Maternal Factors In luencing Exclusive Breastfeeding Practices in the First Six Months of Infant Life in the Sudair and Al Zul i Areas of Saudi Arabia

This study aims to determine the prevalence of and maternal factors that are associated with exclusive breastfeeding (EBF) in Sudair and Al Zul i, Riyadh, Saudi Arabia. A cross-sectional study was undertaken by means of recruiting 522, mother-infant pairs with infants aged six months. These participants were attending the Well-Baby Clinics in Sudair and Al Zul i from January 1 to April 30, 2016, using a pilot-tested Arabic questionnaire. The EBF prevalence was determined via the “recall since birth” technique and regression analysis. EBF prevalence among mothers of infants (6 months) was 17.1%. Mothers’ insights of insuf icient milk were the most recurrently reported reason (42.5%) for not practising exclusive breastfeeding. Saudi mothers (adjusted odds ratio: 10.06; 95% con idence interval: 8.46, 12.53), mothers aged 28–38 years (36.03; 1.96, 62.21), motherswho attended breastfeeding health education (90.52; 5.49, 134.8), multiparous mothers (67.25; 5.83, 122.8), andmotherswithhousekeeping availability (19.59; 1.36, 281.47) were more likely to practice exclusive breastfeeding in comparison to their counterparts. EBF rates in both areas are far below the WHO recommended level. The mother’s nationality, age, parity, breastfeeding health education, and housekeeping availability were essential determinants to the practice EBF. Thus, aggressive multisectoral governmental interventions should be made to promote as well as support breastfeeding.


INTRODUCTION
Human milk is considered to be the healthiest nutrition for infants during their initial six months of life. Breastfeeding is demonstrated to have bene its as it reduces the risk of many chronic diseases or illnesses (WHO, 2008). In addition to the seamless blend of fats, proteins, luids, and carbohydrates, human milk comprises of antibodies that support the infant against many childhood diseases such as "otitis media, respiratory tract infections, atopic dermatitis, asthma, diabetes mellitus (DM), and leukaemia" (UNCF, 2009). Infants and mothers may lose the psychological, immunological and physiological bene its if they fail to breastfeed. This may confer to an increase in the risk for much different chronic and acute diseases (Tewabe et al., 2016). If a mother does not breastfeed, they may experience an increased risk of ovarian or breast cancer, postpartum bleeding, and increased risk for rheumatoid arthritis, Diabetes mellitus and osteoporosis. It may further take a long time to return to the pre-pregnancy weight compared to mothers who breastfeed and a short interval between births (Tewabe et al., 2016;Al-Hreashy et al., 2008). Moreover, it reduces both infant morbidities and mortalities (UNCF, 2009).
Hence, WHO and UNICEF recommend initiating breastfeeding in the irst hour of an infant's life and exclusive breastfeeding (EBF) for six months, with the introduction of complementary foods, and continued breastfeeding after that (WHO, 2008;UNCF, 2009). Despite its demonstrated advantage, the EBF practice is suboptimal in many developing states such as Saudi Arabia. In 2017, a recent Saudi study conducted in Riyadh found that only 13.7% of all infants were breastfed exclusively at six months of age (Alyouse i et al., 2017). Additionally, low rates were observed in the United Arab Emirates (25%) (Radwan, 2013). The low prevalence of EBF is a global issue; a prevalence of 43.1% has been reported in Malaysia (Tan, 2011) and 7.9% in the United States of America (USA) (Li et al., 2003).
Several reports have found that there are multiple factors associated with breastfeeding practices and EBF. These factors include mother's age, income, education level, parity, marital status, and delivery mode as well as breastfeeding counselling and psychosocial support received by the mother (Mekonen et al., 2013). Moreover, the effects of social modernization, as well as persuasive advertisements for infant formula and other infant foods, have in luenced breastfeeding traditions. Thus, the practice of EBF is relatively low and represents a challenging issue among mothers worldwide. However, there are no data about breastfeeding practices in our study area. This study aimed to evaluate the prevalence of EBF, and the in luencing factors associated with breastfeeding practices during the irst six months of an infant's life in the Sudair and Al Zul i areas in Riyadh, Saudi Arabia.

Design
We conducted a cross-sectional which is based on a pilot-tested Arabic questionnaire. The respondents from Sudair and Al Zul i Areas of Riyadh, Saudi Arabia agreed to take part in the study. All infants who were six months and brought by their mothers to the Well-Baby Clinics were included in the survey. The study was conducted at the Well-Baby Clinics at primary healthcare (PHC) centres within the Sudair and Al Zul i areas between January 1 st and April 30 th , 2016.

Sample/Participants
Inclusion criteria included all infants who were six months and brought by their mothers to the Well-Baby Clinics at PHCs during the study period were considered. Mothers of all eligible infants agreed to participate. Exclusion criteria included infants older than six months, infants with congenital anomalies that interfere with feeding, and mothers who could not speak Arabic. The ive PHCs from each area (Sudair and Al Zul i) were selected randomly using an updated PHC list. Data were collected through a complete enumeration sampling method. The study included all eligible "mother-infant pairs attending the clinics" during the conduction of this study.

Data collection
After acquiring verbal informed consent from the eligible mothers, data were gathered through a face-to-face interview utilizing a pilot-tested Arabic questionnaire previously utilized in a similarly designed study (Al-Hreashy et al., 2008). The interviews were conducted by trained female Arabicspeaking nurses recruited at each PHC. The principal investigator visited the PHCs on ixed days to supervise data collection. The questionnaire was utilized to obtain sociodemographic characteristics such as mother's area, age, educational level, marital status, employment, parity, and delivery mode and information related to the infant's gestational age as well as gender. The survey also collected information concerning the diverse feeding practices, for example, EBF, mixed and exclusive bottle feeding as well as the nature and timing of introducing complementary solids and non-milk liquids to infants. Additionally, mothers were inquired for how long they breastfed their infants and what were the causes of discontinuation.

De initions
In this study, the de inition by Clark et al. and WHO were used for the following infant feeding patterns (Clark et al., 2017;WHO, 2008).
EBF: an infant who received only human milk; no other solids or liquids are given, except for vitamins or oral medicines" (Clark et al., 2017).

Mixed feeding: An infant who was fed with both human milk and infant formula.
Exclusive bottle feeding: An infant who was fed with formula milk since birth and not human milk.
Complementary feeding: An infant who was chie ly breastfed, however, infant formula and some other liquid, solid, or semi-solid foods were contained within their diet." (WHO, 2008)

Ethical consideration
Ethical approval was attained from the Deanship of Scienti ic Research at Majmaah University. Participant's consent was obtained before administering the questionnaire. The infants' mothers were reassured that information given will be kept con idential and only utilized for research.

Data analysis
IBM SPSS software (IBM Corp., version 25; Armonk, NY, USA) was utilized to evaluate the data. Descriptive statistics were computed to determine the prevalence of EBF. To identify factors that might have effects on EBF, binary logistic regression analysis was performed. All analyses were conducted at an alpha level of 0.05.

RESULTS
In this study, 522 infants, 55.2% female and 44.8% male, were enlisted. A majority were infants born at term (96.6%) by normal vaginal delivery (64.4%). Approximately 63% of participating mothers were in age groups (26-30 years). Most mothers were Saudi (87%), with 42.2% coming from the Al Zul i area. More than half of them (57.5 %) graduated from university, and 51.7% were employed. Although most of them had regular follow-up during pregnancy (86.2%), only 28% attended breastfeeding health education. More than two-thirds were multiparous (69%), and 40% did not use contraception (Table 1).

DISCUSSION
Although considering the evidence-based advantages of EBF for infants, mothers, or society, the EBF practice rate is not satisfactory worldwide (WHO, 2017). In our study, the overall prevalence of EBF practice was 17.1%. Perception of mothers' regarding the insuf icient milk was the most frequently informed reason for not practising EBF. In binary logistic regression investigation, the mother's nationality, age, health education on breastfeeding, delivery mode, housekeeping availability, parity, marital status, and contraception use were signi icant factors associated with EBP.
Our results show 17.1% prevalence of EBF in the initial six months of an infant's life that was found to be higher than that reported recently by Alyouse i et al. (13.7%) (Alyouse i et al., 2017). However, other local report found a higher EBF practice rate in Taif (19%) and Jazan (26.9%) (Dorgham et al., 2014). Moreover, this local prevalence was far lower than those in several recent international studies in Sri Lanka (71.3%), and Malaysia (49.5%), (Perera et al., 2012;Hamid et al., 2017). The health risks for child associated with not receiving the human milk or not breastfeeding include but is not limited to increase in morbidity from respiratory, gastrointestinal, allergic disease, atopic illness and increased childhood obesity risk together with type 2 and type 1 diabetes (Tewabe et al., 2016).
The frequency of ever having breastfed was high (95.4%), which indicates high rates of breastfeeding initiation. This inding agrees with those in multiple local and international studies (Alyouse i et al., 2017;Hamid et al., 2017). Regarding breastfeeding patterns, more than half of the infants had received mixed breastfeeding since birth, i.e., human milk and formula, with a rate of 54%. This parallels the inding by Al-Hreashy et al., who found that mixed breastfeeding was the most frequent practice (78.8%) (Al-Hreashy et al., 2008).
Unfortunately, in this analysis, 28.9% of infants were deprived of the well-con irmed protective effects of maternal colostrum and mature human milk as they had received exclusive formula feeding (Debes et al., 2013). This percentage is higher than those reported by Alyouse i et al. (18.3%) and Malaysian (9%) studies (Alyouse i et al., 2017;Hamid et al., 2017). Moreover, almost one-quarter of the infants studied (25.8%) were supplemented by non-milk liquids within the irst six months of life. For example, water was provided for the irst few weeks of age to prevent dehydration. Moreover, as a traditional practice, mothers used to give chamomile tea and herbals like cumin drink to relieve infantile colic. Similarly, the Emirati study showed that 30% of the infants were given traditional drinks while breastfeeding such as gripe water, anise seed drink, and tea before three months of age (Radwan, 2013).
The mothers' perception of insuf icient milk was the most frequently reported reason (42.5%) for not practising EBF in this study. This reason was also recorded in a study of Pakistan (Yaqub and Gul, 2013). In contrast to this widespread perception, most mothers produce enough milk to meet the needs of their infant's growth. Therefore, practising EBF on demand is critical for optimal human milk production (Hoi and McKerracher, 2015). Other mothers, in the current study, stopped EBF because of their work (32.2%). Maternal work is a wellknown barrier to breastfeeding. A study from Ghana investigated the effect of maternal work on EBF and found that a majority of mothers working in the formal sector (84%) were unable to exclusively breastfeed after their maternity leave (Nkrumah, 2016). This is possibly due to a lack of facilities at workplaces to support breastfeeding. Another reported obstacle to EBF, in this study, was using contraception. However, a 2010 systematic review found limited evidence on the effect of combined oral contraception on breastfeeding success as well as dura-tion (Kapp and Curtis, 2010).
This study identi ied several factors that interplay with EBF practice. Saudi females were more likely to exclusively breastfeed compared to non-Saudi mothers who were mostly working mothers and had less opportunity to stay at home to practice EBF. Additionally, mothers who had a cesarean delivery or were divorced were unable to breastfeed exclusively. These factors were identi ied as constraints to breastfeeding in the previous report (Smart, 2013). This could be attributed to the pain after cesarean section and psychological distress associated with separation or divorce.

Figure 1: Patterns of breastfeeding in the irst six months of infant life in the Sudair and Al Zul i areas of Riyadh, Saudi Arabia (N = 522)
Moreover, mothers with higher education levels were less likely to breastfeed than those with lower educational levels. This might be explained by the fact that mothers with higher educational levels tended to have better opportunities for employment and were less likely to stay at home, compromising EBF. However, in a study conducted in Malaysia, a higher educational level is associated with a longer breastfeeding duration (Hamid et al., 2017). The present study showed that maternal age might in luence EBF practice, and mothers aged 28-38 years were more likely to intend to breastfeed exclusively. This is supported by the study by Hamid et al., where Malaysian women aged less than 30 were most likely to practice EBF compared to  This suggests that all maternity healthcare clinics should provide breastfeeding counselling because of its usefulness in re ining maternal knowledge and enhancing the EBF rate (Haroon et al., 2013).
Our study had several limitations. This crosssectional design conveys associations between determinant factors and EBF, rather than inferences; a prospective cohort design might be more suitable. Besides, a possibility of recall bias cannot be precluded as we sought evidence of breastfeeding from the mothers since their infants' birth. Moreover, the enrolled participants were from PHC centres only. Those who received analogous care at different health facilities may have different socioeconomic status (SES), that may infer different determinants or breastfeeding patterns.

Recommendations
Although in May 2016, the Saudi Council of Ministers called the establishment of a national association to promote breastfeeding, the practice of EBF is still suboptimal among Saudi mothers. Thus, according to the indings of this study, there are several recommendations for better infant feeding practices 1. Provide counselling and training sessions for every pregnant mother in antenatal and postnatal visits, as this would help increase the initiation rates and support the maintenance of breastfeeding.
2. Apply the ten steps of the Baby-Friendly Hospital Initiative created by the UNICEF and WHO for successful breastfeeding practices for mother-infant initiatives at all maternity hospitals.
3. Restrict the use of infant formula within maternity hospitals unless medically indicated.
4. Encourage every new mother to initiate breastfeeding after delivery as soon as possible.
5. Engage multiple governmental sectors including educational, medical, media, and religious to promote, protect, and support optimal practices for breastfeeding nationally.
6. Provide more paid days off for maternity leave.
7. Establish proper breastfeeding places at work as well as public places.

CONCLUSIONS
The study results emphasize the consistent low prevalence of EBF among Saudi women. Mother's age, nationality, delivery mode, contraception use, marital status, maternal education, parity, breastfeeding health education during antenatal care, and housekeeper availability were important determinants to EBF practice in the study area. Aggressive governmental actions should be taken to protect as well as promote breastfeeding in the Saudi community.

ACKNOWLEDGEMENT
I would like to express my sincere thanks to the mothers and PHC staff who participated in this study. Special thanks for the biostatistician Mr Waqas Sami from the Community Medicine Department at Majmaah University, who helped in the statistical analysis.