006 0.952 0.03 0.00659 0.719 2.75
 Large 0.00010 0.807 0.04 0.00422 0.584 1.76
Skin-­to-­skin contact
 Put to chest touching bare skin* Ref Ref
 Put to chest no bare skin touch 0.01887 0.005 7.87 0.12842 0.006 53.57
 Not put to chest 0.01785 0.038 7.45 0.00028 0.826 0.12
Constants 0.27095 0.124 113.02
 E/C 0.05846 0.031 24.39 0.29818 0.000 124.39
 R 0.23973 0.000

*Reference category.
†
.ANC, antenatal care; CS, caesarian section; R, Residual.

those residing in the rural areas are less likely to timely
initiate breastfeeding than those who desired the preg-
nancy and living in urban areas, respectively. Which has
been identified as a barrier to early breastfeeding practice
among adolescents in Nigeria.47 Also, having average or
large child size at birth decreased the odds of early initi-
ation as mother had the tendency to perceive the large
size as a reason to delay breastfeeding which was equally
reported in outcome of a cross-­sectional study in Namibia
but in disagreement with findings from another SSA.11 22
Employed women and those exposed to mass media are
as well less likely to initiate breastfeeding earlier than
those unemployed and not exposed to mass media,
respectively. Surprisingly, the adjusted effects of partner
educational level, ANC visit and SBA use on TIBF were
negative though the unadjusted effects were positive.
However, women’s place of delivery is positively associ-
ated with TIBF as those who delivered in a hospital are
about 34% more likely to initiate breastfeeding earlier
than those who had home delivery. This reflects the
benefit of SBA in health facility delivery as against home
birth,39 and analogous to the findings from population-­
based study in Nigeria that reported 40% increase in odds
as well as the study findings from 35 SSA countries.11 19
Equivalently, women in Southwest have a 34% likelihood
of initiating breastfeeding earlier than those in the North-
central. This was evident from improved breastfeeding
practice in the region compared with the north.2 19 48
Having a skilled prenatal provider increases the chance of
early breastfeeding by about 30% compared with having
an unskilled prenatal provider. Thus highlighting the
impact of skilled health professionals as an educational

12 Oyedele OK. BMJ Open 2023;13:e072849. doi:10.1136/bmjopen-2023-072849


intervention to improve TIBF.49 The association increases
positively as parity increases and thus women with two
births have higher odds than those with one birth and
those with three births have higher odds than those with
two births and so on. Also, the chance of early breast-
feeding initiation increases with wealth quintiles as the
odds are 37% among the middle class and 44% among
the rich class compared with the poor. This is owing to
socioeconomic inequality since women in high socio-
economic class will afford nutritional food to replenish
during breastfeeding than those in low socioeconomic
class.6 50 Women practicing Islam, with tertiary education
and from Yoruba ethnic group are 18%, 20% and 22%
as likely to timely initiate breastfeeding than the Chris-
tians, without formal education and from Hausa ethnic,
respectively.
The overall caesarian-­vaginal delivery differentials were
significantly attributed to endowment (24%) and coef-
ficients (124%) components. With the difference due
to endowment being raised by the effect of the women
tertiary education (22%), exposure to mass media (8%)
and partial SSC (ie, placing child on the chest with
obstruction of bare skin) (8%) and parity (2%). Lack
of SSC (not putting child to chest and without bare
skin contact) however decrease the effect of caesarian-­
vaginal delivery gap on timely initiation of breast feeding
by about 8%. Whereas the coefficients effect of CS-­vag-
inal delivery on TIBF was increase by 8% in women with
tertiary education compared with women without formal
education. The coefficient effect would have increase by
about 21% if women not exposed to mass media have the
distribution of those exposed to mass media. Also, women
with birth order three increase the coefficient effect by
8% compared with those with birth order one. Maximum
contribution (about 54%) to the negative CS-­ vaginal
differential effect on TIBF due to coefficients component
was observed when partial kangaroo mother care was
practiced compared with the full SSC. Which implies that
not having SSC post CS childbirth positively increases
the negative effect on TIBF and thereby encourages and
widens the gap in CS-­vaginal delivery. The positive effect
of the SSC as a kangaroo mother care on breastfeeding
practice has been compatibly reported in Nigeria and
China.27–29 51
TIBF varies across women subnational level with
highest prevalence (3.5%) found in Kano, out of which
CS delivery contributed 1% compared with 2.5% from
normal birth while the lowest prevalence was in Taraba
(0.2%). TIBF prevalence following CS birth was highest
in Lagos and Oyo while it is close to non-­existence in
Sokoto, Gombe, Ondo, Bauchi, Kebbi, Kwara, Borno,
Zamfara and Katsina. This can be attributed to the high
prevalence of CS delivery in the Southwestern states as
evidently reported in previous cross-­sectional study.33 The
chance of TIBF is about 64 times higher in Bayelsa than
Kano and more than 5 times as likely in Oyo, Kogi and
Ogun. Which can be attributed to the high prevalence of
SSC and breastfeeding initiation and thus correspond to
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the findings from state-­level analysis of SSC and breast-
feeding practice in Nigeria.29 The likelihood of early
breastfeeding initiation is however lower in Taraba,
Bauchi, Sokoto, Adamawa, Gombe, Nasarawa and Kebbi
than Kano. These statistics thus indicate poor breast-
feeding practice in the north compared with the south
despite a higher mother/childbirth ratio.
Study strengths and limitations
This study was subjected to the operationalised variable
measured in the DHS and thus the type of health facility
(primary or secondary or tertiary) where caesarian and
vaginal delivery took place, which could influence breast-
feeding initiation was not assessed. The study might have
also suffered from responder bias mainly associated with
cross-­sectional designs due to possible bias in retention
(recall) of breastfeeding initiation timing. The study is
not free from social desirability bias as respondent has the
tendency to provide desired response to breastfeeding
question rather than what was practiced or experienced.
However, study strength can be found in generalisability
of the nationally representative survey and the reliability
of the weighted sample estimate which support external
validity. The uniqueness of the study in decomposing the
effect of CS delivery on breast feeding with the application
of multivariate decomposition analysis is also a strength.
CONCLUSIONS
This study reported that less than half of nursing mothers
in Nigeria initiated breast feeding within the first hour
of birth. Only one-­fifth of the women who had caesarian
birth compared with the over two-­fifth of women who had
vaginal delivery initiated breast feeding early. Caesarian
birth is strongly but negatively associated with timely initi-
ation of breast feeding. Hence, the chance of early breast-
feeding initiation is in five folds less likely in women with
caesarian delivery compared with vaginal birth. Facility-­
based delivery, skilled prenatal provider, multiparity and
wealth are positive predictors while undesired pregnancy,
partial SSC and rural residency are negative predic-
tors. Tertiary education and media exposure bridge the
caesarian-­vaginal delivery gap in early breastfeeding initi-
ation. Compared with full SSC, practicing partial SSC for
newborn encourages and widens the negative effect of
caesarian birth on timely initiation of breastfeeding.
Recommendations
Findings from this study highlighted the need for prenatal
providers to intensify on early and continuous breast-
feeding education talk for women throughout pregnancy.
Governmental and non-­ governmental organisations
should support sensitisation programmes that encourage
facility-­
based delivery and provide more breastfeeding
support (adopting kangaroo mother care) to optimise the
baby friendly hospital initiatives particularly for women
who had caesarian delivery. The north should learn from
the breastfeeding practices in the south to bridge the
13
 Open access
subnational gap. Contextual research targeting women
who had caesarian delivery is required to understand the
low prevalence of TIBF. Also, studies stratifying the CS
by type is essential to further determine the proportion
to treat and guide the intervention strategy to improve
breastfeeding practice.
Acknowledgements The author appreciates the ICF Macro, owners of the
MEASURE DHS data for granting the use of the dataset. Faith Fasuba and Queen
Dagala are appreciated for article collections.
Contributors OKO conceptualised and designed the study, analysed the data,
interpreted the result, wrote and reviewed the manuscript. The author read and
approved the final version of the manuscript. OKO is the guarantor of this study.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests None declared.
Patient and public involvement Neither the patients nor the public were involved
in the design, conduct, analysis, and reporting of the study.
Patient consent for publication Not applicable.
Ethics approval Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available in a public, open access repository.
Data are available upon reasonable request. The anonymised data is available in
the public domain.52 Data set used (generated and/or analysed) in this current
study are available on reasonable request from the corresponding author and at the
open repository of the DHS program, www.​dhsprogram.​com.
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ORCID iD
Oyewole K Oyedele http://orcid.org/0000-0003-4275-8111
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15