Health System and Socioeconomic Determinants of Delayed Initiation of Breastfeeding Among Cesarean Deliveries in Kenya: Analysis of the 2022 Kenya Demographic and Health Survey

Background Timely initiation of breastfeeding within one hour of birth reduces neonatal mortality and supports optimal child development. Women who deliver by cesarean section (CS) face disproportionate barriers to early breastfeeding, yet the determinants of these delays remain poorly characterized in Kenya. Objective To examine health system and socioeconomic determinants of delayed breastfeeding initiation among CS-delivered women in Kenya using nationally representative data from the 2022 Kenya Demographic and Health Survey (KDHS 2022). Methods The analytical sample comprised 536 women who delivered by CS in the two years preceding the survey, had a live birth, and had valid breastfeeding timing data. Delayed initiation was defined as first breastfeeding occurring more than one hour after birth. Multilevel logistic regression models were used to account for community-level clustering. Predictors included facility type, facility level, antenatal care (ANC) adequacy, postnatal care (PNC) within 48 hours, maternal education, household wealth, urban-rural residence, birth size, plurality, and birth order. Results Among CS-delivered women, 63.3% experienced delayed breastfeeding initiation (weighted: 66.1%). The intraclass correlation coefficient from the null multilevel model was 18.8%, confirming significant community-level clustering. In the fully adjusted model, no predictor reached statistical significance at p < 0.05. Multiple birth showed the strongest borderline association (AOR = 2.80; 95% CI: 0.85–9.30; p = 0.092). Higher education trended toward increased odds of delay (AOR = 1.39; 95% CI: 0.90–2.15; p = 0.140). Model fit did not improve significantly with addition of socioeconomic or child-level variables. Conclusion Delayed breastfeeding initiation is highly prevalent among CS-delivered women in Kenya. Meaningful community-level clustering suggests that facility practices and contextual factors are important drivers. Targeted postnatal breastfeeding support protocols for CS mothers, including Baby-Friendly Hospital Initiative adaptations, are urgently needed.