|Year : 2017 | Volume
| Issue : 2 | Page : 392-398
Breastfeeding practice and knowledge among women attending primary health-care centers in Riyadh 2016
Norah Faleh Al-Mutairi1, Yousef Abdullah Al-Omran1, PJ Parameaswari2
1 Department of Family Medicine, King Saud Medical City, Riyadh, KSA
2 Research Centre, King Saud Medical City, Riyadh, KSA
|Date of Web Publication||7-Dec-2017|
Dr. Norah Faleh Al-Mutairi
Department of Family Medicine, King Saud Medical City, Ulaishah, 7790 Al Imam Abdul Aziz Ibn Muhammad Ibn Saud, Riyadh 12746
Source of Support: None, Conflict of Interest: None
Introduction: Breast milk is the best natural essential nutrition to newborns and infants. However, the practice of breastfeeding (BF) has declined in Saudi Arabia. Objective: The objective of this study was to assess the knowledge and practice of BF with their determinants among mothers in Riyadh. Materials and Methods: In this cross-sectional study, 252 mothers attending the well-baby clinics in Riyadh from March 2016 to May 2017 were selected randomly with their consent and studied by a standardized questionnaire. Results: Of the 252 women, 69.4% were 25–35 years of age and 56.7% with a bachelor degree or higher education. Nearly 75% mothers had education on BF before our study. Mixed feeding was the most preferred method (51.6%) followed by artificial milk (29.4%). The most reported reason for discontinuing BF was breast milk insufficiency (37.3%) and of breastfeed continuation was their perceived benefit (36.6%). Excellent knowledge was observed among 12.7%, good knowledge in 57.1%, and unsatisfactory level in 30.2% mothers. The regression model shows that high school education improved the knowledge by 10.9 points (P = 0.024) and undergraduate by 18.7 points (P value = 0.001) when compared to women who were literate. Women with parity >5 improved knowledge score by 17.3 points (P < 0.001). Conclusion: We observed that majority (57.1%) of Saudi mothers had a moderate level of knowledge on BF benefits and 19% had practiced exclusive BF. There is a need for better educational programs to increase awareness on its benefits for the health situation in the country on the long term.
Keywords: Breastfeeding, cross-sectional study, knowledge, practice
|How to cite this article:|
Al-Mutairi NF, Al-Omran YA, Parameaswari P J. Breastfeeding practice and knowledge among women attending primary health-care centers in Riyadh 2016. J Family Med Prim Care 2017;6:392-8
|How to cite this URL:|
Al-Mutairi NF, Al-Omran YA, Parameaswari P J. Breastfeeding practice and knowledge among women attending primary health-care centers in Riyadh 2016. J Family Med Prim Care [serial online] 2017 [cited 2021 Jul 24];6:392-8. Available from: https://www.jfmpc.com/text.asp?2017/6/2/392/220002
| Introduction|| |
Breastfeeding (BF) is the natural way for infants' nutrition, it provides the ideal nutrients they need for healthy development and growth., Both the baby and the mother benefit from BF on the short- and long-terms as noted by several studies.,, In newborns, it promotes the development of cognitive skills,, immune system,, and growth., Also, it reduces the risk of sudden infant death syndrome (SIDS),,,, type 1 diabetes,,, and many other diseases.,, Additionally, it reduces the mother's risk of developing breast cancer., The accumulated evidence over the last three decades on BF benefits is overwhelming. Based on this evidence, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommended BF to be initiated within the first hour of birth, exclusively in the first 6 months, and to be continued for 2 years and beyond with other adequate sources of nutrition. However, the practice of BF, especially exclusive BF in the first 6 months, remains very low in most countries., Investigating women's knowledge and the association with actual practice is not new., It has been shown that higher knowledge in both mothers and fathers about BF is associated with the better practice., Several studies tried to assess the knowledge of BF benefits, misconceptions, practices, and other aspects and the trends of BF practices locally, regionally, and globally.
The present study aimed to assess the level of knowledge about BF with its determinants among a sample of women attending primary health-care centers (PHCs) in Riyadh. A predictive model was formulated with the influence of sociodemographic factors on the knowledge and practice.
| Materials and Methods|| |
This study was carried out in seven PHCs under the jurisdiction of the Ministry of health (MOH), Riyadh city, KSA. Ethical approval was granted by the Institutional Review Board. And, it included Saudi and non-Saudi women nursing last child between the age group of 4 and 12 months.
- Mothers who were attending one of the designated PHCs
- Mothers who can read and self-administer the questionnaire.
Mothers who refused to participate.
Study design and sampling method
This cross-sectional study  was conducted at seven PHCs. Two-stage random sampling was adopted. In the first stage, seven PHCs were selected randomly by lottery method from 98 PHCs of seven regions in Riyadh. In the second stage, 55 mothers were randomly selected using a set of random numbers from each PHC. The participants were approached in the well-baby clinic by the trained, Arabic-speaking, nurse in-charge of the health center and explained the purpose of the study to the mothers. The structured questionnaires were provided to them with a written informed consent.
A pilot study was conducted at one of the PHCs among thirty women and we observed a 45% prevalence with inadequate knowledge on BF. Hence, the required sample size was estimated using the following formula:
The equation for the sample size calculation  was as follows:
The minimum required sample size with 5% level of significance and 15% precision was 250.
The research tool
We adopted a standardized self-administered questionnaire developed by Ayed with minimal change for the same purpose and setting of our study with the permission from the author. The questionnaire is divided into three parts: the first part consisted of demographic data: mother's age, last child age, the number of children, nationality, employment status, education of mother, type of delivery, and receiving health education about BF. The second part consisted of the questions regarding the type of BF for the last child, reasons of continuity, and barriers for BF. The final part consisted of 38 items covering the following scopes of knowledge on BF: general knowledge, colostrum, advantages to mothers and babies, effective feeding method, duration of feeding, complementary feeding, and problems with BF.
Scoring system for level of knowledge
In this study, we introduced weightage by giving scores to the correct responses for the questions.
- For 38 questions, correct answer was given a score of “1” and the incorrect answer “0”
- The total scores were converted as percentages for each participant. (A score out of 100 was calculated by dividing the actual score over the maximum score)
- Total score <50% was considered “unsatisfactory knowledge”
- Total score between 50% to <75% was considered “good knowledge”
- Total score ≥75% was considered “excellent knowledge.”
The data were collected and the identity of the participants remained anonymous.
The data were analyzed using SPSS 21 (Released 2012. IBM SPSS Statistics for Windows, Version 21.0. IBM Corp., Armonk, NY), the results were presented as descriptive statistics for sociodemographic data, and the scores obtained by the participants were assessed for the level of knowledge and practice on BF using inferential statistics. Comparisons between the participants on the knowledge score were conducted using independent two sample t-test and ANOVA. The relationship between the score and practice was investigated using ANOVA when considering the sociodemographic data. The association between categorized score and the sociodemographic data were tested using Chi-Square nursing children (Fisher's exact test was used when the cells contained <5). Multiple linear regressions  were applied to study the effect of the variables on the level of knowledge score without loss of power due to the categorizing employed in the descriptive part. Regarding the choice of the best linear model, we considered using Akaik Information Criterion (AIC) and Bayesian Information Criterion (BIC). The model that produced the lowest Information Criterion (IC) score (AIC and BIC) will be considered the best fitting model.
| Results|| |
The study selected 400 mothers and 252 had participated with a response rate of 63%. [Table 1] presents the baseline characteristics of the study population. The mean age was 29.1 years, ranging from 17 to 43 years, with a majority of 69.4% between 26–35 years. Almost 60% of nursing children were >6 months. The level of education was college, university (56.7%), or secondary school (27.4%). We observed that 71% of women were unemployed and only 6% of them had more than five children. Nearly 74.6% were educated on BF benefits, 38.1% by physicians. About 51.6% mothers practiced mixed feeding, 29.4% artificial milk, and only 19% reported exclusive BF. The correct responses contributed to the level of knowledge on BF are presented in [Table 2] and graph in [Figure 1]. We observed that 37.3% mothers reported insufficient breast milk followed by 15.8% mothers reported “return to work,” 38 (13.0) reported baby's rejections to breast milk as the prime reason, and 6 (2.1) reported that pregnancy again was the least reason for artificial feed. The majority (36.6%) of women chose the benefits of BF followed by religious beliefs (22.3%), for example, the Quran recommendation for BF continuation. Nearly 84.9% reported that correct position helps to achieve effective BF, 83.3% said complementary feeding should be introduced at 6 months of age, and 82.5% observed that babies sleep well after adequate BF. Almost 10.7% mothers said that they may provide breast milk and formula milk while on complementary food and 14,7% mothers felt that they cannot breastfeed their babies due to their cracked nipples.
The mother's higher level of education, women with children more than 5 and who reported mixed BF practice for their last child when associated with their level of knowledge about BF showed statistical significance and the Chi-Square is shown in [Table 3].
|Table 3: Inferential statistics Chi-square test for level of knowledge on breastfeeding|
Click here to view
The overall mean score (55.9) was tested using one-sample test against 50% (the passing mark) for knowledge. The test showed significant difference between the participants' mean score and the proposed passing mark with 95% CI: 53.1% to 58.4%.
The independent two sample t-test shows that there are three variables with statistically significant differences. Employed women have higher mean scores than that of unemployed women by ~7 points. Second, women with more than 5 children scored on an average of 20 points higher than women with 1–5 children. Finally, women who received health education about BF have on an average of higher score by ~9 points.
The ANOVA revealed that mothers older than 35 years showed higher average score than mothers younger than 25 years and mothers between the ages of 25 and 35. In addition, women with college or university degrees have higher average score than women who can only read and write. Finally, women who reported “other” health education providers have statistically higher average score than women with no BF education (health education provider).
The combinations of all the variables were tested by modeling the data against the score using regression analysis. The model shows [Table 4] that woman with college or university degree can have an improved score by an average of 18.7 points and women with secondary school degree can have an improved knowledge score by 10.9 points in comparison to women who can only read and write. Women with more than 5 children have higher knowledge score than women with 1 or 5 children by 17.3 points. No health education about BF can reduce the average knowledge score by 6.5 points.
|Table 4: Best model for the relationship between the level of knowledge on breastfeeding and its determinants|
Click here to view
| Discussion|| |
The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend BF to be exclusive in the first 6 months of age and to be continued with adding complementary feeds until the child reaches 2 years. The medical evidence about the benefits of BF is overwhelming. However, the practice of BF, especially exclusive BF, has declined over the years in Saudi Arabia. In Riyadh, in a study done in PHCs on 1000 participants with a child aged 6 months or below, the rate of exclusive BF was 62.9% at birth, 13.2% at 4 months, and only 3.3% at the age of 6 months. Another study conducted in Abha city with a sample size of 600 mothers observed an exclusive BF of 7.3% in the first 6 months. Higher rates were reported in Makkah with sample size of 65 participants practicing exclusive BF in the first 6 months to be 18.5%. In AlHassa region, the rate was 24.4% in the first 6 months. In our study, the rate of exclusive BF among infants at age of 4–12 months was 19%. The reason for the low rate in the previous study done in Riyadh was the PHC staff who had failed to give proper education to mothers, and a high number of pamphlets containing a list of their products and promotion messages of bottle-feeding were distributed by manufacturing companies on formula milk.
Mixed feeding was the preferred feeding system in our study with a rate of 51.6% as well in many studies.,,, Perceived breast milk insufficiency was considered as the main reason for BF discontinuation in our study (37.3%). Several studies have reported that it can be due to the lack of knowledge about the frequencies of BF, timing of initiating BF, lack of counseling and support, incorrect practices, and medical and health-related issues.,,, The other reason for discontinuation of BF was maternal work (15.8%). Multiple studies showed that maternal occupation acts as a barrier to BF., 24, ,, It was mentioned that the reasons behind that were embarrassment to breastfeed in public, lack of lactation room in workplace, and lack of facilities of child care and short maternal leave (2 months)., 24, ,,
The majority of the mothers recognized the benefits of BF as the main cause to continuing BF. This is also supported by religious beliefs as reported by many mothers who considered the Quran recommendation in the subject. This seems to be correlated with other studies in the literature.,,, Such issue should be further enhanced among women so that the BF practice can increase in the future. The regression analysis showed that the mother's level of education was a very important factor to increase knowledge (14%) for college or university education and (11.6%) for secondary education. Our result was close to a study done in Alhassa city. Other studies stated that mothers with high education level have excellent knowledge about BF compared to low-educated mothers.,,, The higher educational levels can be associated with more exposure to sources of knowledge and more modern approach to maternal and medical education.,, In addition, employed mothers have good knowledge compared to unemployed mothers as they have higher chance to contact and meet experienced persons.,
The increased number of pregnancies also increased the overall knowledge significantly. In our study, mothers with five children or more have high knowledge and good attitude toward BF practice, a finding similar to study by Maheswari. This could be due to more exposure to maternity clinic visits and the higher personal experience as a mother.,
The statistically significant factor was the lack of health education about BF. This factor negatively affected the overall score as observed in many studies. The lack of BF education and counseling was associated with low knowledge level and low rate of BF practice.,,,, We compared our results in the knowledge of mothers about BF with several local, regional, and global studies. In this study, the level of knowledge was divided into three categories; excellent level of knowledge 12.7%, good 57.1%, and unsatisfactory 30.2%, compared to two studies with the same categorical scoring technique. One was Ayed's study in Abha reported results with excellent level of knowledge 30.7%, good 55.3%, and unsatisfactory 14%. The other one was done by El-Khedr in Makkah with excellent level as 20%, good level as 27.5%, fair as 35%, and poor level as 17.5%. Both were nearly similar to our finding as most of the mothers have moderate level of knowledge. Other studies had no clear method in calculating the score for the knowledge, so we used the overall mean score (55.9%) in our study for comparison. Most studies concluded a moderate overall knowledge which is similar to our result,,, for example in Eldeek et al's. study, the overall knowledge was 52.6%.
The highest score in the level of knowledge was found in a study conducted in the US (75.9%). The reasons were related to effort of awareness intervention to promote BF and social and public support.,, One study had a different trend from the studies we reviewed which was conducted in Kuwait (2010) with 1106 participants reported the level of misconceptions to be high (66%) among the surveyed women, which is equal to unsatisfactory level of knowledge.
Limitations of the study
- The sample included PHC attendee's mothers; it did not involve mothers in other health-care facilities (private sector), who may have different attitude toward BF and different socioeconomic status, which might imply different patterns of BF
- The adequate sample size had limited to cover equal proportion of mothers on patterns of BF and its awareness from the general population.
| Conclusion|| |
The level of knowledge about BF among the sampled women was moderate. Mixed feeding method was more preferred. The practice of natural BF was lower than other studies in the Kingdom, and the main reason for BF discontinuation was the perceived feeling of breast milk insufficiency.
- To conduct campaigns aiming at raising the knowledge of women about BF benefits and correcting the misconceptions about BF
- To use the social media and public figures to advertise for BF
- To encourage the adoption of strategies to support and promote BF as baby-friendly hospital initiative.
I am grateful to the MOH in granting permission to conduct this study, health professionals from King Saud Medical City, all nurses from the seven PHCs who were involved in selecting the participants, and all the mothers enrolled in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jackson KM, Nazar AM. Breastfeeding, the immune response, and long-term health. J Am Osteopath Assoc 2006;106:203-7.
Schack-Nielsen L, Larnkjær A, Michaelsen KF. Long term effects of breastfeeding on the infant and mother. In: Koletzko B, Dodds P, Akerblom H, Ashwell M, editors. Early Nutrition and its Later Consequences: New Opportunities: Perinatal Programming of Adult Health-EC Supported Research. Dordrecht: Springer Netherlands; 2005. p. 16-23.
Labbok MH. Effects of breastfeeding on the mother. Pediatr Clin North Am 2001;48:143-58.
Crenshaw JT. Healthy birth practice #6: Keep mother and baby together- it's best for mother, baby, and breastfeeding. J Perinat Educ 2014;23:211-7.
Wolf JB. Is breast really best? Risk and total motherhood in the national breastfeeding awareness campaign. J Health Polit Policy Law 2007;32:595-636.
Oddy WH, Kendall GE, Li J, Jacoby P, Robinson M, de Klerk NH, et al.
The long-term effects of breastfeeding on child and adolescent mental health: A pregnancy cohort study followed for 14 years. J Pediatr 2010;156:568-74.
Brion MJ, Lawlor DA, Matijasevich A, Horta B, Anselmi L, Araújo CL, et al.
What are the causal effects of breastfeeding on IQ, obesity and blood pressure? Evidence from comparing high-income with middle-income cohorts. Int J Epidemiol 2011;40:670-80.
Zhou Q, Li M, Wang X, Li Q, Wang T, Zhu Q, et al.
Immune-related microRNAs are abundant in breast milk exosomes. Int J Biol Sci 2012;8:118-23.
Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al.
Breastfeeding in the 21st
century: Epidemiology, mechanisms, and lifelong effect. Lancet 2016;387:475-90.
Hauck FR, Thompson JM, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and reduced risk of sudden infant death syndrome: A meta-analysis. Pediatrics 2011;128:103-10.
Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics 2010;125:e1048-56.
World Health Organization, United Nations Children's Fund. Global Strategy for Infant and Young Child Feeding. Switzerland: World Health Organization; 2003.
Cai X, Wardlaw T, Brown DW. Global trends in exclusive breastfeeding. Int Breastfeed J 2012;7:12.
Chezem J, Friesen C, Boettcher J. Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: Effects on actual feeding practices. J Obstet Gynecol Neonatal Nurs 2003;32:40-7.
Susin LR, Giugliani ER, Kummer SC, Maciel M, Simon C, da Silveira LC, et al.
Does parental breastfeeding knowledge increase breastfeeding rates? Birth 1999;26:149-56.
Bonita R, Beaglehole R, Kjellstrom T. Basic Epidemiology. 2nd
ed. Switzerland: WHO Library Cataloguing-in-Publication Data; 2006. p. 44.
Winner L. Introduction to Biostatistics. University of Florida; 2004. p. 52, 78, 97-100, 139.
Ayed AA. Knowledge, attitude and practice regarding exclusive breastfeeding among mothers attending primary health care centers in Abha City. Int J Med Sci Public Health 2014;3:1355-63.
El Khedr SM, Lamadah SM. Knowledge, attitude and practices of Saudi women regarding breast feeding at Makkah Al Mukarramah. Breastfeed Med J 2011;6:154-63.
Al Juaid DA, Binns CW, Giglia RC. Breastfeeding in Saudi Arabia: A review. Int Breastfeed J 2014;9:1.
Al-Amoud MM. Breastfeeding practice among women attending primary health centers in Riyadh. J Family Community Med 2003;10:19-30.
Al-Mohandis E. Exclusive breast-feeding among children attending well-baby clinic at Al-Eskan PHC Center, Makkah Al-Mokarramah. Int J Med Sci Public Health 2015;4:279-85.
El-Gilany AH, Shady E, Helal R. Exclusive breastfeeding in Al-Hassa, Saudi Arabia. Breastfeed Med 2011;6:209-13.
Al-Binali AM. Breastfeeding knowledge, attitude and practice among school teachers in Abha female educational district, Southwestern Saudi Arabia. Int Breastfeed J 2012;7:10.
Alwelaie YA, Alsuhaibani EA, Al-Harthy AM, Radwan RH, Al-Mohammady RG, Almutairi AM, et al.
Breastfeeding knowledge and attitude among Saudi women in Central Saudi Arabia. Saudi Med J 2010;31:193-8.
El-Khedr SM, Lamadah SM. Knowledge, attitude and practices of Saudi women regarding breast feeding at Makkah Al Mukarramah. Breastfeed Med J 2011;6:154-63.
Desai A, Mbuya MN, Chigumira A, Chasekwa B, Humphrey JH, Moulton LH, et al.
Traditional oral remedies and perceived breast milk insufficiency are major barriers to exclusive breastfeeding in rural Zimbabwe. J Nutr 2014;144:1113-9.
Nor B, Ahlberg BM, Doherty T, Zembe Y, Jackson D, Ekström EC, et al.
Mother's perceptions and experiences of infant feeding within a community-based peer counselling intervention in South Africa. Matern Child Nutr 2012;8:448-58.
Agunbiade OM, Ogunleye OV. Constraints to exclusive breastfeeding practice among breastfeeding mothers in Southwest Nigeria: Implications for scaling up. Int Breastfeed J 2012;7:5.
Webb-Girard A, Cherobon A, Mbugua S, Kamau-Mbuthia E, Amin A, Sellen DW, et al.
Food insecurity is associated with attitudes towards exclusive breastfeeding among women in urban Kenya. Matern Child Nutr 2012;8:199-214.
Saied H, Mohamed A, Suliman A, Al Anazi W. Breastfeeding knowledge, attitude and barriers among Saudi women in Riyadh. J Nat Sci Res 2013;12:6-13.
El-Gilany AH, Sarraf B, Al-Wehady A. Factors associated with timely initiation of breastfeeding in Al-Hassa Province, Saudi Arabia. East Mediterr Health J 2012;18:250-4.
Amin T, Hablas H, Al Qader AA. Determinants of initiation and exclusivity of breastfeeding in Al Hassa, Saudi Arabia. Breastfeed Med 2011;6:59-68.
Maheswari E, Vishnu B, Mohamed A. Knowledge, attitude and practice of breastfeeding among postnatal mothers. Curr Pediatr Res 2010;14:119-24.
Khassawneh M, Khader Y, Amarin Z, Alkafajei A. Knowledge, attitude and practice of breastfeeding in the North of Jordan: A cross-sectional study. Int Breastfeed J 2006;1:17.
Stuebe AM, Bonuck K. What predicts intent to breastfeed exclusively? Breastfeeding knowledge, attitudes, and beliefs in a diverse urban population. Breastfeed Med 2011;6:413-20.
Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al.
Why invest, and what it will take to improve breastfeeding practices? Lancet 2016;387:491-504.
Kavanagh KF, Lou Z, Nicklas JC, Habibi MF, Murphy LT. Breastfeeding knowledge, attitudes, prior exposure, and intent among undergraduate students. J Hum Lact 2012;28:556-64.
Brodribb W, Fallon A, Jackson C, Hegney D. The relationship between personal breastfeeding experience and the breastfeeding attitudes, knowledge, confidence and effectiveness of Australian GP registrars. Matern Child Nutr 2008;4:264-74.
Kishore MS, Kumar P, Aggarwal AK. Breastfeeding knowledge and practices amongst mothers in a rural population of North India: A community-based study. J Trop Pediatr 2009;55:183-8.
Eldeek BS, Tayeb SO, Habiballah SB. Knowledge, attitudes and practice of mothers toward breast feeding at well baby clinic, King Abdulaziz University Hospital. J Am Sci 2012;8:157-62.
Rosen IM, Krueger MV, Carney LM, Graham JA. Prenatal breastfeeding education and breastfeeding outcomes. MCN Am J Matern Child Nurs 2008;33:315-9.
Ebrahim B, Al-Enezi H, Al-Turki M, Al-Turki A, Al-Rabah F, Hammoud MS, et al.
Knowledge, misconceptions, and future intentions towards breastfeeding among female university students in Kuwait. J Hum Lact 2011;27:358-66.
[Table 1], [Table 2], [Table 3], [Table 4]