Birth and newborn care policies and practices limit breastfeeding at maternity facilities in Vietnam

fnut-09-1041065 November 1, 2022 Time: 8:16 # 1

TYPE Original Research

PUBLISHED 28 October 2022

DOI 10.3389/fnut.2022.1041065

OPEN ACCESS

EDITED BY

Mary A. Uyoga,

North-West University, South Africa

REVIEWED BY

Laura Galante,

University of Turku, Finland

Masahide Hamaguchi,

Kyoto Prefectural University

of Medicine, Japan

*CORRESPONDENCE

Tuan T. Nguyen

[email protected]

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This article was submitted to

Nutritional Epidemiology,

a section of the journal

Frontiers in Nutrition

RECEIVED 10 September 2022

ACCEPTED 10 October 2022

PUBLISHED 28 October 2022

CITATION

Nguyen TT, Cashin J, Tran HT,

Hoang TA, Mathisen R, Weissman A

and Murray JCS (2022) Birth and

newborn care policies and practices

limit breastfeeding at maternity

facilities in Vietnam.

Front. Nutr. 9:1041065.

doi: 10.3389/fnut.2022.1041065

Mathisen, Weissman and Murray. This

is an open-access article distributed

under the terms of the Creative

Commons Attribution License (CC BY).

The use, distribution or reproduction in

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does not comply with these terms.

Birth and newborn care policies

and practices limit breastfeeding

at maternity facilities in Vietnam

Tuan T. Nguyen

, Jennifer Cashin

, Hoang T. Tran

Tuan A. Hoang

, Roger Mathisen

, Amy Weissman

1,5

and

John C. S. Murray

Alive & Thrive East Asia Paciﬁc, FHI 360, Hanoi, Vietnam,

Alive & Thrive East Asia Paciﬁc, FHI 360,

Washington, DC, United States,

Neonatal Unit and Human Milk Bank, Department of Pediatrics,

School of Medicine and Pharmacy, Da Nang Hospital for Women and Children, The University of Da

Nang, Da Nang, Vietnam,

Department of Maternal and Child Health, Vietnam Ministry of Health,

Hanoi, Vietnam,

Asia Paciﬁc Regional Ofﬁce, FHI 360, Bangkok, Thailand,

Independent

Researcher, Iowa City, IA, United States

The prevalence of early and exclusive breastfeeding in Vietnam remains sub-

optimal. The objective of this study was to determine factors associated with

early initiation of breastfeeding (EIBF) and exclusive breastfeeding for the ﬁrst

3 days after birth (EBF3D). We conducted a population-based, cross-sectional

survey of 726 mothers with children aged 0–11 months in two provinces and

one municipality from May to July 2020. Multinomial logistic regression was

used to examine factors associated with EIBF and EBF3D. The prevalence of

EIBF was 39.7% and EBF3D 18.0%. The EIBF prevalence is positively associated

with immediate and uninterrupted skin-to-skin contact (SSC) for 10–29 min

(aOR: 2.55; 95% CI: 1.49, 4.37), 30–59 min (aOR: 4.15; 95% CI: 2.08, 8.27),

60–80 min (aOR: 4.35; 95% CI: 1.50, 12.6), or ≥90 min (aOR: 5.87; 95% CI:

3.14, 10.98). EIBF was negatively associated with cesarean birth (aOR: 0.24;

95% CI: 0.11, 0.51), bringing infant formula to the birth facility (aOR: 0.49; 95%

CI: 0.30, 0.78), purchased it after arrival (aOR: 0.37; 95% CI: 0.24, 0.60), or

did both (aOR: 0.43; 95% CI: 0.21, 0.89). EBF3D was negatively associated

with cesarean section birth (aOR: 0.15; 95% CI: 0.06, 0.39), vaginal birth with

episiotomy (aOR: 0.40; 95% CI: 0.18, 0.88), bringing formula to the maternity

facility (aOR: 0.03; 95% CI: 0.01, 0.07), purchased it after arrival (aOR: 0.02; 95%

CI: 0.01, 0.06) or did both (aOR: 0.04; 95% CI: 0.02, 0.10). Receiving counseling

from any source was not signiﬁcantly associated with early breastfeeding

practices. Policy and health service delivery interventions should be directed at

eliminating infant formula from birthing environments, reducing unnecessary

cesarean sections and episiotomies, providing immediate and uninterrupted

SSC for all births, and improving breastfeeding counseling and support.

KEYWORDS

early essential newborn care, early initiation breastfeeding, exclusive breastfeeding,

maternity facilities, newborn, policy, the Code, Vietnam

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Introduction

Breastfeeding is nature’s perfect food system and the

biological norm for feeding human infants and young children

(1). Early initiation of breastfeeding (EIBF) within the ﬁrst

hour of life and exclusive breastfeeding (EBF) up to 6 months

are associated with reduced child morbidity and mortality and

provide long-term beneﬁts for both mother and child (2–

4). Although almost all mothers are biologically capable of

breastfeeding their children (5) and 95% of babies globally

receive some breastmilk, breastfeeding practices remain sub-

optimal (6). Countries in East Asia and the Paciﬁc have lower

prevalence rates of EIBF (38%), exclusive breastfeeding for the

ﬁrst 2 days after birth (57%), and EBF up to 6 months (31%)

compared to corresponding global rates of 48, 65, and 44% (7,

8). In Vietnam, rates of EIBF fell nationally between 2011 and

2020 from 39.7 to 23.5% (9, 10); and bottle-feeding rates rose

(from 38.7 to 54.3%) (9, 10). Further, the cesarean section rate

rose from 20.0% nationally in 2011 to 33.4% in 2020, with rates

in some cities above 50.0% (9–11), a trend that is likely to further

reduce the likelihood of breastfeeding (12–15).

These declines have occurred in Vietnam despite eﬀorts

since the 1990s to put in place policies to protect, promote,

and support breastfeeding (16, 17). A number of policies and

regulations have been adopted, including: national legislation on

the Code of Marketing of Breast milk Substitutes (“the Code”)

(18–20); public and private hospital accreditation standards

that promote the Ten Steps to Successful Breastfeeding (21);

early essential newborn care practice standards for vaginal

and cesarean births, a package of evidence-based interventions

applied in the second stage of labor and early newborn

period to improve maternal and newborn outcomes, including

early and exclusive breastfeeding (22–25); policies promoting

breastfeeding counseling and support from pregnancy through

the ﬁrst 2 years of life (25); and designation criteria

and assessment mechanisms for Centers of Excellence for

Breastfeeding (26).

Early initiation of breastfeeding and EBF for 6 months are

associated with several individual factors including maternal

education, type of work, parity, smoking, race, and ethnicity;

as well as practices during and immediately following childbirth

(27–29). Health service-related factors around childbirth known

to inﬂuence breastfeeding include cesarean birth, episiotomy,

immediate and uninterrupted skin-to-skin contact (SSC) of

adequate duration, rooming-in of mother and newborn, and

breastfeeding counseling (27–29). EIBF and EBF at hospital

discharge are associated with EBF up to 6 months and continued

breastfeeding (30–34). Aggressive marketing of commercial

milk formula for infants, children, and pregnant women

impedes breastfeeding and the provision of breastfeeding

support by health workers (27–29, 35–38).

Given Vietnam’s high institutional birth rate (96.3% in

2020) (10), health facility environments and health worker

behaviors play important roles in inﬂuencing early and

exclusive breastfeeding around the time of birth. Adoption

of early essential newborn care protocols in studies of

maternity hospitals in Vietnam has been associated with

improved early and exclusive breastfeeding practices prior

to discharge (24, 34). However, there are limited data

on how widely these protocols are being implemented.

Additionally, the impact of factors around childbirth on post-

discharge breastfeeding practices has not been documented

in a population-based sample of women. Population-based

data from a study investigating breastfeeding promotion,

protection and support in Vietnam provided an opportunity

to examine factors associated with early and exclusive

breastfeeding in a representative sample of Vietnamese women

(39). The primary objective of this study was to identify

maternal and health system factors, including antenatal care

and birth practices, which were associated with early and

exclusive breastfeeding in the ﬁrst 3 days after birth. The

goal was to use these ﬁndings to identify policy and

program interventions to address priority barriers to improve

breastfeeding practices in Vietnam.

Materials and methods

Sample and data sources

Primary data collection was conducted for a population-

based, cross-sectional study reviewing the content,

implementation, and potential impact of policies to protect,

promote, and support breastfeeding in Vietnam. The design

was a population-based, cross-sectional observational survey

using both quantitative and qualitative methods. Data were

collected between May and July 2020. Details of study design,

sampling and data collection tools (Supplementary material)

were presented in a research protocol (39) published prior to

the data analysis.

The sampling frame included two provinces and one

municipality selected to be representative of the diﬀerent socio-

economic characteristics of Vietnam: Bac Ninh, a province

that is transforming from a predominantly agricultural to a

more industrialized province in Red River Delta Region (north),

with an estimated population of 1,380,000 of which 28% is

urban; Binh Duong, a predominantly industrial province in

the Southeastern Region (south) with an estimated population

of 2,460,000 of which 80% is urban; and Ho Chi Minh City

(HCMC), the most populous city in Vietnam (south), with an

estimated population of 9,040,000 of which 80% is urban (40).

In 2019, there were about 34,200 live births in Bac Ninh, 43,200

in Binh Duong, and 127,400 in HCMC (40).

A stratiﬁed multiple-stage cluster sampling design was used

to obtain an estimated minimum sample size of 620 mothers

of children 0–11 months (38, 39). Within each study location,

all sub-districts were divided into three categories: industrial

zone, urban without an industrial zone, and rural without an

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industrial zone; in each category, one district was randomly

sampled. Within each sampled district all sub-districts were

listed, and ten sub-districts randomly selected; and within each

sub-district all mothers of infants aged 0–11 months were listed

using immunization records provided by community health

workers. Mothers of infants aged 0–11 months were then

selected using systematic random sampling. Because the lists

used for sampling were from immunization records, the sample

included both permanent and temporary residents (i.e., migrant

workers) of the selected sub-districts.

Health workers contacted selected mothers and invited them

to participate. If the sampled woman was unable or unwilling

to participate in the survey, she was replaced by another

woman randomly selected from the sub-district list. The non-

response rate was 14.6%. Those who agreed to participate were

contacted by the research coordinators who arranged a time for

a household visit (38, 39). Evaluators visited sampled households

in pairs and obtained written consent from all participants. All

interviews were conducted using a structured questionnaire in

Vietnamese by a team of two trained supervisors in a private

and quiet place with the mother of the child alone (i.e., without

the presence of father, grandmother, or other caregivers).

Quantitative data from mothers were collected electronically

using tablets and uploaded daily to a secure cloud-based server.

A data manager downloaded the data from the cloud-based

server and conducted frequent data quality checks (39).

Deﬁnition of variables

Dependent variables

The main outcome variables for this analysis were EIBF

and exclusive breastfeeding during the ﬁrst 3 days after birth

(EBF3D) (41, 42) among infants <12 months, which can be

aﬀected by early practices and facility support around birth.

EIBF was deﬁned as infants who were put to the breast for the

ﬁrst time within 1 h of birth (41, 42). The mother was asked

“How soon after birth did you put (NAME) to the breast for the

ﬁrst time?” and if she responded with a time less than 1 h, was

deﬁned as practicing EIBF.

Exclusive breastfeeding during the ﬁrst 3 days after birth

was deﬁned as infants who were fed exclusively with breast

milk for the ﬁrst 3 days after birth. The interviewers asked the

mothers whether their infant had received any of the following

in the ﬁrst 3 days of birth: breastmilk, breastmilk from another

woman, infant formula/other infant milk, plain water, honey,

sugar or glucose water, lemon juice/herbal tea (e.g., licorice

root), and any other food or drink. A mother who responded yes

to human milk and no to any other food or drink was deﬁned as

practicing EBF3D.

Independent variables

Independent variables for analysis were selected if they were

collected by the survey data collection tools and had been

associated or potentially associated with breastfeeding outcomes

in the World Health Organization (WHO) data synthesis

reviews developed using the Grading of Recommendations

Assessment, Development and Evaluation methodology (32,

43), namely: antenatal care (ANC) contacts, mode of birth

(cesarean section, vaginal with or without episiotomy), SSC,

breastfeeding before separation, rooming-in of mother and

newborn, intention to use infant formula in the perinatal period,

distribution of infant formula samples during the facility stay,

and several sociodemographic characteristics.

Birth mode was deﬁned by using two questions: “Did you

have a cesarean section when you gave birth to (NAME)?” and

for those who had vaginal birth “Did you have an episiotomy

when you gave birth to (NAME)?” Respondents were then

grouped into one of three mutually exclusive categories based

on their responses: (1) Vaginal birth without episiotomy, (2)

Vaginal birth with episiotomy, and (3) Cesarean birth.

Skin-to-skin contact was deﬁned by using three questions:

“After giving birth, was (NAME) placed on your chest skin to

skin?,” “How long did it take from (NAME)’s ﬁrst cry until

(he/she) was put onto your chest?,” and “For how long was

(NAME) kept skin to skin on your chest with you with no break

or separation?” Respondents were then grouped into one of six

mutually exclusive categories based on their responses: (1) Not

applied or applied after 1 min and (2) applied within 1 min and

uninterrupted for (a) <10 min, (b) 10–29 min, (c) 30–59 min,

(d) 60–89 min, and (e) at least 90 min (29, 32).

Intention to use infant formula during the perinatal period

was indirectly deﬁned by using two questions: “Did you or your

family member bring any infant formula to the health facility

when you gave birth to (NAME)?” and “Did you or your family

member purchase any infant formula at or near the health

facility shortly after you gave birth to (NAME)?” Respondents

were then grouped into one of four mutually exclusive categories

based on their responses: (1) Did not bring or purchase, (2)

Brought, (3) Purchased, and (4) Brought and purchased (38).

Antenatal care received was deﬁned by both type of provider

and number of care visits received during pregnancy. Women

were asked whether they visited public or private facilities for

each ANC visit and the type of facility categorized into public

health facilities only, both public and private health facilities,

and private health facilities only. The number ANC visits made

between the beginning of pregnancy and birth was categorized

into 0–3, 4–7, and at least 8 times (25, 44).

Birthweight was reported by the mother, and newborns

weighing less than 2,500 g were classiﬁed as low birth weight.

Gestational age was deﬁned as the number of weeks of

pregnancy reported by the mother at the time of the birth of

their baby; babies born at less than 37 weeks of gestation were

deﬁned as preterm (45). The number of previous child(ren) was

identiﬁed by subtracting one from the total number of child(ren)

the mother had. It was then categorized into zero (ﬁrst child),

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one and two or more. In addition, we included the sex of the

child (male or female) in the analysis.

Advice received on breastfeeding during pregnancy and in

the ﬁrst 3 days after birth by a health worker or lay person

was deﬁned as any verbal information, counseling, observation

and breastfeeding assessment with feedback or any other

information received, as reported by the mother.

Socio-economic characteristics of participating women

included age (years), ethnicity (Kinh, the ethnic majority group

in Vietnam, and other ethnicities), marital status (married

or unmarried), education (never attended school, primary

school, junior secondary school, secondary school, diploma

or postgraduate), and employment status (farmer, blue-collar,

white-collar, small trader or self-employed, and unemployed,

homemaker, student or other) (38).

Data analysis

Data analysis was performed using Stata 15.1 (Stata

Inc., College Station, TX, USA). For descriptive analysis, we

analyzed general characteristics, experience during ANC and

feeding practices in the ﬁrst 3 days after birth. We conducted

multinomial logistic regression to examine associations between

exposure variables and EIBF and EBF3D controlled for potential

confounding factors and adjusted for clustering [e.g., province

or municipality and the 30 primary sampling units (PSUs)

within each province] by using the robust option. We neither

estimated sampling weights nor used them in the analysis

because our primary focus was on the assessment of association

rather than the estimation of prevalence (39). For EBF3D, in

addition to variables included in the regression model for EIBF,

we included the following variables: EIBF, completion of the ﬁrst

breastfeed before separation, rooming-in, and receipt of a free

infant formula sample during hospital stay.

Results

A total of 726 interviews with mothers with infants aged 0–

11 months (infants) were completed. Of the 726 mothers, 95.3%

were of Kinh ethnicity; and the remaining ethnicities were Hoa

(1.1%), Khmer (1.1%), Muong (0.8%), Nung (0.7%), Tay (0.6%),

Cham (0.1%), Tho (0.1%), and Xtieng (0.1%) (Table 1). Ninety-

nine percent (98.9%) of mothers were married, 62.8% had a

secondary diploma or higher, and 23.1% had a white-collar job

(Table 1).

While most mothers in our sample (98.9%) report

breastfeeding their newborns during the ﬁrst 3 days of life,

only 39.7% initiated breastfeeding in the ﬁrst hour after birth

(Table 2). Mothers from HCMC were more likely to report EIBF

(53.1%) while those from Bac Ninh were least likely (30.2%)

(Table 2). During the ﬁrst 3 days of life, 90.8% of mothers fed

their newborns with their own breastmilk, 1.1% with breastmilk

from other mothers (either donor human milk from a milk bank

or wet nursing), and 3.3% from both (Table 2).

Less than one ﬁfth (18.0%) of mothers reported EBF3D:

the prevalence was higher in Binh Duong and HCMC at 23.7

and 23.5%, respectively, than in Bac Ninh (7.0%) (Table 2).

Infant formula was the most common supplement provided to

newborns in the ﬁrst 3 days of life, with 79.3% of mothers across

the three provinces (72.0% in HCMC, 73.4% in Binh Duong, and

92.6% in Bac Ninh) reporting that they provided infant formula

to their newborns during this period. Provision of plain water

(16.4%) was the second most common supplement, which was

given on its own in 2.1% of cases and used to mix formula for

the remainder (Table 2). Provision of honey (3.3), sugar water

(0.7%), and lemon juice (0.1%) was far less common (Table 2).

Sampled women were more likely to seek antenatal care

ANC in a private health facility (35.5%) and a mix of public

and private facilities (35.5%) than public facilities (24.2%);

and 71.3% of mothers reported four or more ANC visits

(Table 3). Nearly three quarters of respondents (72.6%) reported

consuming commercial milk formula for pregnant women at

least once during their pregnancy (Table 3), with a similar

prevalence across provinces. About two thirds of respondents

received breastfeeding guidance from a health worker in a

health facility, with the highest prevalence in HCMC followed

by Binh Duong, and lowest in Bac Ninh (Table 3). Nearly

two thirds (59.1%) received breastfeeding advice from another

person, mainly mothers or mothers-in-law, husband, other

family members, neighbors, friends, and co-workers (Table 3).

In our sample, 28.5% of mothers were ﬁrst-time mothers

(Table 3).

Eighty-nine percent of women gave birth in public health

facilities (59.2% in a public hospital; 29.5% in a public polyclinic)

(Table 4). A high proportion of newborns were born at term

(94.2%), heavier than 2,500 g (95.3%), and birthed by cesarean

(44.6%) or vaginally with an episiotomy (46.1%); 9.2% were

birthed vaginally without an episiotomy. Birth practices were

similar across provinces. Overall, 49.3% of mothers reported

immediate (within 1 min after birth) SSC, with 27.8 receiving

uninterrupted SSC for less than 30 min and 11.6% receiving

uninterrupted SSC for the recommended 90 min (Table 4). The

prevalence of immediate and prolonged SSC for 90 min was

highest in HCMC (18.1%), then Binh Duong (16.2%) and lowest

in Bac Ninh (0.4%) (Table 4).

The prevalence of EIBF showed an increased trend with

the duration of SSC, rising from 23.4% among newborns who

did not receive immediate SSC to around 70% among those

who received immediate and uninterrupted SSC for at least

90 min (Figure 1). The prevalence of EBF3D also showed an

increased trend with the duration of SSC, rising from 12.5%

among newborns who did not receive immediate SSC to 42.9%

among those receiving 60–89 min of uninterrupted SSC, and

34.5% of those receiving over 90 min (Figure 1).

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A third (29.9%) of newborns completed their ﬁrst breastfeed

before being separated from their mothers and 66.0% stayed

with their mothers from birth (rooming-in) (Table 4). Many

mothers (87.9%) reported bringing infant formula or buying it

near the maternity facility; and 5.9% reported receiving an infant

formula sample during their stay at the facility (Table 4). Just

over half (55.2%) of mothers reported receiving breastfeeding

counseling and support from a health worker during their

hospital stay. More mothers in HCMC received breastfeeding

support by a health worker during the hospital stay (70.0%) than

Binh Duong (59.3%), and Bac Ninh (36.4%) (Table 4). About

one in four mothers (27.0%) received breastfeeding advice from

another person, mainly from mothers or mothers-in-law during

the ﬁrst 3 days after birth (Table 4).

Multinomial logistic regression showed that women who

received ANC from a mix of both public and private facilities

were signiﬁcantly less likely (aOR: 0.59; 95% CI: 0.40, 0.87)

to initiate breastfeeding within the ﬁrst hour than those who

received ANC at public health facilities only (Table 5). The

likelihood of EIBF was signiﬁcantly lower among those who gave

birth via cesarean (aOR: 0.24; 95% CI: 0.11, 0.51), brought infant

formula to the maternity facility (aOR: 0.49; 95% CI: 0.30, 0.78),

purchased it after arrival (aOR: 0.37; 95% CI: 0.24, 0.60), or did

both (aOR: 0.43; 95% CI: 0.21, 0.89) (Table 5). Mothers were less

likely to practice EIBF in Binh Duong (aOR: 0.42; 95% CI: 0.22,

0.83) and Bac Ninh (aOR: 0.44; 95% CI: 0.21, 0.94) than those

from HCMC. EIBF was signiﬁcantly more likely if immediate

and uninterrupted SSC was applied for 10–29 min (aOR: 2.55;

95% CI: 1.49, 4.37), 30–59 min (aOR: 4.15; 95% CI: 2.08, 8.27),

TABLE 1 Socio-economic characteristics of mothers of infants 0–11 months, three provinces, Vietnam 2020

HCMC

(n = 243)

Binh Duong

(n = 241)

Bac Ninh

(n = 242)

Total

(n = 726)

Kinh ethnicity 95.1 95.4 95.5 95.3

Age (Mean ± SD; median, p25–p75) 30.7 ± 5.7

31 (27–35)

29.5 ± 5.3

30 (26–33)

29 ± 5.3

29 (25–33)

29.7 ± 5.5

29 (26–34)

Marital status, Married 97.9 99.2 99.6 98.9

Highest level of education:

Primary school or less 18.9 18.3 8.7 15.3

Junior secondary school 26.3 24.5 14.9 21.9

Secondary school 25.5 24.1 30.2 26.6

Diploma, bachelor, or higher 29.2 33.2 46.3 36.2

Main occupation:

Blue-collar or farmer 28.4 35.7 30.6 31.5

White-collar 18.5 22.0 28.9 23.1

Small trader, self-employed, small self-owned business, services 30.5 18.7 32.6 27.3

Unemployed, homemaker, student 22.6 23.7 7.9 18.3

Data presented as % except for age presented as mean ± Standard Deviation (SD) and median and interquartile range. HCMC, Ho Chi Minh City.

TABLE 2 Feeding practices in the ﬁrst 3 days after birth reported by mothers of infants 0–11 months, three provinces, Vietnam, 2020

HCMC

(n = 243)

Binh Duong

(n = 241)

Bac Ninh

(n = 242)

Total

(n = 726)

Early initiation of breastfeeding 53.1 35.7 30.2 39.7

Exclusive breastfeeding for the ﬁrst 3 days after birth 23.5 23.7 7.0 18.0

Food and drink given in the ﬁrst 3 days after birth:

Human milk:

Any 93.4 92.5 89.7 91.9

Mothers’ own milk 93.0 90.5 88.8 90.8

Milk from another mother 3.3 3.3 6.6 4.4

Infant formula/other infant milk 72.0 73.4 92.6 79.3

Plain water 20.6 21.2 7.4 16.4

Honey 4.9 4.6 0.4 3.3

Sugar or glucose water 0.8 1.2 0.0 0.7

Lemon juice/herbal tea (e.g., licorice root) 0.0 0.4 0.0 0.1

Data presented as %. HCMC, Ho Chi Minh City.

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TABLE 3 Experience during pregnancy reported by the mothers of infants 0–11 months, three provinces, Vietnam, 2020

HCMC

(n = 243)

Binh Duong

(n = 241)

Bac Ninh

(n = 242)

Total

(n = 726)

Places of antenatal care visits:

Public hospital only 37.4 28.2 7.0 24.2

Both public and private hospital or clinic 25.5 29.5 51.7 35.5

Private hospital or clinic only 37.0 42.3 41.3 40.2

The number of antenatal care visits

0–3 times 6.2 7.5 56.6 23.4

4–7 times 21.4 17.8 25.2 21.5

≥8 times 72.4 74.7 18.2 55.1

Used commercial milk formula for pregnant women 68.7 79.7 69.4 72.6

Received breastfeeding advice by a health worker from a health facility 81.1 67.2 50.4 66.3

Received breastfeeding advice by another person: 65.8 62.2 49.2 59.1

Mother or mother-in-law 56.0 53.5 39.3 49.6

Husband 22.6 21.6 9.9 18.0

Other family members 24.3 37.3 19.4 27.0

Neighbors, friends, or co-workers 23.0 24.9 21.1 23.0

Nutrition collaborator 0.8 0.0 0.0 0.3

Hamlet health worker 0.4 0.0 2.9 1.1

Women union staﬀ 0.4 0.0 0.0 0.1

Number of the previous child(ren)

Zero (this was the ﬁrst child) 30.5 32.4 22.7 28.5

1 52.3 47.7 39.7 46.6

≥2 17.3 19.9 37.6 24.9

Data presented as %. HCMC, Ho Chi Minh City.

60–80 min (aOR: 4.35; 95% CI: 1.50, 12.6), or ≥90 min (aOR:

5.87; 95% CI: 3.14, 10.98). In addition, women who had one

child (aOR: 1.96; 95% CI: 1.26, 3.04) or two or more children

(aOR: 2.41; 95% CI: 1.26, 4.61) were signiﬁcantly more likely

to practice EIBF than mothers giving birth to their ﬁrst child

(Table 5). No other variables showed signiﬁcant relationships

with EIBF.

Exclusive breastfeeding during the ﬁrst 3 days after birth

was less likely among mothers who gave birth by cesarean

section (aOR: 0.15; 95% CI: 0.06, 0.39), had a vaginal birth

with episiotomy (aOR: 0.40; 95% CI: 0.18, 0.88), brought infant

formula to the maternity facility (aOR: 0.03; 95% CI: 0.01, 0.07),

purchased it after arrival (aOR: 0.02; 95% CI: 0.01, 0.06) or

did both (aOR: 0.04; 95% CI: 0.02, 0.10) (Table 5). Women

who had a primary school or less education were less likely to

practice EBF3D (aOR: 0.22; 95% CI: 0.09, 0.56), as were those

who received a free infant formula sample during their hospital

stay (aOR: 0.12; 95% CI: 0.02, 0.55) (Table 5). No other variables

showed signiﬁcant relationships with the prevalence of EBF3D.

Discussion

This study of 726 mothers with infants aged 0–11 months

from provinces representative of the socio-economic

characteristics of Vietnam found a low prevalence of EIBF

(39.7%) and EBF3D (18.0%), and high prevalence of infant

formula use (79.3%). Rates of cesarean birth (44.6%) and

vaginal births with episiotomy (46.1%) were high. Forty-nine

percent of mothers received immediate SSC after birth and

11.6% uninterrupted SSC for the recommended duration

of 90 min or more.

In univariate analysis both EIBF and EBF3D showed an

increased trend with the duration of SSC, with prolonged SSC of

90 min associated with an EIBF prevalence of 70% and EBF3D

of 34%. Eighty-eight percent of mothers brought formula to

the birth hospital or purchased it after arrival. All women in

this population received ANC, with 55% receiving at least eight

contacts and most gave birth at public health facilities. Most

babies were normal birthweight and term. We found that EIBF

was signiﬁcantly less likely among women who received ANC

at both public and private facilities, gave birth by cesarean,

brought formula to the birth facility, or purchased it after

arrival, or lived in Binh Duong province. EIBF was 2.49–5.66

times more likely if immediate and uninterrupted SSC was

applied 10–90 min after birth; and among women with one

or more children. EBF3D was signiﬁcantly less likely among

mothers who gave birth by cesarean section, had a vaginal

birth with episiotomy, brought formula to the birth facility

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TABLE 4 Experience during the perinatal period reported by mothers of infants 0–11 months, three provinces, Vietnam 2020

HCMC

(n = 243)

Binh Duong

(n = 241)

Bac Ninh

(n = 242)

Total

(n = 726)

Birthplace:

Public hospital (provincial and central levels) 61.7 65.1 50.8 59.2

Public polyclinic, district health center 26.3 18.7 43.4 29.5

Private hospital 11.9 16.2 5.8 11.3

Sex of newborn

Female 51.0 47.7 43.0 47.2

Male 49.0 52.3 57.0 52.8

Birthweight:

Birthweight of 2,500 g or heavier 95.9 93.8 96.3 95.3

Birthweight (g)Mean ± SD, median (p25–p75) 3,185 ± 428

3,200

(2,900–3,450)

3,163 ± 446

3,200

(2,900–3,450)

3,250 ± 418

3,200

(3,000–3,500)

3,199 ± 432

3,200

(2,900–3,500)

Gestational age:

Gestational age of 37 weeks or longer 92.2 95.4 95.0 94.2

Gestational age (weeks)Mean ± SD, median (p25–p75) 38.6 ± 1.4

39 (38–40)

38.8 ± 1.6

39 (38–40)

38.9 ± 1.3

39 (38–40)

38.7 ± 1.4

39 (38–40)

Birth mode:

Vaginal birth without episiotomy 11.5 5.8 10.3 9.2

Vaginal birth with episiotomy 42.8 50.6 45.0 46.1

Cesarean birth 45.7 43.6 44.6 44.6

Skin-to-skin contact:

None or later than 1 min 48.1 47.7 56.2 50.7

Within 1 min any duration 51.9 52.3 43.8 49.3

<10 min 8.6 8.7 21.9 13.1

10–29 min 14.0 14.1 16.1 14.7

30–59 min 7.0 9.1 5.0 7.0

60–89 min 4.1 4.1 0.4 2.9

≥90 min 18.1 16.2 0.4 11.6

Completed ﬁrst breastfeed before being separated from mothers 46.5 30.3 12.8 29.9

Rooming-in 54.7 57.7 85.5 66.0

Brought or purchased infant formula by the health facility of birth:

Did not bring or purchase 17.3 14.9 4.1 12.1

Brought 45.3 24.9 64.5 44.9

Purchased 31.3 55.6 19.4 35.4

Brought and purchased 6.2 4.6 12.0 7.6

Received free infant formula sample during the hospital stay 7.0 7.5 3.3 5.9

Received breastfeeding advice by a health worker during the hospital stay 70.0 59.3 36.4 55.2

Received breastfeeding advice by another person during the hospital stay: 30.5 19.9 30.6 27.0

Mother or mother-in-law 25.1 17.4 26.9 23.1

Husband 0.8 0.4 0.8 0.7

Other family members 9.1 2.5 6.6 6.1

Neighbors, friends, or co-workers 2.1 1.2 1.2 1.5

Nutrition collaborator 0.4 0.0 0.0 0.1

Hamlet health worker 0.4 0.0 0.0 0.1

Women union staﬀ 0 0 0 0

Data presented as % except for birthweight and gestational age presented as mean ± SD.

or purchased it after arrival, and who received a free infant

formula sample during their hospital stay. Mothers who had a

primary school or less education were signiﬁcantly less likely

to practice EBF3D.

The association of cesarean birth and episiotomy with

reduced likelihood of early and exclusive breastfeeding is

consistent with previous studies (12, 13, 33, 46, 47). Cesarean

births are well recognized as a barrier to successful breastfeeding

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TABLE 5 Multinomial logistic regression analysis of the relationship between key variables and breastfeeding practices reported by mothers of

infants 0–11 months, three provinces, Vietnam 2020

Early initiation of Exclusive breastfeeding for the

breastfeeding (n = 726) ﬁrst 3 days after birth (n = 726)

aOR 95% CI aOR 95% CI

Place of antenatal care visits:

Public hospital only 1.00 (1.00, 1.00) 1.00 (1.00, 1.00)

Both public and private hospital/clinic 0.59** (0.40, 0.87) 0.89 (0.45, 1.74)

Private hospital only 0.68 (0.44, 1.05) 1.23 (0.69, 2.17)

The number of antenatal care visits

0–3 times 1.00 (1.00, 1.00) 1.00 (1.00, 1.00)

4–7 times 1.03 (0.61, 1.74) 0.74 (0.38, 1.42)

≥8 times 1.79 (0.86, 3.72) 1.27 (0.46, 3.53)

Received breastfeeding advice during

antenatal visits from a facility-based

health worker

1.36 (0.95, 1.95) 1.30 (0.63, 2.69)

Newborn characteristics

Sex of newborn

Female 1.00 (1.00, 1.00) 1.00 (1.00, 1.00)

Male 1.30 (0.92, 1.83) 1.00 (0.58, 1.73)

Birthweight of 2,500 g or heavier 2.40 (0.73, 7.87) 1.04 (0.26, 4.17)

Gestation age of 37 weeks or longer 1.15 (0.53, 2.48) 1.23 (0.62, 2.46)

Birth mode:

Vaginal birth without episiotomy 1.00 (1.00, 1.00) 1.00 (1.00, 1.00)

Vaginal birth with episiotomy 0.75 (0.39, 1.46) 0.40* (0.18, 0.88)

Cesarean birth 0.24*** (0.11, 0.51) 0.15*** (0.06, 0.39)

Skin-to-skin contact:

None or later than 1 min 1.00 (1.00, 1.00) 1.00 (1.00, 1.00)

<10 min 1.42 (0.75, 2.67) 0.61 (0.20, 1.85)

10–29 min 2.55*** (1.49, 4.37) 0.69 (0.29, 1.63)

30–59 min 4.15*** (2.08, 8.27) 1.19 (0.48, 3.00)

60–89 min 4.35** (1.50, 12.60) 1.04 (0.28, 3.88)

≥90 min 5.87*** (3.14, 10.98) 1.35 (0.43, 4.23)

Brought or purchased infant

formula at the health facility at the

time of birth:

Did not bring or purchase 1.00 (1.00, 1.00) 1.00 (1.00, 1.00)

Brought 0.49** (0.30, 0.78) 0.03*** (0.01, 0.07)

Purchased 0.37*** (0.24, 0.60) 0.02*** (0.01, 0.06)

Brought and purchased 0.43* (0.21, 0.89) 0.04*** (0.02, 0.10)

Received breastfeeding advice after

birth from a facility-based health

worker

1.47 (0.92, 2.34) 1.39 (0.75, 2.59)

Number of the previous child(ren)

Zero (this was the ﬁrst child) 1.00 (1.00, 1.00) 1.00 (1.00, 1.00)

1 1.96** (1.26, 3.04) 1.48 (0.71, 3.08)

≥2 2.41** (1.26, 4.61) 1.80 (0.60, 5.33)

Highest level of education:

Primary school or less 0.69 (0.36, 1.32) 0.22** (0.09, 0.56)

Junior secondary school 0.87 (0.45, 1.69) 1.51 (0.57, 3.95)

Secondary school 1.31 (0.78, 2.20) 1.08 (0.52, 2.27)

Diploma, bachelors or higher 1.00 (1.00, 1.00) 1.00 (1.00, 1.00)

(Continued)

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TABLE 5 (Continued)

Early initiation of Exclusive breastfeeding for the

breastfeeding (n = 726) ﬁrst 3 days after birth (n = 726)

aOR 95% CI aOR 95% CI

Place of residence:

Ho Chi Minh City 1.00 (1.00, 1.00) 1.00 (1.00, 1.00)

Binh Duong 0.42* (0.22, 0.83) 1.43 (0.81, 2.51)

Bac Ninh 0.44* (0.21, 0.94) 0.48 (0.20, 1.15)

Early initiation of

breastfeeding

1.47 (0.76, 2.85)

Completed ﬁrst breastfeed

before being separated from

mothers

1.26 (0.66, 2.43)

Rooming-in 1.12 (0.62, 2.00)

Received free commercial

milk formula sample during

the hospital stay

0.12** (0.02, 0.55)

Data from the Code impact study in Vietnam in 2020. Values are adjusted odds ratios (aOR) and 95% Conﬁdence Intervals (95% CI) from Multinomial logistic regression, controlled

for use of commercial milk formula for pregnant women, received breastfeeding advice from lay person during antenatal visits, type of birthplace (public/private health facility), received

breastfeeding advice from a lay person after birth, mothers’ ethnicity, age, and main occupation. We used robust option to account for clustering. Signiﬁcantly diﬀerent from the null value

(aOR = 1; two-sided t-tests): *p < 0.05, **p < 0.01, ***p < 0.001.

FIGURE 1

Skin-to-skin contact (SSC) and breastfeeding practices reported by mothers of infants 0–11 months, three provinces, Vietnam, 2020.

for a number of reasons including: early separation of

newborns to neonatal intensive care units (NICUs) or nurseries

for observation (24), staﬀ concerns that immediate SSC or

breastfeeding will compromise the procedure, reduce the safety

of mothers and babies, or add to their work burden; physical

organization of the operating room; lack of coordination and

communication between anesthesiology and obstetrics staﬀ;

and the belief that maternal pain after the procedure makes

breastfeeding diﬃcult (48, 49). However, data from Vietnam and

elsewhere show that SSC can be introduced successfully with

cesarean section, is safe for both mothers and newborns, and

can decrease NICU admissions, improve newborn outcomes,

increase maternal satisfaction and exclusive breastfeeding rates

(31, 50–52). Similarly, pain following episiotomy may limit the

comfort of the mother and contribute to reported breastfeeding

diﬃculties (46).

The signiﬁcant association between EIBF and the duration

of immediate and uninterrupted SSC is consistent with a

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previous study of in eight countries in Asia and the Paciﬁc,

including Vietnam (29). This association remains signiﬁcant

even in the presence of remarkably high rates of cesarean

birth, episiotomy, and formula availability at birth facilities

and after controlling for low birthweight and preterm birth.

Readiness to breastfeed is highly variable between newborns,

with the mean time of the ﬁrst breastfeed around 50 min

postpartum. Because a high proportion of mothers require well

over 1 h to complete feeding, longer periods of uninterrupted

SCC allow this process to be completed (50). SSC promotes

thermoregulation, early and exclusive breastfeeding, bonding,

reduced stress, earlier expulsion of the placenta and reduced

risk of bleeding in the mother among other beneﬁts (31, 50, 51).

By preventing separation, newborns are further protected from

the negative consequences of harmful procedures including

early cord clamping, routine suction, and early bathing, which

may slow down the readiness to breastfeed and have other

negative health impacts (53). SSC is often interrupted for

routine care, including weighing and administration of vitamin

K and vaccines, procedures that can be delayed until after

90 min, and which may further interfere with early breastfeeding

(50). During the COVID-19 pandemic, provision of SSC has

been further negatively impacted by inappropriate national

and international guidance recommending the separation

of mothers and newborns to prevent disease transmission

(54). We found that mothers in HCMC were more likely

to practice EIBF. This may suggest better implementation

of early essential newborn care standards in facilities in

this province and therefore better facility staﬀ preparation,

supportive environments, and counseling practices. Since Tu

Du Hospital, an early implementer of early essential newborn

care is present in HCMC and led hospital coaching in the

South of Vietnam, including in Binh Duong province, this

association may explain improved breastfeeding practice at birth

in southern hospitals (34).

We did not ﬁnd a statistically signiﬁcant association

between EBF3D and either EIBF or early and uninterrupted

SSC. It has been noted previously in population studies in

Vietnam that EIBF may not lead to EBF3D (33, 47). However,

this ﬁnding is not consistent with data from several studies

that have demonstrated SSC to be associated with increased

likelihood of exclusive breastfeeding from hospital discharge

up to 6 months post birth (31). Data from early essential

newborn care implementing hospitals in Vietnam have shown

that SSC is associated with increased likelihood of exclusive

breastfeeding at discharge in hospitals that have conducted staﬀ

clinical coaching and upgraded environments to support SSC

and early breastfeeding using quality processes (24, 29, 52).

It seems therefore that provider behaviors (e.g., unnecessary

medical procedures and separation of mothers and newborns),

caregiver behaviors (e.g., intention to use formula milk), and

lack of an enabling environment for breastfeeding mitigate

the expected eﬀect of prolonged SSC on EBF3D, even when

breastfeeding is initiated early.

The high proportion of mothers who intended to provide

infant formula to their newborns in the ﬁrst few days of

life (52.5% brought infant formula to maternity facilities

at birth, 35.4% bought infant formula at and nearby the

hospital) is consistent with previous ﬁndings that social norms

both within and outside of the health facility encourage

artiﬁcial feeding and low self-eﬃcacy toward breastfeeding

(32). Intention to breastfeed may be inﬂuenced by a number

of factors, including family and social norms, work status,

availability of childcare, planned cesarean birth, aggressive

marketing of commercial milk formula; and by a lack of eﬀective

breastfeeding counseling particularly during ANC (55–57). This

study found that women with previous children were more

likely to provide EIBF, suggesting that previous experience may

play a role in establishing breastfeeding as a norm and for

gaining conﬁdence in breastfeeding techniques as has been

reported in other studies (58, 59). The data showed that

women with primary school education or less were less likely

to practice EBF3D because these women feed the newborns

both infant formula (i.e., a practice allowed by a non-supportive

environment) and other ﬂuids (i.e., as a traditional practice).

This is a concerning ﬁnding given that children of mothers

with lower educational attainment are often at higher risk of

poor infant health and require additional support (33, 60, 61).

We found that no other associations between breastfeeding and

education or occupation, with prevalence of formula use similar

across women of all education levels and occupations. These

ﬁndings suggest that social norms discouraging intention to

breastfeed have spread widely across geographical regions and

socioeconomic groups (27, 61–63).

The ﬁnding that 35.4% of mothers bought infant formula

at or nearby the birth hospital and 5.9% received a free

infant formula sample during their hospital stay suggests that

breastfeeding is not being adequately protected or supported

in maternity facilities. The association between the availability

of infant formula in hospital (brought or purchased) and

provision of free samples with reduced likelihood of EBF3D is

consistent with previous ﬁndings that commercial milk formula

advertising, promotional materials and formula availability can

limit breastfeeding (32, 64). Commercial milk formula industry

representatives often use tactics that circumvent hospital

regulations to promote formula milk to pregnant women and

new mothers, including collecting contact information and

promoting products like commercial milk formula for pregnant

women that are not covered by the Code (65). These practices

undermine breastfeeding and the provision of breastfeeding

support by health workers during ANC and at the time of birth.

Further, the data also indicate that breastfeeding promotion

and support provided by health workers at ANC and birth

contacts is insuﬃcient to inﬂuence breastfeeding practices.

Although all mothers have access to ANC and 76.6% made at

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least four ANC visits, only 66.3% received breastfeeding advice

by a health worker during an ANC visit; and breastfeeding

counseling from a health worker was not signiﬁcantly associated

with breastfeeding practices, suggesting inadequate quality or

frequency of counseling. This study is limited in not being

able to grade the quality and frequency of advice received.

Women in the sample preferred going to private clinics for

ANC (possibly due to convenience) but giving birth at public

hospitals (possibly due to perceived quality of service). In fact,

the availability of breastfeeding support is likely to be lower, and

Code violations higher in private clinics than public hospitals

(38). Only 55.2% of mothers reported receiving breastfeeding

counseling and support by a health worker around the time

of birth at hospital and the receipt of such support was

not associated with increased EBF3D, suggesting that quality

is suboptimal. Previous studies in Vietnam have shown that

eﬀective breastfeeding counseling and support has a positive

eﬀect on early and exclusive breastfeeding (66), however, if

health workers have insuﬃcient time or skills, quality of support

provided will be low and they may recommend the use of infant

formula when feeding diﬃculties or concerns arise (60). The

fact that the ﬁrst-time mothers were less likely to practice EIBF

suggests that maternal experience and conﬁdence are important

contributors to feeding practices at the time of birth and call for

extra support from health staﬀ.

To be eﬀective, breastfeeding support should be predictable,

scheduled, and include ongoing visits with trained health

professionals including midwives, nurses, and doctors, or

with trained volunteers (67). Support may be needed to

tailor advice to speciﬁc cultural, geographic, or social settings

(67). In Vietnam, although reproductive health practice

guidelines include breastfeeding counseling (25), counseling

and preventive health are not covered by health insurance (68,

69), which may reduce health worker motivation to provide

these services. In addition, only a few mothers in our sample

received breastfeeding advice and support from village health

workers or nutrition collaborators, indicating that community-

based support services need to be strengthened (66, 70).

Several actions could be taken to strengthen EIBF and

EBF3D based on study ﬁndings, focusing on facility policies and

environments before during and after birth to promote, support

and enable early and exclusive breastfeeding practices.

First, policies and environments in hospitals must be

changed to limit the availability of commercial milk formula

and encourage successful breastfeeding (32, 71). Vietnam’s

national legislation on the Code is moderately aligned with

the International Code of Marketing of Breast Milk Substitutes

(scored at 74 out of 100) (18). Based on the Code in

Vietnam (19, 20), recommended breastfeeding practices and

the Code compliance (Criteria E1.3) have been integrated

as one of 83 criteria under the National Hospital Standards

and Accreditation for both public and private hospitals (21).

However, clinics unaﬃliated with hospitals are not regulated

under these standards (21) while private hospitals have low

motivation to meet criteria E1.3. The study further indicates that

many public hospitals are not meeting Code regulations. In the

longer term, it is critical that monitoring and enforcement of

the Code is strengthened across all facilities providing maternity

services. As an immediate ﬁrst step, maternity hospitals must be

mandated by decree to exclude formula entirely from hospitals

(including preventing it being brought in by patients and

families), ban the distribution of free formula samples and make

it impossible to purchase formula on hospital grounds or in

shops nearby birthing facilities.

Second, the strong association between immediate and

prolonged SSC and EIBF (and potentially also with EBF3D),

indicates that improving this practice for all births should

be a high priority. Study data show that only 49.3% of

women receive immediate SSC and of these, only 11.6%

receive uninterrupted SSC for the recommended 90 min.

Vietnam has guidelines for the implementation of early essential

newborn care for both vaginal (22) and cesarean births (23),

which have been gradually introduced to maternity facilities

nationwide. Early essential newborn care has been demonstrated

to be associated with improved newborn outcomes and

breastfeeding practices in Vietnam (24, 29, 52). Roll out has

used a systematic approach that includes updating policies

and protocols, clinical coaching of staﬀ using adult learning

principles, modiﬁcations to environments and birthing room

supports and introduction of a data-driven quality improvement

process, that has resulted in sustained improvements in practices

around birth (72). Priority should be given to the introduction

and expansion of this approach nationally using existing

facilitators and proven methods.

Third, and related to the second point above, early

newborn care practices at cesarean and vaginal births with

episiotomy should be improved to encourage the principles

of eﬀective early essential newborn care. This includes non-

separation of all clinically stable newborns, immediate and

prolonged SSC, initiation of breastfeeding while in SSC

with the mother and eﬀective breastfeeding counseling and

support, including recognition of feeding cues, position, and

attachment. Introduction requires a collaborative approach

between obstetrics, pediatric and anesthesia staﬀ, a practiced

system of actions with allocation of roles and changes

to operating room environments. It has been successfully

introduced in some hospitals in Vietnam, with clearly deﬁned

methods and protocols that should now be introduced more

widely (23, 52).

Ongoing eﬀorts to limit unnecessary cesarean births and the

use of episiotomy must continue. We found that the prevalence

of cesarean birth and episiotomy were high and associated

with lower prevalence of EIBF and EBF3D. The prevalence

of cesarean birth (44.6%) in our study was higher than the

national rate of 34.4% (10) and much higher than the WHO’s

recommended prevalence of between 10 and 15% (12, 13, 46).

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The high rate of episiotomy (46.1% of all births and 83.3%

of vaginal births) suggests that the practice is routine, rather

than restricted as recommended by WHO (73). Episiotomy

is considered a harmful procedure that is associated with

postpartum hemorrhage, postnatal hospitalization for more

than 4 days, and third- or fourth-degree perineal tears (32,

55, 74). Limiting these harmful and unnecessary procedures

should be a high priority at all levels, beginning with national

guidelines and regulations; and integrating with eﬀorts to

improve respectful and evidence-based maternal care, including

those promoted by early essential newborn care. Dealing with

incentives to conduct procedures is an ongoing challenge (13,

15, 52).

Fourth, linked with the second and third points above,

breastfeeding counseling and support at both ANC contacts and

at the time of facility birth must be strengthened. Adequate

support requires staﬀ to have appropriate skills, time and a

motivating environment that supports eﬀective practices. Early

essential newborn care includes a focus on this area, for the

period around birth. Eﬀorts to improve counseling and support

have been demonstrated to be eﬀective in many settings (67).

This gap may require improved medical, midwifery and nursing

pre- and in-service training, task-shifting in clinical settings

and re-organization of care environments to provide adequate

skills, time, and space for adequate counseling (75). It may

also be helpful in Vietnam to include breastfeeding support in

insurance reimbursement packages for ANC and childbirth; and

to strengthen the skills of village health workers or nutrition

collaborators with special focus on ﬁrst time mothers and those

with lower education. Mass and digital media campaigns may

be useful to create social norms that are more supportive

of breastfeeding.

Limitations

This study has several strengths, including representative

population-based sampling, use of validated standardized

questionnaires (32, 41–44), and use of hand-held devices to

reduce errors during data collection and entry. The data allow

identiﬁcation of interventions that should be prioritized to

prevent substantial economic and health losses (75). Several

limitations are noted including purposive selection of sampling

areas which may limit national representativeness; use of

immunization household listings which were assumed to

be complete; and inclusion of migrant women in district

sampling lists who may not represent the socio-economic or

cultural characteristics of women in the sampled province.

The impact of these potential sampling biases is believed

to be minor. In-person data collection occurred during the

COVID-19 pandemic, which made some women hesitant

to participate in the interview (a non-response rate of

14.6% was noted). It is not possible to know whether this

group diﬀered signiﬁcantly on socio-demographic or other

characteristics, although the non-response rate was similar

between all provinces.

Other limitations include recall bias (since women up

to 11 months post birth were included) and reporting bias

(respondents may have been inﬂuenced by the desire to

report recommended breastfeeding practices and not report

non-recommended practices such as formula use). However,

validity and reliability for recalled breastfeeding data is reported

as relatively high for survey data, which may have a recall

period up to 24 months (42). Further, previous validation of

the mothers’ recall of immediate newborn care practices has

shown high levels of agreement between observed and reported

measures of initiation of SSC and duration of uninterrupted

SSC in the ﬁrst 24–72 h after birth (76). Although the

validity and reliability of reported durations of SSC contact

for recall periods of up to 11 months postpartum were not

yet documented, mothers tend to remember well practices

and events around birth even after 24 months (42). In

addition, the relationships between EIBF and duration of SSC

and associations of EBF3D with availability of formula were

consistent between all provinces and diﬀerent socio-economic

groups suggesting that systematic bias was not a problem.

Finally, this analysis of existing survey data meant researchers

were unable to measure all potential factors associated with

the likelihood of breastfeeding, including previous breastfeeding

experiences, body mass, smoking, birth companion, diﬃculties

initiating breastfeeding, availability of childcare or child

support, and perinatal depression. Similarly, the quality and

frequency of breastfeeding counseling and advice received could

not be determined.

Conclusion

This study of 726 mothers with infants aged 0–11 months

from provinces representative of the socio-economic

characteristics of Vietnam found a low prevalence of EIBF

(49.7%) and EBF3D (18.0%), and high prevalence of infant

formula use (79.3%). Barriers to recommended breastfeeding

practices in the ﬁrst days of life included provider behaviors

and medical procedures (cesarean birth, episiotomy, lack of

immediate and uninterrupted SSC and limited eﬀectiveness

of breastfeeding counseling and support during antenatal care

and around the time of birth) and unsupportive breastfeeding

environments (bringing or purchasing formula milk at the

health facility and receipt of free infant formula samples) at

maternity facilities.

To improve breastfeeding practices, both health care

provider practices and environments at maternity facilities must

be improved. Quality improvement approaches to strengthen

staﬀ coaching, protocols, and health facility environments

should be scaled up to ensure consistent implementation

Frontiers in Nutrition 12 frontiersin.org

fnut-09-1041065 November 1, 2022 Time: 8:16 # 13

Nguyen et al. 10.3389/fnut.2022.1041065

of early essential newborn care, including immediate and

prolonged SSC, and to reduce unnecessary cesarean sections

and episiotomies. In tandem, action is urgently needed to

improve breastfeeding counseling and support at all facility

and community contacts around birth; mass and digital media

campaigns may be useful to create social norms that are more

supportive of breastfeeding from birth and during the ﬁrst days

of life. Stronger enforcement of national policies to regulate the

presence of commercial milk formula industry representatives,

provision of free samples, and availability of infant formula in

public and private health facilities is needed, including ensuring

that formula cannot be purchased in or around hospitals.

Data availability statement

The raw data supporting the conclusions of this article will

be made available by the authors, without undue reservation.

Ethics statement

This study was conducted according to the guidelines of

the Declaration of Helsinki and approved by the Institutional

Review Board (or Ethics Committee) of FHI 360 (protocol code

1383644; approved on April 16, 2019) and Hanoi University

of Public Health (protocol code 019-501/DD-YTCC; approved

on June 12, 2019). Written informed consent for participation

was not required for this study in accordance with the national

legislation and the institutional requirements.

Author contributions

TN, JC, JM, and RM: conceptualization. TN, JC, and JM:

methodology, validation, data curation, and writing—original

draft preparation. TN: software, formal analysis, investigation,

visualization, supervision, and project administration. RM:

resources and funding acquisition. TN, JC, HTT, TAH, AW, RM,

and JM: writing—review and editing. All authors have read and

agreed to the published version of the manuscript.

Funding

This work was supported in part by the Bill & Melinda

Gates Foundation (Grant Number: OPP50838) and Irish Aid.

The views and opinions set out in this article represent those

of the authors, and do not necessarily represent the position

of the Bill & Melinda Gates Foundation or Irish Aid. Under

the grant conditions of the Foundation, a Creative Commons

Attribution 4.0 Generic License has already been assigned to the

author accepted manuscript version that might arise from this

submission.

Acknowledgments

We thank Tina Sanghvi from the Alive & Thrive initiative

at FHI Solutions/FHI 360 Headquarters for the comments and

suggestions to improve this manuscript.

Conﬂict of interest

The authors declare that the research was conducted in the

absence of any commercial or ﬁnancial relationships that could

be construed as a potential conﬂict of interest.

Publisher’s note

All claims expressed in this article are solely those of the

authors and do not necessarily represent those of their aﬃliated

organizations, or those of the publisher, the editors and the

reviewers. Any product that may be evaluated in this article, or

claim that may be made by its manufacturer, is not guaranteed

or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be

found online at: https://www.frontiersin.org/articles/10.3389/

fnut.2022.1041065/full#supplementary-material

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