Determinants of Initiation and Exclusivity of Breastfeedingin Al Hassa, Saudi Arabia

Tarek Amin,1,2 Hatem Hablas,3 and Ahmed AlAbd Al Qader3

Abstract

Aims: The objectives of this cross-sectional study were to define the possible determinants of early initiation andexclusivity of breastfeeding and to assess knowledge towards breastfeeding among Saudi mothers in Al Hassa,Saudi Arabia.Subjects and Methods: Six hundred forty-one Saudi mothers with singleton infants approximately 24 months oldattending well-baby clinics at four urban and six rural primary health care centers were selected through themultistage sampling method. Eligible mothers were invited to a personal interview using pretested question-naires to gather data regarding sociodemographics, health-related variables, breastfeeding initiation, and currentbreastfeeding practices and to assess mothers’ knowledge about breastfeeding.Results: Breastfeeding was initiated by 77.8% of mothers within the first 24 hours of childbirth. Exclusivebreastfeeding at birth was reported in 76.1%, which declined to 32.9% and 12.2% at the age of 2 and 6 months,respectively. Increased maternal age, multiparity (three or more children), and vaginal delivery were significantpositive predictors for early breastfeeding initiation as revealed by stepwise logistic forward regression. Rural,less-educated, low-income multiparous mothers were more likely to exclusively breastfed their infants as re-vealed by multivariate logistic regression. Irrespective of educational status, surveyed mothers demonstratedseveral misconceptions towards breastfeeding. Furthermore, early initiations and exclusivity were significantlyinfluenced by sociodemographics, especially maternal educational and employment status.Conclusions: The rate of initiation and exclusivity of breastfeeding in Al Hassa is far below the World HealthOrganization recommendations.

Introduction

Breastfeeding is well recognized as the most appro-priate mode for infant feeding. Providing several short-

and long-term benefits for both infants and mothers, it isclosely related to optimal physical and psychomotor devel-opment and chronic disease prevention.1,2 For several rea-sons, breastfeeding epidemiology is crucial for anunderstanding of the health outcomes shaped by the nutritiontransition currently underway in many developing coun-tries.3

Exclusive breastfeeding for the first 6 months of life andcontinued breastfeeding up to 2 years of age or beyond arerecommended by the World Health Organization (WHO)1

and other health authorities.4 The patterns of breastfeedingshowed variation when comparing developed and develop-ing countries. For instance, 38% of all infants�5 months of agein the developed world and half of infants in many develop-

ing countries are exclusively breastfed for the first 6 months.5

Exclusive breastfeeding rates in Sub-Saharan Africa and EastAsia/Pacific demonstrated an upward trend in the last de-cade from 24% to 32%5 and from 27% to 32%,6 respectively.Surprisingly, the rates of exclusive breastfeeding remainedroughly constant or declined in the Middle East and NorthAfrican region.6

In Saudi Arabia there has been a considerable change in thepattern of breastfeeding in recent decades due to populationtransition as a result of advancements in socioeconomic sta-tus.7 Breastfeeding in Saudi Arabia has been customary;8 itsduration used to exceed the age of 24 months, and solid foodwould be introduced as late as 12–18 months and comple-mentary to breastfeeding.9 Studies from Saudi Arabia haverecorded a progressive decline in breastfeeding practice andduration, especially among young mothers in urban areas,10–12

with early introduction of bottle feeding12,13 and earlier in-troduction of solid foods.14

1Department of Family and Community Medicine, College of Medicine, King Faisal University, Hofuf, Saudi Arabia.2Department of Community Medicine, Cairo University, Cairo, Egypt.3Department of Pediatrics, College of Medicine, King Faisal University, Al Hassa, Saudi Arabia.

BREASTFEEDING MEDICINEVolume 6, Number 2, 2011ª Mary Ann Liebert, Inc.DOI: 10.1089/bfm.2010.0018

59

The initiation and duration of breastfeeding depend onseveral determinants, namely, sociodemographic, psychoso-cial, biomedical, and healthcare-related factors, communityattributes, and public policy;15 however, the importance ofthese factors varies across countries and over time. Fewstudies14–16 have addressed factors related to initiation andexclusivity of breastfeeding in Saudi Arabia with inherentfaults either in samples studied of purely urban mothers14 orusing different cutoffs for exclusive breastfeeding.16 There aremany factors that influence breastfeeding duration: Some in-vestigators have suggested that mothers’ knowledge, atti-tudes, and support were stronger determinants ofbreastfeeding duration along with sociodemographic and bi-ological factors.17 Studies that provide information regardingSaudi mothers’ knowledge towards breastfeeding are scarce.The objectives of this study were to define possible determi-nants of early initiation and exclusivity of breastfeeding and toassess knowledge about different aspects of breastfeedingamong Saudi mothers in Al Hassa, Saudi Arabia.

Subjects and Methods

Setting and design

A cross-sectional descriptive study was carried out in AlHassa Governorate located in the Eastern Province of SaudiArabia, 450 km from Riyadh. Al Hassa is populated withabout 1 million Saudis and consists of three regions: urban,occupied by about 60% of the population; rural, composed ofsix major villages and occupied by 35% of the population; andHegar areas, "Bedouin scattered communities," populated bythe remaining 5%. Primary healthcare services are providedthrough 54 centers in Al Hassa and serving around 85% of thepopulation.

Sampling

Infants 24 months old brought to the Well-Baby Clinics atprimary healthcare centers (PHCs) accompanied with theirmothers were targeted in both urban and rural areas (theHegar areas were excluded for the sake of convenience be-cause of difficulties in transportation). Considering the totalregistered infants 24 months old at Al Hassa PHCs (n¼ 15,993in 2008, according to the local Health Directorate), with aprevalence of exclusive breastfeeding of 40%,10–13 and as-suming the worst acceptable prevalence of 36%, with an alphalevel of 0.05, the total sample size should include 556 infants.Adding a potential non-response rate of 20%, the final samplesize would be around 723 subjects. The proportionate sam-pling method was applied in relation to urban/rural distri-bution using a suitable sampling fraction. Two main urbanareas (Hofuf and Mubaraz) and six major rural villages havebeen identified. Two PHCs from each urban area and onefrom each village were randomly selected using an updatedPHC list. Subjects were selected according to the followinginclusion criteria: Saudi nationality; mothers of singleton in-fants (multiple births were excluded); infants full term at birthwith no congenital anomalies to interfere with feeding; andthe informer should be the biological mother.

Data collection

Eligible mother–infant pairs were approached personallyand invited to an individualized interview after proper ori-

entation. The interviews were carried out by trained femaleArabic-speaking nurses recruited at each health center using apretested questionnaire to gather data regarding:

� Sociodemographics: age in years, residence, maritalstatus, age at marriage, educational and occupationalstatus, family income in Riyals, parity, and age at cur-rent childbirth.

� Detailed inquiries regarding current breastfeedingpractices: time of initiation of breastfeeding in hoursafter childbirth, its duration in months, duration of ex-clusive breastfeeding, time of introduction of formula (ifany), and detailed inquires about time of introductionand types of fluids, solids, and semisolids foods given.

� Number of antenatal care visits, facilities providing theservice, modes and place of childbirth and hospitaliza-tion and its duration (if any), sex of neonate, postpartumuse of contraceptives (types and duration), and historyof chronic illnesses (if any) and its nature. Some datawere ascertained through reviewing of maternal andinfants’ available health records.

� Knowledge about different aspects of breastfeedingpractices through using 14 closed-ended questions,adopted from the available literature,18–20 to assessmaternal knowledge regarding benefits, misconcep-tions, and practices of breastfeeding and infant weaning.They were formulated as closed-ended questions withtrue/false and multiple-option formats. The followingscoring system was applied: Those with correct re-sponses received one point, while those with wrongresponses and those who did not know received nil.

Interviews were carried out at the conclusion of the visit ofthe mothers and their infants to the PHC.

Definitions of breastfeeding patterns

Breastfeeding definitions used in this study were accordingto the infant feeding recommendations of the 2001 WHOExpert Consultation4 and the 55th World Health Assembly.21

� Exclusive breastfeeding: Infant receives only breastmilkwithout any additional food or drink, not even water,except for syrups and drops contain vitamins and min-erals and medications in the first 6 months.

� Partial breastfeeding: Breastfeeding the infant and sup-plementing his or her diet with other fluids or foodssuch as prelacteals, non-human milk, and solid andsemisolid foods.

Pilot testing

Field pretesting was carried out through interviewing at-tendees for routine well-baby care at a nearby PHC (49 sub-jects beyond sample size) to ensure proper administrationand reliability of the instrument. The inter-rater reliabilitywas 0.81, and the knowledge part demonstrated reliability(Cronbach’s alpha of 0.74).

Data analysis

Of the 723 mother–infant pairs eligible, 667 agreed to par-ticipate, for a response rate of 92.3%. Data were analyzedusing SPSS version 16.0 (SPSS Inc., Chicago, IL). Data collec-tion forms missing more than two items were discarded

60 AMIN ET AL.

(n¼ 26). Therefore the total number of valid questionnaireforms was 641. Categorical variables were expressed in pro-portions and a percentage; w2 and Fisher’s Exact tests wereapplied as appropriate. Continuous variables were expressedusing mean, median, and SD; the t test was used for compar-ison. Knowledge scores were also expressed in mean, median,and SD; the Mann–Whitney and t test of significance wereapplied for comparison. Models of multivariate stepwise(forward method) and binary logistic regression analyses weregenerated to define the possible determinants of breastfeedinginitiation and exclusivity (dependent variables), by inclusions

of significant independent variables found at univariateanalysis. Age and parity were entered as continuous variables,while others were entered as a dichotomy. Confidence inter-vals of 95.0% and p value of <0.05 were applied.

Ethical considerations

Permissions from the local Health Authorities as well as ourinstitution were obtained after approval of the study protocoland data collection tools. Participants were provided with fullorientation, with an emphasis on the right not to participate.

Table 1. Sociodemographic and Health-Related Characteristics of the Sample Surveyed

in Relation to Breastfeeding Initiation

No. (%)

Early initiation of breastfeeding

Variable Total (n¼ 641) Yes (n¼ 499) No (n¼ 142)aUnivariate analysis

[OR (95% CI)], p value

Age (years) (mean� SD) 28.9� 4.8 29.8� 5.1 27.9� 3.7 0.001**ResidenceUrban 403 (62.9) 297(59.5) 106 (74.6) ReferenceRural 238 (37.1) 202 (40.5) 36 (25.4) 2.0 (1.29–3.11)**Education status<Secondary 336 (52.4) 285 (57.1) 51 (35.9) Reference�Secondary 305 (47.6) 214 (42.9) 91 (64.1) 0.42 (0.28–0.63)**Marital statusMarried 613 (95.6) 481 (96.4) 132 (93.0) ReferenceDivorced/widowed 28 (4.4) 18 (3.6) 10 (7.0) 0.49 (0.12–1.18)Occupational statusWorking 198 (30.9) 141 (28.3) 57 (40.1) ReferenceHousewife 443 (69.1) 358 (71.7) 85 (59.9) 1.71 (1.13–2.56)*Parity<3 311 (48.5) 219 (43.9) 92 (64.8) Reference�3 330 (51.5) 280 (56.1) 50 (35.2) 2.35 (1.57–3.53)**Family income (in Saudi Riyals):<6,000 332 (51.8) 289 (57.9) 43 (30.3) Reference�6,000 309 (48.2) 210 (42.1) 99 (69.7) 0.34 (0.22–0.52)**Mode of deliveryVaginal 562 (87.7) 473 (94.8) 89 (62.7) ReferenceCesarean section 79 (12.3) 26 (5.2) 53 (37.3) 0.09 (0.05–0.16)**Place of deliveryHospital 622 (97.0) 488 (97.8) 134 (94.4) ReferenceHome 19 (3.0) 11 (2.2) 8 (5.6) 0.38 (0.14–1.05){

Age at childbirth (years):<20 101 (15.8) 53 (10.6) 48 (33.8) Reference20–<30 283 (44.1) 232 (46.5) 51 (35.9) 1.55 (1.04–2.32)*�30 257 (40.1) 214 (42.9) 43 (30.3) 1.71 (1.13–2.60)*Gender of infantMale 328 (51.2) 251 (50.3) 77 (54.2) ReferenceFemale 313 (48.8) 248 (49.7) 65 (45.8) 1.17 (0.79–1.73)Antenatal visit frequency<9 173 (27.0) 131 (26.3) 42 (29.6) Reference�9 468 (73.0) 368 (73.7) 100 (70.4) 1.18 (0.77–1.82)Chronic maternal illnessNo 612 (95.5) 482 (96.6) 130 (91.5) ReferenceYes 29 (4.5) 17 (3.4) 12 (8.5) 0.30 (0.13–0.69)**

Early initiation of breastfeeding was defined as within 24 hours of delivery.aIncludes never breastfed and late initiators of several days.*p< 0.05, **p< 0.001.{Exact confidence intervals.CI, confidence interval; OR, odds ratio.

DETERMINANTS OF BREASTFEEDING INITIATION AND PATTERN 61

Informed consent forms were obtained from those agreed toparticipate.

Results

Sample characteristics

The age of the mothers surveyed ranged from 16 to 44(mean� SD, 28.9� 4.8) years, parity ranged from one to 11(mean� SD, 3.9� 2.1) with a median of 4.0, and the age of theinfants surveyed ranged from 23 to 26 months.

Table 1 demonstrates the sociodemographic characteristicsof the surveyed mothers. Three hundred thirty-six (52.4%)had less than a secondary education; illiteracy was foundamong 24.8%, whereas 13.6% had university degrees. Of themothers surveyed, 30.9% were employed, mostly in thegovernmental sector as teachers, technicians, or accountantsor in clerical jobs. Postpartum contraceptive usage was re-ported by 76.6%: oral hormonal contraceptives in 68.2%, in-trauterine device in 10.8%, and other methods, includingcoitus interruptus, safe period, and condoms, in 21%. Cesar-ean section as a mode of delivery was found in 12.3%. Hos-pitals as places for childbirth were mentioned in 97% of cases;81.9% of cases delivered at hospitals had a median length ofstay of 2 days and in the remaining 113 cases (18.1%) a medianof 10 days. Chronic disease conditions were encountered in 29mothers: Gestational diabetes in eight, bronchial asthma in 12,epilepsy in two, sickle cell disease in three, pregnancy-induced hypertension in four, and anemia in one.

Breastfeeding initiation

The total of non-breastfeeders and late initiators amountedto 142 (22.2%). Of the 641 mothers, 58 (9.0%) had neverbreastfed their infants. For those who never breastfed, lowmilk flow was the main reason (n¼ 33), followed by cesareansection and sedation (n¼ 13) and maternal chronic diseasecondition (n¼ 12).

Eighty-four (13.1%) women had initiated breastfeedingseveral days after delivery; the main stated reasons for latebreastfeeding initiation were pain following delivery(n¼ 18), inability to sit properly to breastfeed due to epi-siotomies (n¼ 12), sedation (n¼ 14), intake of drugs (n¼ 11),weakness and fatigue (n¼ 9), no or low milk flow (n¼ 23),and a combination of several reasons (n¼ 20). For late initi-ators, sugar water, herbal tea, and formula feeding wereused as alternatives.

Breastfeeding was initiated within the first 24 hours for 499(77.8%) neonates: 56 (11.2%) within 1 hour after birth, 141(28.3%) from 1 to <6 hours, 218 (43.7%) from 6 to 24 hours,and 84 (13.1%) �24 hours. The mean onset of breastfeedinginitiation was 15.9� 6.8 (median, 14) hours. Among the 499early breastfeeding initiators, in 284 (56.9%) the initiation wassolely by breastfeeding, in 142 the initiation was by breast-feeding along with bottle feeding, while 73 used sugaredwater and herbal tea with breastfeeding.

Table 1 also demonstrates univariate analysis of breast-feeding initiation in relation to sociodemographics andhealth-related variables. Older maternal age, multiparity

Table 2. Multivariate Stepwise Logistic Regression (Forward Method) for Determinants

of Breastfeeding Initiation Among the Mothers Surveyed

Model, predictor b OR (95% CI) p value* % predicted Model w2 Model p value

Model 1Maternal age 0.231 2.26 (1.10–4.66) 0.000 17.7 63.4 0.031Constant 01.16 3.819 0.000

Model 2Education (�secondary) �0.214 0.81 (0.73–0.89) 0.002 41.6 26.59 0.022Maternal age 0.313 2.04 (1.28–3.30) 0.005Constant 1.269 3.55

Model 3Parity (<3) �0.415 0.66 (0.49–0.96) 0.003 64.6 33.98 0.020Family income (>6,000 SR) �0.380 0.68 (0.49–0.88) 0.010Education (�secondary) �0.213 0.82 (0.74–0.98) 0.022Maternal age 0.205 1.99 (1.06–3.73) 0.033Constant 0.673 1.961

Model 4Mode of delivery (cesarean section) �0.664 0.52 (0.35–0.76) 0.001 68.4 39.88 0.028Parity (<3) �0.641 0.66 (0.49–0.88) 0.005Education (�secondary) �0.412 0.81 (0.73–0.90) 0.010Maternal age 0.219 1.88 (1.13–2.42) 0.029Residence (rural) 0.198 1.61 (1.03–3.43) 0.033Constant 0.772 2.165

Final modelMode of delivery (cesarean section) �0.218 0.71 (0.53–0.94) 0.004 70.4 49.24 0.003Parity (<3) �0.411 0.56 (0.31–0.98) 0.010Maternal age 0.564 2.24 (1.37–3.68) 0.016Constant 1.171 3.235

Reference groups include: maternal educational status (<secondary); parity (three or more children); family income (>6000 Saudi Riyals[SR]); mode of delivery (vaginal); and residence (rural).

*Significance at p< 0.05.b, b coefficient.

62 AMIN ET AL.

(three or more children), rural residence, and being a house-wife were significantly associated with early breastfeedinginitiation, while higher educational status (secondary orhigher), being employed, having a higher income (�6,000Saudi Riyals), cesarean section delivery, and chronic maternalconditions were significant negative predictors.

Table 2 gives the results of multivariate stepwise logisticregression (forward method) analysis of predictors for earlybreastfeeding initiation. The final model shows that lowparity (fewer than three children) and cesarean section werenegative predictors, while increased maternal age was posi-tively associated with early breastfeeding initiation.

Patterns and duration of breastfeeding

Table 3 displays the status of breastfeeding as revealed bythe interviewed mothers in relation to the infant’s age. For-mula feeding reaches its peak in the second month (37.9%). Arapid decline occurs in exclusivity of breastfeeding from66.5% at birth to 19.2% at 4 months and to 12.2% by 6 monthsof age (confidence intervals¼ 9.9–14.9). Median breastfeedingduration was 6.0 (mean, 8.5� 7.4) months and was longeramong low-educated mothers (median of 8.0 [10.8� 7.9] vs. amedian of 6.0 [7.5� 7.0] months for those with secondaryeducation or higher, p¼ 0.001). Rural mothers breastfed lon-ger compared to urban mothers (9.6� 7.6 vs. 7.9� 7.3 months,p¼ 0.007). Also, low-income and older mothers (�30 years)breastfed their infants for longer duration (9.3� 7.4 [p¼ 0.001]and 8.7� 7.2 [p¼ 0.002] months, respectively).

Correlates of exclusive breastfeeding

Table 4 displays the possible independent predictors forexclusive breastfeeding among the sample surveyed. Oldermaternal age, multiparity (three or more children), rural res-idence, and being a housewife were significant positive cor-relates for exclusive breastfeeding as revealed by univariateanalysis, whereas higher education, higher family income,oral hormonal contraceptives, late initiation of breastfeeding,and chronic maternal illnesses were significantly associatedwith nonexclusivity of breastfeeding. Multivariate regressionanalysis revealed that rural residence, older age, being ahousewife, and multiparity were positively correlated withexclusive breastfeeding.

Breastfeeding knowledge

Table 5 demonstrates responses of the mothers surveyedtowards the 14 knowledge items. The total knowledge scores(out of 14 points) were 8.8� 1.4 (median, 8). Knowledgescores were higher among those with secondary education orhigher (10.2� 1.6 vs. 8.4� 1.3 for less than secondary educa-tion, p¼ 0.011). Multiparous mothers (three or more children)scored lower compared to those with lower parity (9.68� 1.10vs. 8.1� 1.0, p¼ 0.003).

Several misconceptions towards breastfeeding were found:Of the mothers surveyed, 34.2% knew that breastfeedingshould be started immediately after birth, 41.7% and 47.0%believed that breastfeeding causes obesity and spoils thebreast’s shape, respectively, over 60.0% believed that breast-feeding should be stopped once pregnancy occurs, 28.9% ofmothers agreed that breastfeeding should be ceased if diar-rhea occurs, 32.3% stated that fluids should be introducedbeginning in the third month, 28.0% were unable to mentionthat breastfeeding should be given on demand, and 55.9%failed to define the exact duration of exclusive breastfeeding.

Discussion

In this study, out of the 641 mothers surveyed, 77.8% hadinitiated breastfeeding within 24 hours of childbirth, of which11.2% were within 1 hour, 28.3% from 1 to 6 hours, and 43.7%from 6 to 24 hours after childbirth. Exclusive breastfeeding asa mode of infant nutrition accounted for 76.1% at birth with anabrupt decline at 2 months of age to 32.9%, and those whoexclusively breastfed were found to be only 19.2% and 12.2%at 4 and 6 months, respectively. The WHO has recommendedthat neonates should be breastfed immediately or within halfan hour after birth, with exclusivity during the first 4–6months of life.4,22 Our figures of breastfeeding initiation arelower than those reported by previous studies carried out inSaudi Arabia10 and neighboring Arab countries:17,23 in Jed-dah10 23.2% of mothers initiated breastfeeding within the firsthour, in Lebanon17 18.3% of mothers breastfed their infantswithin half an hour, and in Kuwait23 39.0% of mothers initi-ated breastfeeding within the first hour after birth. Previousstudies from Saudi Arabia10,12–14 have reported higher rates ofbreastfeeding initiation: For instance, Al Mouzan et al.11 re-ported that breastfeeding was initiated in 91.6% of newborns,

Table 3. Breastfeeding Patterns of Infants Surveyed (Through 24 Months of Age)

in Relation to Their Age in Months

Number (%) [95% CI]

Breastfeeding status (total n¼ 641)

Infant’s age Exclusive Partial Never breastfed Total breastfeeding

Birth 426 (66.5) [62.7–70.0] 73 (11.4) [9.2–14.1] 142 (22.2) [19.1–25.5] 499 (77.8) [74.5–80.9]1 month 488 (76.1) [72.2–79.3] 95 (14.8) [12.3–17.8] 58 (9.0) [7.1–11.5] 583 (91.0) [88.5–92.9]2 months 211 (32.9) [29.4–36.6] 276 (43.1) [39.3–46.9] 154 (24.0) [20.9–27.5] 487 (76.0) [72.5–79.1]4 months 123 (19.2) [16.3–22.4] 312 (48.7) [44.8–58.5] 206 (32.1) [28.6–35.8] 435 (67.9) [64.2–71.4]6 months 78 (12.2) [9.9–14.9] 319 (49.8) [45.9–53.6] 244 (38.0) [34.4–41.9] 397 (61.9) [58.1–65.6]9 months 53 (8.3) [6.4–10.7] 251 (39.2) [35.5–43.0] 337 (52.5) [48.7–56.4] 304 (47.4) [43.6–51.3]12 months — 218 (34.0) [30.4–37.8] 423 (66.0) [62.2–69.6] 218 (34.0) [30.4–37.8]>12 months — 117 (18.3) [15.5–21.4] 524 (81.7) [78.6–84.5] 117 (18.3) [15.5–21.4]

Partial breastfeeding was defined as breastfeeding the infant but supplementing his or her diet with other fluids or foods. Exclusivebreastfeeding was defined as the infant was receiving only breastmilk without any additional food or drink.

DETERMINANTS OF BREASTFEEDING INITIATION AND PATTERN 63

with a rate of 98.9% in Riyadh12 and 94.0% in Jeddah.10 Ourfigures are close to those reported from Kuwait,23 where therate of initiation was reported to be 79%.

Several factors were found to interplay in the process ofbreastfeeding initiation.15,17 Our study delineates that somesociodemographic predictors—maternal age and parity—andhealth-related factors—like cesarean section—may influenceearly initiation of breastfeeding.

These results are consistent with those obtained fromLebanon,17 where it was reported that cesarean section andhospital-related factors significantly influenced breastfeedinginitiation. Previous breastfeeding experience and maternalage were independent significant predictors for breastfeedingintention and feeding choice in a similar study.24

Furthermore, Trussel et al.25 found that children of womenwith higher parity tended to breastfeed the longest; those with

seven or more children were twice as likely to breastfed theirchildren as women with firstborn children.

In Saudi Arabia, the prevalence of exclusive breastfeedingis not precisely known, while considering our findings andothers,11,12 the prevalence of exclusive breastfeeding is farfrom WHO recommendations, which have called for exclu-sive breastfeeding for the first 6 months.4

Rates of exclusive breastfeeding in this study are close to thosereported from other Arab countries: rates of 10.1% and 12% inLebanon17 and Kuwait,23 respectively, at 6 months of age. Thesefigures as well as ours are low compared to those reported fromthe developed world; for example, at 4–6 months, in Lux-embourg 54% of mothers exclusively breastfed their newborns,in The Netherlands 37%, in Japan 41%,15 and in Austria46%.26

The median breastfeeding duration in this study was 6.0(mean� SD, 8.5� 7.4) months and was longer among

Table 4. Multivariate Logistic Regression Analysis of Sociodemographic and Health-Related

Determinants of Exclusive Breastfeeding Among the Mothers Surveyed

Exclusive breastfeeding [n (%)] Multivariable regression analysis

Independent variable Yes (n¼ 78) No (n¼ 563)Univariate analysis

OR (95% CI), p value b OR (95% CI) p value

Age (years)(mean� SD)

29.4� 6.7 27.8� 3.9 0.001* 0.141 1.14 (1.03–1.23) 0.034*

ResidenceUrban 31 (39.7) 372 (66.0) ReferenceRural 47 (60.3) 191 (34.0) 2.95 (1.77–4.94)** 0.371 1.74 (1.28–2.36) 0.008*Educational status<Secondary 63 (80.8) 273 (48.5) Reference Reference�Secondary 15 (19.2) 290 (51.5) 0.22 (0.12–0.42)** �0.488 0.61 (0.39–0.97) 0.026*Occupational statusWorking 11 (14.1) 187 (33.2) Reference ReferenceHousewife 67 (85.9) 376 (66.8) 3.03 (1.51–6.22)** 0.444 1.84 (1.31–2.57) 0.010*Number of children

(mean� SD)4.26� 2.4 3.32� 1.9 0.001** 0.146 1.15 (1.01–1.30) 0.035*

Family income<6,000 SR 65 (83.3) 267 (47.4) Reference Reference�6,000 SR 13 (16.7) 296 (52.6) 0.18 (0.09–0.35)** �0.385 0.53 (0.31–0.91) 0.020*Mode of deliveryVaginal 61 (78.2) 491 (87.2) ReferenceCesarean section 7 (21.8) 72 (12.8) 0.78 (0.31–1.80){

Oral hormonalcontraception

No 51 (65.4) 255 (45.3) Reference ReferenceYes 27 (34.6) 308 (54.7) 0.44 (0.26–0.74)** �0.053 0.95 (0.62–1.44) 0.071Breastfeeding

initiation�6 hours 49 (62.8) 279 (49.6) Reference Reference>6 hours 29 (37.2) 284 (50.4) 0.58 (0.35–0.97)* �0.128 0.84 (0.57–1.24) 0.121Infant’s genderMale 41 (52.6) 287 (51.0) ReferenceFemale 37 (47.4) 276 (49.0) 0.94 (0.57–1.55)Antenatal care

visits<9 21 (26.9) 152 (27.0) Reference�9 57 (73.1) 411 (73.0) 1.00 (0.57–1.77)Maternal chronic

illnessYes 9 (11.5) 20 (3.6) Reference ReferenceNo 69 (88.5) 543 (96.4) 0.28 (0.12–0.70)**{ �0.041 0.92 (0.71–1.19) 0.163

For multivariate logistic regression analysis, constant¼�2.899, w2¼ 38.151, p¼ 0.0001, percentage predicted¼ 73.8%.*p< 0.05, **p< 0.001.{Exact confidence intervals.

64 AMIN ET AL.

low-educated, rural, low-income mothers and those �30years old.

The duration of breastfeeding among our sample is shortercompared to figures previously reported from a community-based survey11 from Saudi Arabia where the duration ofbreastfeeding was 12.5 months; working mothers breastfedtheir children less than nonworking mothers. Another studycarried out in Riyadh12 reported a mean duration of breast-feeding of 8.5� 6.2 months.

Consistent to our results, previous studies27,28 have foundthat urban working mothers in developing countries tend tobreastfed for shorter intervals. Grummer-Strawn29 has reportedthat the odds of breastfeeding for a child whose mother had hadno education was twofold higher than those of a child whosemother had had at least 7 years of education even after con-trolling of other confounding factors. Also, children belongingto higher socioeconomic strata were substantially less likely tobe breastfed. The previous finding is consistent to our resultswhere those belonged to families with higher income (>6,000Saudi Riyals) had a lower likelihood for breastfeeding initiationand exclusivity. Several studies25,30,31 from developing coun-tries have shown that within countries, breastfeeding is moreprolonged among rural and less or non-educated women ratherthan women who reside in urban areas and with higher levels offormal education. Countries with a higher proportion of theirpopulation living in rural areas present more extended breast-feeding compared with more urbanized nations.30,31

Furthermore, in developing countries demonstrating pop-ulation transition with increasing urbanization, womenachieving higher levels of formal education and more work-ing outside of their households are expected to witness a de-crease in the practice and duration of breastfeeding acrosstime,30,31 a scenario that is applicable to the Saudi Arabiancommunity where women account for 55% of universitygraduates and the urban population represents 82% of thetotal with a rate of urbanization equals to 2.5% annual rate ofchange (for the years 2005–2010) and ranked 39th in the globalrank of urbanization in the year 2009.32

In addition, there is a change in the status of Saudi womenin response to the socioeconomic advancement with moreeducational and employment opportunities; for instance, themale to female ratio for students at universities changedconsiderably over a period of a few years from one to over twowomen for every man with a dramatic increase in literacyamong females in a very short period.33

Also, there is a change in the roles of women in contem-porary Gulf societies. Women’s traditional monorole of mar-riage and mothering has changed to multirole models andmore outdoor socialization; they choose to pursuit highereducation and careers and are less accepting of having theirroles restricted to motherhood. More schooling is associatedwith shorter breastfeeding;30,31 however, this differential isdecreasing over time in some developing and most developedcountries, where the direction of this association is already

Table 5. Responses of the Mothers Surveyed to Knowledge-Related Items Towards Breastfeeding (n¼ 641)

Number (%) of responses

Knowledge item Correct Incorrect Do not know

Breastfeeding should start immediatelyafter delivery. (True)

219 (34.2) 306 (47.7) 116 (18.1)

Breastfeeding causes maternal obesity.(False)

179 (27.9) 267 (41.7) 195 (30.4)

Breastfeeding spoils the shape of breasts.(False)

213 (33.2) 301 (47.0) 127 (19.8)

Breastfeeding protects women from breastcancer. (True)

360 (56.2) 119 (18.6) 162 (25.3)

Breastfeeding should be stopped oncepregnancy occurs. (False)

188 (29.3) 386 (60.2) 67 (10.5)

Breastfeeding should continue even if theinfant has diarrhea. (True)

297 (46.3) 185 (28.9) 159 (24.8)

Breastfeeding is inappropriate for workingmothers. (False)

162 (25.3) 417 (65.0) 62 (9.7)

Breastfeeding decreases infant’s respiratoryinfections. (True)

268 (41.8) 171 (26.7) 202 (31.5)

Breastfeeding duration should be for ___ months.(2 years) (multiple options)

463 (72.2) 113 (17.6) 65 (10.1)

Juices and other fluids should be givenat the 3rd month of infant’s age. (False)

309 (48.2) 207 (32.3) 125 (19.5)

Colostrum should be discarded beforeinitiating breastfeeding. (False)

322 (50.3) 163 (25.4) 156 (24.3)

Breastfeeding should be given ___ frequency/dayvs. ___. (On demand) (multiple options)

462 (72.1) 101 (15.8) 78 (12.2)

Exclusive breastfeeding definition? (For 6 months)(multiple options)

283 (44.1) 219 (34.2) 139 (21.7)

Minced food supplements should be givenbefore the 4th month. (False)

244 (38.1) 291 (45.4) 106 (16.5)

Correct answers are given in bold type in parentheses after the statement.

DETERMINANTS OF BREASTFEEDING INITIATION AND PATTERN 65

reversed. Women in the United States and other industrial-ized nations with higher levels of education have improvedbreastfeeding outcomes compared to their less educatedcounterparts.25,30,31

Our study indicates that positive predictors for exclusivebreastfeeding include older maternal age, parity (three ormore children), rural residence, and being a housewife, whilehigher educational levels and economic status were nega-tively associated with exclusive breastfeeding.

Several studies14,17,23 carried out in the region have re-ported similar results where low maternal educational leveland rural residence were the most important factors formaintenance of an ideal breastfeeding pattern, while highermaternal education correlated with a shorter period of ex-clusive breastfeeding.

These changes in the trend of breastfeeding in developingcountries witnessing population and nutrition transition canbe explained by increasing urbanization, improving educa-tion, increase in contraceptive use, and changing pattern ofchildbearing, all contributing to the trend of shorter breast-feeding in these countries30,31,34 and placing proportionatelymore children into those groups that breastfeed least.31

This study and others10,35 have shown that maternal em-ployment is a risk factor for nonexclusivity and early breast-feeding cessation among Saudi women, contrary to patternsfound in developed countries where breastfeeding is posi-tively related to the socioeconomic status, namely, householdincome, higher educational status, and maternal employment;this relation is reversed in developing countries.30,31

In Saudi Arabia, women may work outside the home insettings where they do not have contact with unrelated men:In girls’ schools and the women’s sections of universities,social work and development programs for women, banksthat cater to female clients, medicine and nursing for women,television and radio programming, and computer and librarywork. Significant social implications that act as barriers tobreastfeeding for employed women in Saudi Arabia and theGulf countries include embarrassment at breastfeeding beforeothers, even of the same gender,36 fears of the evil eye37 (su-perstitious fears of envy of the lactating woman with inflictinginjury or bad luck, including refusal of breastfeeding, cessa-tion of milk flow, or disease for the nursing infant), lack ofspecial facilities such as lactation rooms, inconvenience, andisolation.38

Furthermore, in Saudi society, breastfeeding in public isconsidered a taboo, and it is prohibited,39 with the lack offamily support that can overshadow the unquestionablebenefits of breastfeeding.38 Additional constraint for em-ployed women includes the relatively short maternity leave(about 10 weeks in the governmental sector), which may forceSaudi women to hire foreign maids or nannies who often domuch of the work of child rearing and feeding.37,39 Breast-feeding sometimes is rejected for not being modern, especiallyamong those of higher socioeconomic status.34,36 For breast-feeding interventions to be successful, public perceptions andsocietal norms that shape the women’s decisions to initiateand continue breastfeeding should be explored.18,20

Our results demonstrate the prevalence and acceptance ofseveral misconceptions regarding breastfeeding. Urban em-ployed mothers with higher educational levels demonstratedhigher knowledge compared to those with low levels of ed-ucation, rural residence, and housewives, yet this knowledge

was not interpreted in terms of a higher rate of initiation andbreastfeeding exclusivity.

In Iraq, Abdul Ameer et al.18 found that illiterate mothersand those with informal or unknown education lacked ap-propriate knowledge compared to urban women in almost allparameters studied except for frequency of breastfeeding.Lack of such knowledge may result in early introduction ofsupplements prior to 6 months of age with subsequentbreastfeeding cessation.18 Among our participants, 28.9% and60.2% stated that breastfeeding should be stopped in the caseof the baby’s diarrhea or with the occurrence of pregnancy,respectively. Bella and Dabal19 in their study found that 60%of their female college participants believed that breastfeedingshould be stopped immediately once pregnancy occurs. An-other misconception is the false belief that breastfeeding willadversely spoil the shape of the breast and will cause obesity;a similar result was found by the previously mentionedstudy,19 where 33% of participants believed that breastfeed-ing will spoil their figure. This misconception is probablywidely promoted in response to the changing role of Saudiwomen in an urbanized modern society with more opportu-nities for higher education and employment.

Aggressive steps taken to protect and promote breast-feeding in some developing countries have been documentedto slow down negative behaviors and health outcomes asso-ciated with nutrition transition, including the obesity epi-demic. Popkin el al.40 showed that in Honduras theseimprovements are likely to be explained at least in part bymassive, well-planned, well-executed national breastfeedingpolicies and promotion program. In Saudi Arabia as well inother Gulf countries the proposed policies to promotebreastfeeding may include expanding awareness of the ben-efits of breastfeeding to include a larger sample of the com-munity through social clubs and the curricula of high schoolsand universities. Breastfeeding awareness needs to be sup-ported via peer counseling at the crucial period duringbreastfeeding along with allocating comfortable rooms formothers to breastfeed in private and to support breastfeedingin public, especially at work places, hospitals, and other fa-cilities; this may improve social acceptance of breastfeeding.Maternity leave needs to be reconsidered as women’s partic-ipation in the Saudi workforce is increasing. Finally, a tax onor an increase in the price of formula milk would lead to anincrease in breastfeeding by ensuring it as a feasibleoption.36,39

Study Limitations

The study design was cross-sectional with inherent limi-tations basically in the form of recall bias. The sample in-cluded PHC attendees and did not include those receivedsimilar care at other health facilities, including the privatesector, who may have different socioeconomic status, whichmight imply different patterns and determinants of breast-feeding. The study findings merely convey associations ratherthan inferences because of the study design adopted; a pro-spective cohort design would be more appropriate.

Conclusions

Early breastfeeding initiation and breastfeeding exclusivityamong our sample were determined by sociodemographicfactors, especially educational and employment status:

66 AMIN ET AL.

Educated, employed, and high-income mothers were lesslikely to initiate and maintain breastfeeding despite theirrelatively higher level of knowledge. The reported rate ofbreastfeeding initiation and exclusivity are far lower com-pared to the current WHO recommendations. Irrespective ofmaternal educational status, many misconceptions are prev-alent regarding breastfeeding practices.

Disclosure Statement

No competing financial interests exist.

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Address correspondence to:Tarek Amin, M.D.

Department of Family and Community MedicineCollege of Medicine

King Faisal UniversityHofuf 31982, Saudi Arabia

E-mail: amin55@myway.com

68 AMIN ET AL.