Exclusive Breastfeeding in Al-Hassa,Saudi Arabia

Abstract

Background:

The World Health Organization recommends exclusive breastfeeding in the first 6 months of life. The objective of this study was to assess the exclusive breastfeeding rate among infants and its predictors in Al-Hassa, Saudi Arabia.

Subjects and Methods:

Mothers attending for vaccinating their infants at the age of 6 months at primary healthcare centers were interviewed. Various sociodemographic variables, obstetric and infant factors, and breastfeeding practices were assessed for any influence on exclusive breastfeeding.

Results:

Only 24.4% of infants were exclusively breastfed at the age of 6 months. Logistic regression revealed that the independent predictors of exclusive breastfeeding were (in order) being a housewife mother (adjusted odds ratio [AOR] = 4.7), infant on-demand feeding (odds ratio = 3.4), not giving prelacteal feed (AOR = 3.1), rural/hegar residence (AOR = 2.2), timely breastfeeding initiation (AOR = 2.0), average-weight infants (AOR = 1.8), and spontaneous vaginal delivery (AOR = 1.6).

Conclusions:

Mothers at risk of not breastfeeding exclusively should be the target of breastfeeding promotion during prenatal care. Working mothers should continue breastfeeding after returning to work.

Introduction

The benefits of breastfeeding to both infants and mothers are now evident.^1,2 It is the ideal and most natural way of nurturing infants.² Breastfeeding confers significant health, nutritional, immunologic, developmental, psychological, social, economic, and environmental benefits to infants, mothers, families, and society.^2,3 International health agencies recommend exclusive breastfeeding during the first 6 months of an infant's life in both developed and developing countries.^3,4 According to the World Health Organization definition, exclusive breastfeeding means no other food or fluids (including plain water and juices), and the infant consumes human milk with no supplements of any type except for vitamins, minerals, and medications.^5,6

Breastfeeding is said to be on decline,⁷ and there is a trend toward bottle feeding in both urban and rural areas.⁸ This probably is affected not only by knowledge on breastfeeding but also by factors such as education, occupation, and socioeconomic status of the parents.^9,10 The percentages of infants younger than 6 months old who were exclusively breastfed in 2000–2007 were 38% worldwide, 23% in West/Central Africa, 39% in Eastern/Southern Africa, 44% in South Asia, 26% in Middle East/North Africa, and 43% in East Asia/Pacific.¹¹

Recent data on the pattern and correlates of exclusive breastfeeding in infants are scanty for many countries, including Saudi Arabia. The aims of the current study are to estimate the exclusive breastfeeding rate and to determine the role of some factors that may have an effect on exclusive breastfeeding in Al-Hassa, Saudi Arabia.

Population and Methods

This cross-sectional study was carried out in Al-Hassa, Saudi Arabia during June and July 2009. Al-Hassa is the largest province in Saudi Arabia's Eastern region with a population of 908,366. Maternity care in Al-Hassa is provided through a network of 62 primary healthcare centers (PHCCs) covering the urban, rural, and hegar (Bedouin desert collection) areas. Eligible candidates were all infants attending for vaccination in PHCCs at the age of 6 months. Mothers were counseled and assured that data collected would be dealt with confidentially. They were requested to give verbal informed consent before interview. The study was approved by the Al-Hassa Directorate of Health.

Sample size was calculated using the EPI Info™ statistical program (Centers for Disease Control and Prevention, Atlanta, GA). During 2008 a total of 15,132 live births were recorded in Al-Hassa. A pilot study on 100 infants 6 months old (not included in the full-scale study) revealed that about 25% of them were exclusively breastfed. The sample size was calculated to be about 1,801 infants assuming the worst acceptable level of 23% and 95% confidence level. It is expected that this sample could be recruited during the 2-month period. The response rate is more than 99% as few women refused to participate in the study because they are busy at their homes. This high response rate was due to good relations between nurses working in PHCCs and all mothers.

Mothers were interviewed at the PHCCs by Arabic-speaking female nurse interviewers who were oriented about the study and trained on data collection during the pilot study. Data were completed from the family file, from maternity cards kept at PHCCs, and also from the hospital discharge form.

Data collected covered the following: family residence and income; mother's education and work; parity; infant's sex, gestational age, birth weight, and mode of delivery; place of delivery; giving prelacteal feed to infants; and timing of breastfeeding initiation and pattern of breastfeeding (whether on demand or on schedule). Gestational age and birth weight were obtained from maternity cards and hospital discharge forms. Gestational age at birth was defined as the number of completed weeks of gestation based on the estimated delivery date in the clinical record. Preterm delivery was defined as live infant delivered at <37 weeks' gestation, and low birth weight was defined as live infant weighting <2,500 g at birth. The outcome variable (exclusive breastfeeding) is expressed as the proportion of infants who were exclusively breastfed at the age of 6 months. Exclusive breastfeeding was based on the current status for the 24 hours preceding the interview as recommended by the World Health Organization.⁵

The χ² test was used as a test of significance for comparison of categorical variables. Odds ratios (ORs) and their 95% confidence intervals were calculated to assess the association between the outcome (exclusive breastfeeding) and different variables. Significant predictors of exclusive breastfeeding at bivariate analysis were entered into a logistic regression analysis using the forward stepwise Wald method to predict the independent predictors of the outcome variable. A value of p ≤ 0.05 was chosen as the level of statistical significance using SPSS (Statistical Package for Social Sciences) version 17 (SPSS, Inc., Chicago, IL).

Results

Table 1 reveals that only 24.4% of all infants were exclusively breastfed at the age of 6 months. Exclusive breastfeeding is more likely to be reported by mothers of rural/hegar residence, housewives, less educated mothers, full-term infants, average-weight infants, infants delivered normally, infants not given prelacteal feed, infants with timely breastfeeding initiation, and infants given on-demand feeding.

Table 1.

Exclusive Breastfeeding and Factors Affecting It in Al-Hassa, Saudi Arabia

	Number (%)
	Total	Exclusive breastfeeding	Significance test
Overall	1,904 (100)	465 (24.4)
Residence
Rural/hegar	559	182 (32.6)	χ² = 28.4, p ≤ 0.001
Urban	1,345	283 (21.0)
Mother's work
Housewives	1,725	456 (26.4)	χ² = 40.3, p ≤ 0.001
Working/students^a	179	9 (5.0)
Mother's education
Less than secondary	1,010	253 (25.0)	χ² = 11.9, p ≤ 0.001
Secondary	623	171 (27.4)	χ² = 15.8, p ≤ 0.001
Above secondary	271	41 (15.1)
Family income
Satisfactory	1,513	364 (24.1)	χ² = 0.5, p = 0.5
Unsatisfactory	391	101 (25.8)
Mother's age (years)
<20	96	24 (25.0)	χ² = 0.14, p = 0.7
20–35	1,510	372 (24.6)	χ² = 0.3, p = 0.6
>35	298	69 (23.2)
Parity
Primipara	402	101 (25.1)	χ² = 0.3, p = 0.6
2 and 3	652	162 (24.8)	χ² = 0.3, p = 0.6
≥4	850	202 (23.8)
Infant's sex
Male	955	236 (24.7)	χ² = 0.1, p = 0.8
Female	949	229 (24.1)
Gestational age
Preterm	87	13 (14.9)	χ² = 4.4, p = 0.035
Full term	1,817	452 (24.9)
Birth weight
Average weight	1,759	443 (25.2)	χ² = 4.9, p = 0.03
Low birth weight	145	22 (15.2)
Delivery
Spontaneous vaginal	1,627	418 (25.7)	χ² = 9.7, p = 0.002
Operative^b	277	47 (17.0)
Prelacteal feed^c
No	1,302	390 (30.0)	χ² = 68.3, p ≤ 0.001
Yes	602	75 (12.5)
Timely breastfeeding
Yes	217	103 (47.5)	χ² = 70.5, p ≤ 0.001
No	1,687	362 (21.5)
Feeding pattern
On demand	1,624	420 (25.9)	χ² = 12.4, p ≤ 0.001
On schedule	280	45 (16.1)

Teachers (n = 132), nurses (n = 16), and students (n = 31).

Cesarean section (n = 322) and ventouse (vacuum) (n = 39).

Water, glucose water, teas, and herbal preparations.

Logistic regression revealed that the independent predictors of exclusive breastfeeding were not giving prelacteal feed (adjusted OR [AOR] = 3.1), rural/hegar residence (AOR = 2.2), infant on-demand feeding (AOR = 3.4), timely breastfeeding initiation (AOR = 2.0), average-weight infants (AOR = 1.8), spontaneous vaginal delivery (AOR = 1.6), and being a housewife mother (AOR = 4.7) (Table 2).

Table 2.

Univariate and Multivariate Logistic Regression Analysis of the Predictors of Exclusive Breastfeeding in Al-Hassa, Saudi Arabia

	Univariate [crude OR (95% CI)]	Multivariate [adjusted OR (95% CI)]
Residence
Rural/hegar	1.8 (1.4–2.3)	2.2 (1.7–2.9)
Urban	Reference	Reference
Mother's work
Housewives	6.8 (3.3–14.3)	4.7 (2.4–9.4)
Working/students	Reference	Reference
Mother's education
Less than secondary	1.9 (1.3–2.7)
Secondary	2.1 (1.4–3.2)
Above secondary	Reference
Family income
Satisfactory	0.9 (0.7–1.2)
Unsatisfactory	Reference
Mother's age (years)
<20	1.1 (0.6–2.0)
20–35	1.1 (0.8–1.5)
≥35	Reference
Parity
Primipara	1.1 (0.8–1.4)
2 and 3	1.1 (0.8–1.4)
≥4	Reference
Infant's sex
Male	1.0 (00.8–1.3)
Female	Reference
Gestational age
Preterm	0.5 (0.3–1.0)
Full term	Reference
Birth weight
Average weight	1.9 (1.2–3.1)	1.9 (1.2–3.1)
Low birth weight	Reference	Reference
Delivery
Spontaneous vaginal	1.7 (1.2–2.4)	1.7 (1.2–2.4)
Operative	Reference	Reference
Prelacteal feed
No	3.0 (2.3–4.0)	3.1 (2.3–4.2)
Yes	Reference	Reference
Timely breastfeeding initiation
Yes	3.3 (2.5–4.5)	2.0 (1.4–2.7)
No	Reference	Reference
Feeding pattern
On demand	1.8 (1.3–2.6)	3.4 (1.3–8.7)
On schedule	Reference	Reference

The final model was adjusted for all variables listed.

Constant = −5.4, Model χ² = 213.6, p ≤ 0.001, percentage correctly predicted = 80.4%.

OR, odds ratio; CI, confidence interval.

Discussion

Currently the recommendations from the global strategy for infant and young child feeding, developed by the World Health Organization and UNICEF, is that infants should be exclusively breastfed for the first 6 months of life.¹² Still, less than 40% of infants under 6 months of age in the developing world are exclusively breastfed.¹¹ Despite the great advances in health services in Saudi Arabia, studies have reported a downward trend in breastfeeding practice.^13–17 In this study 24.4% of infants were exclusively breastfed at the age of 6 months. Much lower rates were reported from other regions of Saudi Arabia. In Riyadh only 0.8% of infants were exclusively breastfed for the first 4–6 months,¹⁷ and the rate rises to 1.7% among infants at the age of 6 months in Jidda.¹⁶ Higher rates of 27.3% and 33.1% were reported in Al-Kharj¹⁴ and in Dammam,¹⁸ respectively.

The rate of exclusive breastfeeding varies in Middle Eastern countries. In Al-Ain, United Arab Emirates, only 4% of mothers practiced exclusive breastfeeding during the first month of their infants' lives.¹⁹ In Iran, a recent study reported that 82% of infants were exclusively breastfed during the first month of life, but this statistic decreased to 44% and 2% at the ages of 4 and 6 months, respectively.²⁰ A more recent study in Iran reported rates of 56.8% and 27.7% at 4 and 6 months of age, respectively, at the national level.²¹ In Aqaba, Jordan, the exclusive breastfeeding rate was 46% for infants in the first 6 months of life.²² In Egypt a rate of 42.5% was reported among infants less than 4 months of age.²³ A study in Bangladesh reported an exclusive breastfeeding rate of 53% at 1 month and then a gradual decline to 5% at 6 months of age.²⁴ A recent study in Bangladesh showed that this rate gradually declined from 87.1% at 1 month to 77.2% at 3 months and 61.4% at 6 months.²⁵ In the United States, only 13.3% of infants were exclusively breastfed at 6 months of age.¹ It has been commented that exclusive breastfeeding in the first 4 months of life varies from 1% to 90%, depending on where the baby is born; this variability is influenced by cultural beliefs, socioeconomic status, ethnicity, education, urbanization, modernization, and local feeding practices.^26,27

Maternal work is the most important independent predictor of exclusive breastfeeding as revealed by logistic regression analysis (AOR = 4.7). Despite the fact that Saudi women do not work in hazardous occupations, a mother's work per se does adversely affect breastfeeding practice. Breastfeeding and working outside home are commonly believed to be incompatible activities, and maternal employment has long been considered a barrier to successful breastfeeding.^23,28 Because of the short period of paid maternal leave (only 2 months) in Saudi Arabia, only 5% of mothers were able to exclusively breastfed their infants at the age of 6 months. A similar negative effect of maternal work on exclusive breastfeeding has been reported by many studies in different cultures.^23,29–32 However, other studies have reported no effect of maternal work on exclusive breastfeeding.^33,34 The other demographic feature that is independently associated with more likelihood of exclusive breastfeeding is rural residence. Studies in Egypt and China have reported the same finding;^23,35 however, another study from Iran reported no significant differences.²¹

Not giving prelacteal feed, timely breastfeeding initiation, and on-demand feeding all are associated with likelihood of exclusive breastfeeding at the age of 6 months. The same findings were reported by other studies.^35–39 Some studies did not found such an association.^33,40

We found that operative delivery adversely affects the adoption of exclusive breastfeeding in comparison with spontaneous vaginal delivery. Previous studies reported the negative effect of cesarean section on exclusive breastfeeding.^{31,32,35,37,41,42} Other studies did not find such association.^40,43

The associations of the above factors with exclusive breastfeeding at 6 months are difficult to explain and need further in-depth anthropological and cultural studies to be understood. It is possible that these factors, individually or in combination, may affect feeding strategies and attitude towards exclusive breastfeeding for infants of any age.

This study includes only mothers attending for vaccination at PHCCs in one region of the Saudi Arabia, and the results may not be representative of the whole nation.

Encouraging exclusive breastfeeding has to become a high priority in all sectors of the society. Most of the factors affecting exclusive breastfeeding are modifiable by health education. There is a need to educate mothers and revive the Baby-Friendly Hospital initiative to promote breastfeeding in Saudi Arabia. Muslim communities are expected to support, promote, and protect breastfeeding based on religious recommendations. A nationwide survey is warranted to provide a full picture about exclusive breastfeeding.

Footnotes

Disclosure Statement

No competing financial interests exist.

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