Breastfeeding Trends and Determinants Implications and recommendations for Gulf Cooperation Council countries *

Optimal breastfeeding practices entail the early initiation of breastfeeding soon after delivery of the baby, exclusive breastfeeding for the first six months of life and the continuation of breastfeeding complemented by solid food up until two years of age. Breastfeeding has wide-ranging health benefits for both the mother and her child; however, many factors contribute to low rates of exclusive breastfeeding. This article highlights the benefits of optimal breastfeeding as well as trends and determinants associated with breastfeeding both worldwide and in Gulf Cooperation Council (GCC) countries. Strategies to optimise breastfeeding and overcome breastfeeding barriers in the GCC region are recommended, including community health and education programmes and ‘baby-friendly’ hospital initiatives. Advocates of breastfeeding are needed at the national, community and family levels. In addition, more systematic research should be conducted to examine breastfeeding practices and the best strategies to promote breastfeeding in this region.


B
reast milk is a natural, renewable and complete source of food during the first six months of life, fulfilling all of an infant's nutritional requirements. 1The United Nations International Children's Emergency Fund (UNICEF) defines optimal breastfeeding as the practice of exclusively breastfeeding during the first six months, followed by breastfeeding with the appropriate addition of complementary food thereafter up until two years of age. 2 The early initiation of breastfeeding-defined as breastfeeding within an hour of delivery-is considered an indicator of best practice. 3The beneficial effects of breastfeeding on maternal and child health are well recognised.Due to its excellent immunological and anti-inflammatory properties, breast milk can protect both mothers and children against various illnesses and diseases. 4In addition, breastfeeding also improves bonding between a mother and her newborn as well as avoiding the cost of purchasing infant formula. 5,68][9] According to UNICEF, improving breastfeeding practices worldwide could save the lives of an estimated 1.5 million children annually. 2Furthermore, the risk of mortality before the age of five years is expected to decrease from 13% to 11.6% if optimal breastfeeding practices are followed. 10While both the WHO and UNICEF have made tremendous efforts to encourage universal exclusive breastfeeding, this goal has been achieved only at a suboptimal level, with some children not breastfed at all. 2,7156 | SQU Medical Journal, May 2017, Volume 17, Issue 2 A recent report indicated that the rate of exclusive breastfeeding among infants of 4-6 months of age increased from 32% in 1995 to 40% in 2013. 11However, as per rates reported by UNICEF for the Middle East in 2016, exclusive breastfeeding rates for infants at 6 months of age in this region have declined. 12This article aimed to highlight the benefits of exclusive breastfeeding, analyse existing breastfeeding trends and determinants and identify strategies and recommendations to improve breastfeeding rates in Gulf Cooperation Council (GCC) countries.

Benefits of Optimal Breastfeeding
Breast milk is the ideal source of nutrition for infants, as it contains the appropriate proportion and quantity of vitamins, protein and fat. 1 A recent meta-analysis indicated that breastfeeding protects infants against diarrhoea, otitis media and respiratory infections, thus reducing related hospital admissions. 9Moreover, intelligence quotient (IQ) has been found to correlate positively with breastfeeding practices for both mother and child. 9A 30-year prospective birth cohort study conducted in Brazil also showed a positive correlation between mean breastfeeding duration and IQ and educational attainment; in addition, breastfeeding was to found to improve an infant's immune system as well as have a significant positive influence on long-term economic and social outcomes. 13 the GCC region, a case-control study conducted in 2012 reported that autism spectrum disorder (ASD) was significantly correlated with suboptimal breastfeeding practices in Oman. 14The risk of ASD was related to the late initiation of breastfeeding and insufficient intake of colostrum, whereas longer periods of continued breastfeeding lowered the risk of ASD.Moreover, the risk of ASD was linked with premature delivery; this may be because premature babies are often separated from their mothers and may therefore not receive sufficient quantities of breast milk. 14or breastfeeding mothers, both exclusive and continued breastfeeding practices are strongly linked with maternal amenorrhoea, which is considered a natural birth spacing method. 9In addition, mothers who do not breastfeed have an increased risk of premenopausal breast cancer, ovarian cancer, retained gestational weight gain, type 2 diabetes, myocardial infarctions and metabolic syndrome. 15Figure 1 shows the extent to which breastfeeding can reduce the risk of various maternal and child health problems. 9

Breastfeeding Trends in Gulf Cooperation Council Countries
In the Middle East, universal breastfeeding rates are low and do not achieve the target set by the WHO, with breastfeeding rates decreasing from 30% in 1990 to 26% in 2006. 10,14In Saudi Arabia, a study reported that exclusive breastfeeding practices were suboptimal in Abha city, despite most participants demonstrating either good (55.3%) or excellent (30.7%) levels of knowledge regarding breastfeeding practices and 62.2% reporting positive attitudes towards breastfeeding; in contrast, unsatisfactory levels of knowledge were found in only 14% of mothers overall. 16In Bahrain, exclusive and continued breastfeeding rates in 2010 among children <6 and 20-23 months old were 34% and 41%, respectively. 17Moreover, two-thirds of Bahraini mothers supplemented breastfeeding with other forms of nutrition before their babies were six months old. 17 Oman, breastfeeding rates are reportedly still suboptimal despite implementation of a 'baby-friendly' hospital initiative (BFHI) in 1990 to promote exclusive breastfeeding for the first six months of a baby's life. 18he rate of exclusive breastfeeding at birth was 97.5% in 2005 but decreased to 94.9% in 2012; in addition, only 31.3% of children were exclusively breastfed at six months in 2005, with this rate decreasing to 9.1% in 2012.Overall, the majority of Omani children received infant formula at six months of age in both 2005 and 2012 (60.7% and 90.1%, respectively). 18In Kuwait, exclusive breastfeeding rates at birth and six months of age in 2011 were 81.8% and 15.2%, respectively. 19Overall, 45.3% of women reported food supplementation at six months, although the rate of continued breastfeeding at 12-15 months was not reported.The average duration of breastfeeding was 2.7 months. 19In the United Arab Emirates (UAE), mixed feeding and complementary food and fluid addition to breastfeeding is a common practice reported to start as early as one month after birth. 20In Qatar, a cross-sectional study conducted among 770 mothers with children under 24 months old indicated that breastfeeding practices did not align with the recommendations of the WHO and UNICEF. 21While 49.9% of infants were reportedly breastfed for up to one year after birth, the percentage of those breastfed up until two years dropped to 45.4%. 21Figure 2 shows recent breastfeeding trends in GCC countries based on data reported by the UNICEF. 12

Global Determinants of Breastfeeding Practices
The WHO has identified several factors which contribute to a low rate of universal exclusive breastfeeding, including sociocultural, health systemrelated, marketing, environmental and knowledgerelated factors. 5Common inaccurate societal beliefs cast doubt on the nutritional sufficiency of breast milk and falsely indicate the need for additional supplementation of liquids and solids while a baby is being breastfed.Moreover, existing policies at hospitals and birth centres may be inadequate and perceived as neither supportive nor encouraging of breastfeeding. 5 There is also a shortage of adequately trained health professionals to aid and advocate for breastfeeding.
Increased marketing and promotion of high-quality breast milk substitutes and non-supportive work environments and employment conditions have also been observed to negatively impact breastfeeding rates. 5,22milarly, rates of early and continued breastfeeding are significantly affected by individual attributes of the mother and infant and the mother-infant relationship in general. 22Method of delivery, parity, alcohol consumption, breast-related problems (i.e.breast engorgement or nipple soreness), occupation and education level are considered influential maternal factors affecting successful breastfeeding. 23verall, members of the global community at all levels-including individuals, families, healthcare professionals and policy-makers-lack appropriate knowledge of the risks and negative outcomes of suboptimal breastfeeding practices. 22

Determinants of Breastfeeding Practices in Gulf Cooperation Council Countries
In Saudi Arabia, an analysis of 70 studies revealed that increased maternal age, low levels of education, rural residency, low income, increased parity and nonadherence to contraceptive use were contributing factors to a higher rate and longer duration of breastfeeding, whereas insufficient breast milk production, breastfeeding problems, sickness and getting pregnant again were identified as common barriers to breastfeeding. 24Another study among Saudi Arabian employed mothers who had undergone Caesarean deliveries and did not receive breastfeeding education noted that the main factors which doubled the risk of failing to breastfeed were work-related problems, insufficient breast milk and maternal and neonatal health problems. 16 Oman, suboptimal breastfeeding practices have reportedly been linked to a lack of continuity of support, inadequate healthcare staff training/education and increased marketing of infant formula. 18,25Fortunately, in order to revitalise the BFHI campaign, Oman has recently adopted the WHO international guidelines for the marketing of breast milk substitutes. 18,26In the UAE, maternal age, education level and parity, the practice of 'rooming-in' (i.e.placing the infant with the mother immediately after delivery), nipple problems and the use of contraceptives were significantly related to breastfeeding practices. 20Furthermore, getting pregnant again, insufficient breast milk and selfweaning on the part of the infant were reported as the main reasons for breastfeeding cessation. 20The UAE Ministry of Health (MOH) recommends six months of exclusive breastfeeding; however, to achieve this target, breastfeeding promotion strategies and programmes need to be implemented and supported. 20n Kuwait, identified determinants of suboptimal breastfeeding rates include a lack of/inadequate antenatal breastfeeding education and support polices, with only three out of 11 non-governmental hospitals expressing an interest in BFHI practices and none as yet implementing any BFHI activities or procedures. 19Women have also reported a lack of postnatal breastfeeding support at the community level; this finding is not surprising as there are only 35 certified lactation specialists currently available in Kuwait. 19Decreased rates of breastfeeding in both Kuwait and Bahrain have also been associated with the early addition of complementary food. 17,19In addition, a short maternity leave period of 45 days was reported by Bahraini mothers to be the main factor inhibiting breastfeeding intentions after giving birth. 179][20][21]24,25

Global Strategies and Recommendations to Promote Breastfeeding
In 2014, the WHO published recommendations to promote breastfeeding with the aim of achieving a target universal exclusive breastfeeding rate of 50% by 2025. 7All hospitals and birth centres are encouraged to provide the maximum level of breastfeeding support possible, for example by implementing optimal BFHI breastfeeding policies, hiring specialised healthcare professionals and, at the institutional level, maintaining breastfeeding certifications and birth records. 7These recommendations are important to ensure continuity of support for breastfeeding mothers during the postnatal period.Another recommendation is the implementation of community projects and special strategies under the supervision of community leaders to support breastfeeding mothers at home once they have been discharged after delivery. 7As such, effective channels of communication and the media should be utilised to increase community knowledge and awareness of breastfeeding.Individualised and group counselling by a trained health professional would also be helpful in improving rates of exclusive breastfeeding. 7The WHO also recommends strict adherence to marketing legislation for breast milk substitutes, with any violations to be observed and controlled by legal regulations. 7,26Governmentimplemented improvements in working conditions are highly recommended to encourage breastfeeding; for example, by ensuring a mandatory six-month paid maternity leave period for all new mothers. 7Finally, the WHO recommends additional training for healthcare professionals focusing on problem-solving abilities and efficient counselling of breastfeeding mothers so as to promote optimal breastfeeding practices. 7cording to joint WHO and UNICEF guidelines, all hospitals and birthing facilities should have a written breastfeeding policy which should be regularly distributed to all healthcare staff. 27In addition, special training sessions for healthcare personnel should be routinely implemented to enhance the skills necessary to implement the policy. 27Pregnant women should be informed of the benefits of breastfeeding and new mothers encouraged to initiate early breastfeeding, for example by allowing 'rooming-in' practices. 22,27In addition, practical education regarding breastfeeding should also be provided, instructing mothers on how to continue breastfeeding in a variety of scenarios (e.g. after discharge, on demand or if they have been separated from their infant) and reminding them not to give their infants pacifiers or supplement breast milk with any other kind of food or drink unless medically advised to do so. 27The recommendations also stress the need to maintain hospital links with breastfeeding support groups to which new mothers can be referred after discharge. 27

Strategies to Promote Breastfeeding in Gulf Cooperation Council Countries
According to the available literature, breastfeeding rates in GCC countries are suboptimal and achievement

Table 1: Breastfeeding determinants in Gulf Cooperation
Breastfeeding practices in GCC countries can be improved by adopting universal breastfeeding recommendations and integrating and implementing them using breastfeeding interventions and programmes with the support of policy-makers and community stakeholders.In order to achieve an increase in exclusive breastfeeding rates, it is essential that GCC countries look to one another's experiences with breastfeeding promotion strategies.28 This regional collaboration should then be maintained while planning and implementing country-specific breastfeeding community programmes and initiatives.
In Saudi Arabia, the World Breastfeeding Trends Initiative has recommended government-led organisation of breastfeeding awareness campaigns targeting different populations in the community as well as the integration of breastfeeding education in the curricula of secondary schools and universities. 29reastfeeding counselling was also advised, as well as the creation of breastfeeding-conducive spaces in public and at work to increase social acceptance of breastfeeding, perhaps through the establishment of 'breastfeeding rooms' .Moreover, Saudi Arabian policymakers were encouraged to increase the number of days of paid maternity leave for new mothers and to introduce legislative controls over the marketing of formula/breast milk substitutes. 30Additionally, community awareness should be raised on the benefits of breast milk as compared to breast milk substitutes.
In Oman, the MOH has set an exclusive breastfeeding target rate of >90% to be achieved by 2025. 18In pursuit of this goal, it has been recommended that cultural and social barriers to breastfeeding specific to Oman should be taken into consideration during development and implementation of community breastfeeding programmes. 28For such programmes to be successful, researchers have stressed the importance of promoting awareness and knowledge of breastfeeding policies among Omani healthcare providers. 28In addition, the Omani MOH aims to introduce marketing regulations for formula and breast milk substitutes during the planning of a future exclusive breastfeeding initiative. 18n 2006, the Bahraini Breastfeeding Committee reported that the national decree implemented in 1995 regarding the marketing of breast milk substitutes had been violated. 17,26The Bahraini MOH subsequently took necessary action by ensuring all health centres were committed to the decree and increasing awareness of the importance of breastfeeding among healthcare practitioners by conducting lectures and regular meetings. 17This approach can be adopted by other GCC countries to control adherence to the WHO international guidelines for the marketing of breast milk substitutes. 26In the UAE, a community intervention plan has been identified as essential to promote breastfeeding in the country. 20Similarly, a health policy revision has been recommended in Kuwait to enable adequate breastfeeding training for healthcare providers, as well as to discourage use of formula feeding at hospitals. 30In addition, the quality of postnatal education should be improved, with breastfeeding support maintained after delivery and the current maternity leave period of 18 weeks extended so as to facilitate maternal commitment to continued breastfeeding practices. 19nother recommendation for improving exclusive breastfeeding rates in the GCC region is the promotion of BFHI-certified hospitals.In 2002, only six of 28 hospitals and birth institutions in Bahrain were certified as 'baby-friendly'; recommendations were subsequently made to increase the number of BFHI hospitals in the ountry. 17Similarly, only six hospitals in the UAE have embraced BFHI policies. 31As in Bahrain, Emirati policy-makers have been encouraged to commit to universal breastfeeding recommendations by setting up a comprehensive national breastfeeding promotion plan. 20Implementation of BFHI policies needs to be encouraged throughout the GCC region.

Recommendations for Future Research in Gulf Cooperation Council Countries
There are several areas of potential research which should be conducted in the GCC region, such as the actual economic cost of suboptimal breastfeeding practices at the individual and national levels.In addition, there is currently a lack of comprehensive information regarding the determinants and indicators of breastfeeding practices in GCC countries.The majority of the current data describing breastfeeding practices and its determinants have not recently been updated and originate from individualised countryspecific studies with a wide variety of methodologies.In addition, there is a lack of knowledge regarding detailed applications of recommendations to improve breastfeeding practices in GCC countries.Further in-depth cohort-driven research is needed to explore breastfeeding practices in this region. 24Future research should aim to identify variables associated with exclusive breastfeeding and assess knowledge among members of the public and health professionals regarding the benefits of breastfeeding and the risks associated with breast milk substitutes.
Moreover, more studies are necessary to describe actual breastfeeding practices in GCC countries in relation to international recommendations.In this regard, an assessment of common contributing barriers and facilitators of exclusive breastfeeding practices would be of great benefit.In addition, special attention should be given to correlations between infant morbidity and mortality rates and breastfeeding practices.National surveys should be carried out on a regular basis to provide current updates of indicators of breastfeeding and infant feeding statuses in each GCC country.

Conclusion
Exclusive breastfeeding for the first six months of life has wide-ranging health benefits for both the infant and mother.However, universal breastfeeding rates are suboptimal in GCC countries and many barriers to breastfeeding exist, including individual factors (e.g.maternal age, education level and getting pregnant again), sociocultural factors (e.g.negative perceptions of insufficient breast milk or breastfeeding in public), healthcare-related factors (e.g. a lack of well-trained specialists to provide breastfeeding support to new mothers) and workplace-related factors (e.g.short maternity leave allowances).As such, breastfeeding practices in this region can be enhanced by implementing policies that are supportive of optimal breastfeeding practices at the individual, family, community and governmental levels, as per the WHO and UNICEF recommendations.

Figure 1 :
Figure 1: Chart showing percentage reductions attributable to breastfeeding of various maternal and child health problems. 9

Figure 2 :
Figure 2: Chart showing breastfeeding trends in Gulf Cooperation Council countries according to recent data* reported by the United International Children's Emergency Fund. 12 UAE = United Arab Emirates.*Data sourced from the following years: 2014 (Oman), 2012 (Qatar), 1996 (Saudi Arabia and Kuwait; national surveys) and 1995 (UAE and Bahrain; national surveys).