Original Article
Pattern of Breast Feeding among Saudi and Non-Saudi Mothers in Al-Qassim Region
Aqeel A Alaqeel
Department of Pediatrics, College of Medicine. Qassim University, Qassim, Saudi Arabia.
For correspondence: [email protected] Abstract
Background: Breastfeeding (BF) is a well-known method of infant feeding and has demonstrated health benefits for both child and mother. Furthermore, it has been shown to reduce health care costs. Breastfeeding knowledge varies widely in the regions of Saudi Arabia. Moreover, the rate of exclusive BF has not yet been determined. To the best of my knowledge, no prior studies in the Qassim region have investigated BF knowledge, practices and factors that may affect BF.
Objectives: This study aimed at exploring BF knowledge and practice among mothers attending outpatient clinics in the Qassim region.
Participants and Methods: A cross-sectional study, using a self-administered questionnaire, was conducted among mothers who attended 2 clinics in Buraydah City, Qassim, Saudi Arabia, with their currently nursing children aging between 6 months and 4 years. The questionnaire included demographic data, knowledge, practices and factors that may limit (affect) BF practice.
Results: A total of 140 females were enrolled in this study. The majority were Saudi (74%). Six percent had not breastfed their infants, 24% breastfed for the initial 6 months of life, and 16% continued BF until 2 year of age. It has been noted that only 28% of mothers initiated formula on the day of delivery. Insufficient breast milk was the most common reported cause of BF cessation (48%). On average, Saudi mothers breastfed for 4 months, compared to their counterpart expatriates who BF for 12 months. There was a considerable difference in the exclusive BF rate in Saudi mothers (15%) compared to non-Saudi mothers (30%). Work, primigravida mothers, early initiation of formula milk, and, BF delay after delivery were significant factors influencing BF duration. The prevalence of poor knowledge of BF in this study prevailed among 42.1% while good knowledge prevailed among 57.9% of the participants.
Conclusion: Though most of the participants attended BF education, still adherence to first 6 months of exclusive BF in this study was moderately low which likely indicate insufficient BF education and/or adherence. Furthermore, the overall knowledge of mothers about BF was deemed moderate while type of hospital, nationality, employment and number of children are the significant factors associated with poor knowledge.
Keywords: Breastfeeding, Mother, Knowledge, Pregnancy, Practice.
Citation: Alaqeel AA. Pattern of breast feeding among Saudi and Non-Saudi mothers in Al-Qassim region. AUMJ, June 1, 2018; 5(2): 1 - 9.
Introduction
Breastfeeding (BF) is a well-known method of infant feeding and has demonstrated health benefits for child optimal growth and development.
Additionally, it has the benefit of reducing the risk of communicable
disease such as gastroenteritis, otitis media, respiratory illness, and sudden infant death syndrome, and necrotizing enterocolitis. Also, BF reduces later in life obesity and hypertension. Furthermore, BF has been shown to reduce health care costs(1).
The World Health Organization (WHO) and The American Academy of Pediatrics (AAP) currently recommend exclusive BF for the first 6 months of life to achieve optimal development and growth. After the first 6 months, the infant requires additional nutrition to meet their nutritional requirements, while BF is recommended to continue for up to 2 years of age. Exclusive BF means that the infant is fed no additional food unless medically indicated(2). However, the rate of exclusive BF and the duration of BF in Saudi Arabia have not been reported by the WHO due to the unavailability of national BF data(3). In Saudi Arabia, published national and regional studies have shown that the prevalence of exclusive BF is variable among studies and regions; with a rate of 0.8 - 43.9%(3). Partial BF and exclusive formula feeding are the trends for feeding in the first 6 months of life. The single most commonly reported reason for the early introduction of bottle feeding is the insufficiency of breast milk(4). Although studies have addressed BF in a different region of Saudi Arabia in terms of BF practice, factors influencing BF, and attitudes towards BF(5–11), no enough BF data have been reported among mothers in the Qassim region. Therefore, this study was implemented to assess the prevalence and pattern of BF among mothers in two healthcare settings in Al-Qassim region and to compare between Saudi and non- Saudi mothers. As a secondary objective, the factors affecting this pattern were also studied. Additionally, this study aimed to assess impact of mothers' knowledge on BF practicing.
Materials and Methods
Participants and Setting: This cross- sectional study was conducted in Buraydah at the Pediatric Clinic of Qassim National Hospital and Al-Eskan Dispensary during the period from February 2016 to April 2016. Buraydah is the capital of Al-Qassim Region in north central Saudi Arabia, with a population of 534 893 according to the 2010 census.
Eligible participants were mothers who attended these clinics with their children aged between 6 months and 4 years at the time of the study. Mothers who met these
criteria were invited to participate in the study after a clear explanation of the study‟s purpose and after obtaining verbal consents.
A detailed Arabic self-administered questionnaire containing 16 items was developed based on multiple local studies.
A pilot study was done and included 10 mothers to check the questionnaire regarding the sequence, wording of questions, space for answers, reliability of the results and time needed. These mothers were not included in the study sample. The questionnaire addressed socio-demographic data including age, social status, parity, nationality, education level, occupation, and possible causes of BF discontinuation (such as infant illness, maternal illness, infant refusal, insufficient milk, social issues, a new pregnancy, breast problems, work, family or friend advice, and medical advice). The questionnaire also explored other indirect causes of not adhering to BF, including parity, gestational age, mode of delivery, BF education, weaning time, and knowledge about BF. In addition, the questionnaire also included the timing of initial BF, introduction of formula feeding, and BF discontinuation. The study was approved by the regional research ethics committee at Qassim University (Approval # H-04-Q-001).
Statistical analysis: Statistical Packages for Social Sciences (SPSS) version 20, Armonk, New York, IBM Corporation had been used to perform all statistical analyses for this project. Descriptive and inferential statistics had been conducted.
A p value of 0.05 at 95% CI was used to determine statistical significance. The analyses measured the association between independent variables and dependent variable by using Chi-Square test. A multivariate regression analysis has been conducted as well to predict the likelihood ratio between dependent variables against independent factors where odds ratio as well as confidence interval were also being reported. The influence of nationality, maternal age, educational level, employment, parity, gestational age, mode of delivery, BF, and timing of formula initiation as independent variables on BF duration
were tested using multiple variable regression modeling. The evaluation of knowledge toward BF which consisted of 3 questions where “yes” has been coded as 1 and “no” has been coded as 0.
Knowledge score was calculated by adding the 3 questions. The minimum score was 1 and the maximum score was 3. Since there was no clear criteria written in relation to the level of knowledge toward BF, we then categorized good knowledge if the participant answers all 3 questions correctly (yes) and poor knowledge if the participant answers correctly 2 points or below. Furthermore, exclusive BF was calculated from
delivery to the time of introduction of formula.
Results
140 women were recruited in this study.
Table 1 presented the socio-demographic characteristics comparing Saudi vs Non- Saudi participants. About a half of respondents were in the young adult group (20 – 30 years) followed by 31 – 40 years old (40.0%) and the rest was either less than 20 or more than 40 years old (p
= 0.473). Participants were collected into equal proportion from both public and private hospital where significantly more Saudis attended public hospital (p
<0.001).
Table 1: The socio-demographic characteristics of participating mothers stratified for their nationality (n = 140). Data shown are n (%) and p value (Chi Square test).
Variable All
(n = 140)
Saudi (n = 102)
Non-Saudi (n = 38)
P
Mother age
<20 years 08 (05.7) 07 (06.9) 01 (02.6)
0.473 20 – 30 years 67 (47.8) 45 (44.1) 22 (57.9)
31 – 40 years 56 (40.0) 43 (42.2) 13 (34.2)
>40 years 09 (06.4) 07 (06.9) 02 (05.3) Type of hospital
Public 70 (50.0) 63 (61.8) 07 (18.4)
<0.001 Private 70 (50.0) 39 (38.2) 31 (81.6)
Employment
Employed 71 (50.7) 66 (64.7) 05 (13.2)
<0.001 Unemployed 69 (49.3) 36 (35.3) 33 (86.8)
Education level
None 2 (01.4) 2 (02.0) 0
0.517
Elementary 6 (04.3) 6 (05.9) 0
Intermediate 14 (10.0) 10 (09.8) 4 (10.5) Secondary 37 (26.4) 27 (26.5) 10 (26.3) Bachelor degree 81 (57.9) 57 (55.9) 24 (63.2) Number of children
One 30 (21.4) 22 (21.6) 08 (21.1)
0.113 Two 33 (23.6) 21 (20.6) 12 (31.6)
Three 48 (34.3) 33 (32.4) 15 (39.5)
≥Four 29 (20.7) 26 (25.5) 03 (07.9) Method of delivery
Vaginal 78 (55.7) 66 (64.7) 12 (31.6)
<0.001 Caesarian 62 (44.3) 36 (35.3) 26 (68.4)
Gestational age
Term 123 (87.9) 91 (89.2) 32 (84.2)
0.420 Preterm 17 (12.1) 11 (10.8) 06 (15.8)
More than a half of the participants were employed (50.7%) and the rest were
unemployed with significantly more Saudis being employed (p <0.001).
Majority of the respondents were professional (57.9%), followed by secondary (26.4%) and the remaining were intermediate or elementary level of education (p = 0.517). One third of the respondents were having three children and the remaining group was divided into respondents with one, two and four or more children (p = 0.113). With regards to method of delivery, more than half of the participants were normal vaginal delivery (55.7%) while delivery by Caesarian section was reported in 44.3%
of them, with significantly higher proportion of Saudis being normally delivered (p <0.001). Moreover, nearly all participants were term pregnancy (87.9%) with relatively few cases were preterm (12.1%).
The most common cause of BF cessation was insufficient breast milk, followed by health-related problems and child rejection while the least of them was due to new pregnancy (Figure 1).
Figure 1: Causes of breastfeeding cessation among participating mothers. Data shown are percentages.
Figure 2 depicted the prevalence of knowledge toward BF. Based on the results, poor knowledge has been found to 59 (42.1%) of the participants while good knowledge has been found to 81 (57.9%) of the participants.
Figure 2: Level of knowledge regarding breastfeeding among participating mothers.
Data shown are frequencies; n and %.
Table 2 elaborated the knowledge and other related BF behavior of Saudi and non-Saudi women. Nearly all of the participants had BF education before delivery (p = 0.978) while 65% had BF education after delivery, among them, a significantly more Saudis underwent BF
education after delivery (p = 0.001), whereas, almost all of them were having knowledge about BF (p = 0.614). One fourth of participants had BF duration of one month, 24.3% had a duration of 6 months, 16.4% had a duration of 24 months, 10.7% as 2 months, 10% as 4 months 7.9% as 3 months and the remaining were less than a month, with a significantly higher proportion of Saudis with one-month BF duration (p <0.001).
On average, Saudi mothers breastfed for 4 months, compared to their counterparts who BF for 12 months. Controlling for parity, timing of formula initiation, and employment status, a regression analysis for BF duration has been performed in Saudi and non-Saudi mothers. The results confirmed the earlier findings, with a p value of 0.032. With regards to initial BF, majority of them started at 2 – 6 hours while 40.6% were equally divided between first hour & 7 - 24 hours and the rest were more than 24 hours (p = 0.622).
Table 2: Knowledge, and, practice and other breastfeeding (BF)-related behaviors among participating mothers stratified for nationality (n = 140). Data shown are n (%) and p value (Chi Square test). * = excluding missing cases.
Parameters All
(n = 140)
Saudi (n = 102)
Non-Saudi (n = 38) P BF Knowledge
K1. BF education before delivery
Yes 114 (81.4) 83 (81.4) 31 (81.6)
0.978 No 26 (18.6) 19 (18.6) 07 (18.4)
K2. BF education after delivery
Yes 91 (65.0) 75 (73.5) 16 (42.1)
0.001 No 49 (35.0) 27 (26.5) 22 (57.9)
K3. Knowledge about BF
Yes 128 (91.4) 94 (92.2) 34 (89.5)
0.614 No 12 (08.6) 08 (07.8) 04 (10.5)
BF Practices and Other related behaviors BF duration
<1 month 8 (5.7) 7 (06.9) 1 (02.6)
<0.001 1 month 35 (25.0) 31 (30.4) 4 (10.5)
2 months 15 (10.7) 13 (12.7) 2 (05.3) 3 months 11 (7.9) 10 (09.8) 1 (02.6) 4 months 14 (10.0) 12 (11.8) 2 (05.3) 6 months 34 (24.3) 23 (22.5) 11 (28.9) 24 months 23 (16.4) 06 (05.9) 17 (44.7) Initial BF*
First hour 27 (20.3) 22 (22.7) 05 (13.9)
0.622 2 – 6 hours 62 (46.6) 44 (45.4) 18 (50.0)
7 – 24 hours 27 (20.3) 18 (18.6) 09 (25.0)
>24 hours 17 (12.8) 13 (13.4) 04 (11.1) Formula initiation
First day 35 (27.8) 30 (30.3) 05 (18.5)
0.135 First week 27 (21.4) 23 (23.2) 04 (14.8)
First month 20 (15.9) 13 (13.1) 07 (25.9) 2 – 5 months 21 (16.7) 18 (18.2) 03 (11.1)
≥6 months 23 (18.3) 15 (15.2) 08 (29.6) Weaning time*
≤5 months 55 (39.3) 40 (39.2) 15 (39.5)
0.978
>5 months 85 (60.7) 62 (60.8) 23 (60.5) Future plan
Exclusive BF 56 (40.0) 33 (32.4) 23 (60.5)
0.025 Exclusive formula feeding 18 (12.9) 14 (13.7) 04 (10.5)
Mixed feeding 49 (35.0) 41 (40.2) 08 (21.1) Undecided 17 (12.1) 14 (13.7) 03 (07.9) Interestingly, this study found that the
earlier that mothers start BF, the longer the duration of BF (p = 0.054) after controlling for other variables. With regards to formula initiation, first day
were more (27.8%), followed by first week (21.4%), 6 months or more (18.3%) and the rest was either 2 – 5 months or first month (p = 0.135). Based on the sample, mothers who initiated formula
feeding after 3 months of age tended to have a longer BF duration. Being a working mother was a significant factor impacting BF duration, with a mean of 3.7 months compared to 9.3 months for unemployed mothers, even after adjusting for nationality, the number of children, and formula initiation (p = 0.04).
Additionally, mothers with bachelor‟s degrees tended to have the highest BF duration, with a mean duration of almost 7 months. BF duration is increased as the number of offspring increases even after adjusting for other variables (p = 0.01).
Surprisingly, exclusive BF rates were 15% and 30% in Saudi and non-Saudi mothers, respectively. Maternal age, method of delivery, and gestational age were not factors contributing to BF duration. Additionally, more than 60 percent of them had more than 5 months weaning time while 39.3% had 5 months or less (p = 0.978). The most common future plan of the respondents was exclusively BF (40.0%), followed by mixed feeding (35.0%) while exclusively formula feeding was the intent of 12.9%
of them, and there were 12.1% of them were still undecided (p = 0.025).
When we assessed the relationship between the level of knowledge and the socio-demographic characteristics of participants, we found significant difference between type of hospital and the level of knowledge where poor knowledge was significantly more frequent in private hospital (p <0.001).
Saudis were significant more frequent of having good knowledge compared to non- Saudis (p = 0.002). Unemployment was considerably more frequent of having poor knowledge (p = 0.002). Those women with 1 to 2 children were significantly more frequent of being poorly knowledgeable (p = 0.026). Those participants with term pregnancy were significantly more frequent of having poor knowledge (p = 0.044). On the contrary, age group in years, educational level and method of delivery were having no significant relationship with the level of knowledge (Table 3).
Table 3: Association between level of breastfeeding knowledge and the socio-demographic characteristics of participating mothers (n = 140). Data shown are n (%) and p value (Chi Square test).
Factor Level of knowledge
Poor (n = 59) Good (n = 81) P
Age: ≤30 years/>30 years 35 (59.3)/24 (40.7) 40 (49.4)/41 (50.6) 0.244 Type of hospital: Public/Private 19 (32.2)/40 (67.8) 51 (63.0)/30 (37.0) <0.001 Nationality: Saudi/Non-Saudi 35 (59.3)/24 (40.7) 67 (82.7)/14 (17.3) 0.002 Employment: Employed/Unemployed 21 (35.6)/38 (64.4) 50 (61.7)/31 (38.3) 0.002 Educational level 27 (45.8)/32 (54.2) 32 (39.5)/49 (60.5) 0.459 Number of children: 1-2/>2 33 (55.9)/26 (44.1) 30 (37.0)/51 (63.0) 0.026 Method of delivery: Vaginal/Caesarian 30 (50.8)/29 (49.2) 48 (59.3)/33 (40.7) 0.322 Gestational age: Term/Preterm 48 (81.4)/11 (18.6) 75 (92.6)/06 (07.4) 0.044 A multivariate regression analysis has
been conducted to identify the independent predictors of poor knowledge regarding BF. The type of hospital (being private), nationality (being non-Saudi), employment (being unemployed) and number of children (two or less) were significantly associated with poor knowledge. However, the gestational age showed no significant association (Table 4).
Discussion
WHO and AAP continue to recommend exclusive BF for the first 6 months of life.
The rate of exclusive BF in Saudi Arabia has not been determined. However, data from previous studies in Saudi Arabia have shown varying rates of exclusive BF, ranging from 1.7 - 24.4%(3). In a national survey, El Mouzan et al reported a rate of only 10.2% for „any breastfeeding‟ and 8% for exclusive BF(12). Our study, in Al-Qassim region, revealed a higher rate of exclusive BF;
15% among Saudi mothers and 30%
among non-Saudi mothers. In other
Middle Eastern countries, the reported exclusive BF rates have also varied. For example, the rate of exclusive BF for 6 months was 66.4% in Iran, 54% in
Turkey, 9.7% in Egypt, 1.9% in the United Arab Emirates, and was the lowest in Jordan (1%)(4).
Table 4: Multivariate regression analysis to ascertain the effect of poor knowledge toward breastfeeding in relation to the socio-demographic characteristics of participants (n = 140). OR = Unadjusted Odds Ratio, CI = Confidence Interval.
Factor UOR 95% CI P
Type of hospital: Public/Private Ref/3.579 Ref/1.763 – 7.267 <0.001 Nationality: Saudi/Non-Saudi Ref/3.282 Ref/1.511 – 7.127 0.003 Employment: Employed/ Unemployed Ref/2.919 Ref/1.455 – 5.855 0.003 Number of children: 1-2/>2 Ref/0.463 Ref/0.234 – 0.918 0.027 Gestational age: Term/Preterm Ref/2.865 Ref/0.994 – 8.257 0.051 To address compliance to exclusive BF,
mothers are encouraged to attend BF education before and after delivery. In this study, only 27% attended BF education before delivery, while 65% of them attended after delivery. The adherence to BF practice was found to be related to the level of knowledge and counseling about BF in several studies(8,13,14). In this study, poor knowledge was found in 42.1% of participants and good knowledge in 57.9%. Al Ketbi et al(14), reported a prevalence of poor knowledge to only 5.5%, fair in 43.3% and good knowledge was reported in 51.2% of participating mothers.
There is significant interest for screening of plant extracts for the anti-protozoal activities as such use was a traditional homeopathy(35,36). Protozoa have potentially lower resistance and decreased cross-resistance for these natural extracts;
an inherent drawback for the currently Of those mothers who stopped exclusive BF in this study, the most common reason was insufficient breast milk, followed by health-related issue and child rejection.
Insufficient breast milk was the commonest cause of BF cessation among several published papers(3,8,14). In one study that included female school teachers, insufficient breast milk and work related problems were the cause of BF cessation(8). This is consistent with results reported by Al Juaid and colleagues in 2014 who added sickness, new pregnancy and breastfeeding problems as the main reasons for BF cessation. The false perception of insufficient breast milk leads to early
introduction of formula milk. Therefore, mothers should be reassured that breast milk is sufficient for infant‟s nutritional needs. In Saudi Arabia, it has been reported that the duration of BF appears to decline over time from 13.4 months in 1987 to 8.5 months in 2010(3). However, this study shows a lower mean duration (4 months) among Saudi mothers studied in Al-Qassim region.
This study identified 3 factors associated with BF duration. The first of these was that mothers of Saudi Arabian nationality were BF less than non-Saudi mothers living in Saudi Arabia. Although this factor was not well-identified in a previous studies a recent study in Saudi Arabia confirmed this finding(4). The second factor associated with shorter BF duration among working mothers. This is in agreement with previous studies in Saudi Arabia, Lebanon, and Malaysia(4).Thus, extended maternity leave may lengthen BF duration, and this has been demonstrated by Ogbuanu et al(15). Parity was the third factor associated with BF duration, as multi- parity was correlated with a longer duration and higher prevalence of BF.
Primigravida mothers tend to breastfeed for a mean of 5 months, compared to a mean of 9.4 months in mothers who have at least 4 offspring. Other studies have also confirmed this finding(13,16). The initiation of formula milk in the first days after delivery was noted in some mothers in our study. Early initiation of formula milk mainly in primigravida mothers likely indicates poor antenatal and postnatal BF education.
WHO and UNICEF recommend the initiation of BF in the first 30-60 min after delivery. In our sample, only 20% of mothers met this recommendation. In order to increase BF prevalence and the rate of exclusive BF, the health and education ministries have to collaborate to increase awareness of the benefits and management of BF. Furthermore, the steps to successful BF should be applied, such as educating mothers about the benefits of BF, distributing a BF policy to all healthcare staff and training staff in the necessary skills to implement the policy, assisting mothers to initiate BF within the first 30 min of delivery, showing mothers proper BF techniques, and providing education on maintaining lactation if mothers are separated from their infants.
In addition, other steps include providing infants with no food other than breast milk unless medically indicated, allowing infant and mother to remain together at all times, and providing a follow up soon after discharge with a BF provider(17). This paper also assessed which significant factors are associated with poor knowledge toward BF. Based on my assessment, type of hospital, nationality, employment and number of children are significantly associated with knowledge toward BF. Al Ketbi et al(14), reported educational background, occupation, adopted breastfeeding and living with family and relatives were the factors associated with less likelihood of exclusive breastfeeding.
Conclusion
Though most of the participants attended BF education, still adherence to first 6 months of exclusive BF in this study was moderately low. Furthermore, the overall knowledge of mothers about BF was deemed moderate while type of hospital, nationality, employment and number of children are the significant factors associated with BF knowledge. Also, this study revealed that in the same region, Saudi mothers breastfeed significantly less than non-Saudi mothers. This study suggests more effort is needed among healthcare providers in order to address insufficient compliance of first 6 months BF among postpartum Saudi mothers. I recommend replicating this study research
in a bigger sample size involving multicenters to better understand the knowledge of mothers and factors affecting BF.
Limitations of the Study
This study has some limitations which should be taken into account. First, this was a cross-sectional study that assessed exposure and outcomes simultaneously.
Second, the small sample size may not reflect the community practice. Third, our data were collected from 2 health centers which might not be representative of the entire region. Furthermore, I believe more determinant variables are needed carefully assessed the BF knowledge and to include the attitude and practices among predictors of BF.
Funding
This study was funded by Qassim University, Saudi Arabia, as a part of the author's employment duties.
Conflict of Interests
The author declared no conflict of interests.
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