Infant
feeding in Al-Hassa, Saudi Arabia
.........................................................................................................................
Abdel-Hady
El-Gilany (MD)
Professor of Public Health, Community Medicine
Department,
College of Medicine, Mansoura University, Egypt
Correspondence
Abdel-Hady El Gilany
Professor of Public Health,
College of Medicine,
Mansoura University,
Mansoura 35516
Egypt
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ABSTRACT
Background: Recently there has
been an increasing concern about the decline
in breastfeeding in Saudi Arabia. The
objective of this paper is to describe
the pattern and predictors of infant feeding
in Al-Hassa, Saudi Arabia.
Methods: This is a prospective
study involving 2000 infants. Data was
collected from mothers at 2, 4, 6, and
12 months of infant's age during the vaccination
sessions. All infants attending for vaccination
at primary health care centers during
a two months period were included. Pattern
of feeding was expressed as either breast,
bottle, or mixed (both) feeding.
Results: There is a significant
downward trend in breastfeeding and upward
trends in both bottle and mixed feeding
rates with increasing infant's age. At
age of two months, gestational age, birth
weight and mode of delivery all have a
significant effect on feeding pattern.
Breastfeeding is significantly higher
among full term infants, normal weight
infants and infants of spontaneous vaginal
delivery.
At four, six and twelve months of age,
breast feeding was significantly higher
among mothers' of rural residence, housewives
and those of low educational levels. Also
full term infants, average weight infants
and those of spontaneous vaginal delivery
are more likely to be breastfed.
About 14% of infants are still exclusively
breastfed without supplementation at the
age of 12 months.
Conclusion: Breastfeeding, whether
alone or mixed with bottle feeding, dropped
significantly at the age of 6 months with
further decrease at 12 months of infant's
age. Mother's residence, education and
work status had significant effects on
feeding patterns at 4, 6, and 12 months
of age. On the other hand gestational
birth weight and mode of delivery are
significant predictors of feeding pattern
throughout infancy. These predictors can
be used to detect mothers who are more
likely to stop breastfeeding early, to
be targeted in breastfeeding promotion
and support.
Key
words: Infant feeding, Breastfeeding,
Bottle feeding, Mixed feeding
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Breastfeeding is the ideal
and most natural way of nurturing infants. The
importance of breastfeeding has been proved
unequivocally(1). The practice of breastfeeding
has declined considerably over the past decades
and early introduction of bottle milk and solid
food has increased in many parts of the world(2-7).
Saudi Arabia is a country where the legislation
is derived from Quran and Hadiths. Breastfeeding
is considered to be the ideal and the most natural
way of nursing infants due to religious and
cultural beliefs. However, recently major developments
have taken place in Saudi Arabia. This development
has had different influences on lifestyles of
Saudi families. More mothers leave their homes
either to achieve high education or for work.
The majority of mothers start breastfeeding
their infants but soon introduce a bottle(1).
Recent studies showed a decline in breastfeeding
between the ages of 6 and 12 months and the
introduction of bottle formula has been become
more frequent at earlier infant ages(8-13).
The objective of this study is to describe the
pattern and the influencing factors of infant
feeding practices of mothers in Al-Hassa, Saudi
Arabia.
This prospective study was carried out in Al-Hassa,
Saudi Arabia. The target population was all
infants attending for first vaccination session
during a two months period, in June and July
of 2008 AD. These infants were followed-up to
the end of their first year of life.
Al-Hassa is the largest province in Saudi Arabia's
Eastern region (population of 908,366) covering
an area of 534,000 km(²). Maternity care
in Al-Hassa is provided through a network of
47 primary health care centers (PHCCs) covering
urban, rural and Hegar (Bedouin desert collection)
areas. Eligible candidates were all infants
attending for vaccination in primary health
care centers (PHCCs) at the age of two months
and their mothers are willing to keep a vaccination
schedule throughout infancy at the same PHCC.
Mothers were counseled and assured that data
collected would be dealt with confidentially.
They were requested to give verbal informed
consent before interview. The study was approved
by Al-Hassa Directorate of Health.
Sample size was calculated using EPI Info statistical
program. During 2007 a total of 15,032 live
births were registered in Al-Hassa. A pilot
study on 100 infants not included in the study
revealed that about 14% of infants are still
breastfed without any supplementations at the
age of 12 months. The sample size was calculated
to be about 1808 infants with worst acceptable
level of 12.5% and 95% confidence level. The
target was increased to 2000 infants at the
age of 2 months to compensate for loss during
follow-up. The actual number of infants participated
in the study was 2000 at the age of two months.
This number dropped to 1947, 1904 and 1863 at
the ages of 4, 6 and 12 months, respectively.
The infant-mother dyads were followed up during
the routine vaccination sessions. Mothers were
interviewed at the PHCCs by Arabic speaking
female nurse interviewers who were oriented
about the study and trained in data collection.
Data were completed from the family file, and
maternity cards kept at PHCCs and also from
the hospital discharge form.
At the first vaccination session the following
data were collected; family residence and income,
mother's education and work, parity, infant
sex, gestational age, birth weight, and mode
of delivery. Gestational age at birth was defined
as the number of completed weeks of gestation
based on the estimated delivery date in the
clinical record. Pre-term delivery was defined
as live infant delivered at <37 weeks' gestation,
and low birth weight was defined as live infant
weighing <2500 g at birth(14,15).
The outcome variable (pattern of feeding) is
expressed as either breast only, bottle only
or mixed (both breast and bottle). Mothers were
asked about infant feeding patterns at subsequent
vaccination sessions.
The Chi-squared (2) was used as a test of significance
for comparison of categorical variables. P <0.05
was chosen as the level of statistical significance
using the SPSS (Statistical Package for Social
Sciences) version 17 (Chicago, USA).
Out of 2000 infants studied, only 5.2% were
never breastfed. Table 1 reveals that there
is a significant downward trend in breastfeeding
and an upward trend in both bottle and mixed
feeding rates with increasing infant age. Breastfeeding
decreased with increasing age from 64.0% at
two months down to 44.4%, 24.4% and 14.1% at
the ages of 4, 6 and 12 months, respectively.
All studied maternal characteristics as well
as infant sex have no effect on the pattern
of infant feeding at the age of two months.
On the contrary, gestational age, birth weight
and mode of delivery all have a significant
effect on feeding patterns. Breastfeeding is
significantly higher among full term infants,
normal weight infants and infants of spontaneous
vaginal delivery (Table 2).
| Age
(months) |
Total
N
|
Breast
N (%)
|
Bottle
N (%)
|
Mixed
N (%)
|
| 2 |
2000 |
1279(64.0)
|
108(5.4)
|
613(30.7)
|
| 4 |
1947 |
864(44.4)
|
173(8.9)
|
910(46.7)
|
| 6 |
1904 |
465(24.4)
|
336(17.6)
|
1103(57.9)
|
| 12 |
1863 |
263(14.1)
|
516(27.7)
|
1084(58.2)
|
X2=1354.9,
P<0.001
Table 1: Overall pattern of infant feeding
(Click
for Table 2)
Table 2: Factors affecting feeding patterns
at the age of two months
(Click
for Table 3)
Table 3: Factors affecting feeding patterns
at the age of four months
(Click
for Table 4)
Table 4: Factors affecting feeding patterns
at the age of six months
(Click
for Table 5)
Table 5: Factors affecting feeding patterns
at the age of twelve months
At four, six and twelve months of age breast
feeding was significantly higher among mothers
of rural residence, housewives and those of
low educational levels. Also, full term infants,
average weight infants and those of spontaneous
vaginal delivery are more likely to be breastfed
throughout the first year of life (Tables 3,
4 and 5).
The incidence and duration of breastfeeding
in Saudi Arabia has been declining in the
past decades(4). In the present study 5.2%
of mothers never breastfed. This is intermediate
to the previously reported never breastfed
rates in Saudi Arabia from both local and
national studies that ranged from 1.4% up
to 13.1%(13,16-21). This high prevalence of
breastfeeding initiation at birth indicates
the willingness of Saudi mothers to breastfeed(13).
There is a significant downward trend in breastfeeding
and upward trends in both bottle and mixed
feeding rates, with increasing infant's age.
Mixed feeding with breast and bottle appears
to be the popular method among mothers even
from an early age of two months. Breastfeeding
decreased with increasing age from 64.0% at
two months down to 44.4%, 24.4% and 14.1%
at the ages of 4, 6 and 12 months, respectively.
This result supports the decline of breastfeeding
practices by Saudi mothers reported in previous
studies. These studies reported popularity
of bottle and mixed feeding with early introduction
of solid food and weaning(4,11,12,16,17,22-25).
A recent study reported that bottle feeding
was introduced by one month of age to 51.4%
and to 90% by the age of six months. Furthermore,
80.8% of infants were introduced to solid
foods between 4 to 6 months of age and whole
milk feedings were given to 40% of children
younger than 12 months of age(13).
This study revealed that all studied maternal
characteristics as well as infant sex have
no effect on the pattern of infant feeding
at the age of two months. However at four,
six and twelve months of age breastfeeding
was significantly higher among mothers of
rural residence, housewives and those of low
educational levels.
Mothers of rural/Hegar residences are more
likely to breastfeed than those of urban residence
at the ages of four months (49.7% vs. 42.25),
six months (32.6% vs. 21.0%) and 12 months
(20.8% vs. 11.3%). Rural and Hegar areas are
more conservative and mothers are more likely
to be housewives and less educated than urban
mothers.
Working mothers are less likely to breastfeed
than housewives at the ages of four months
(17.6% vs. 47.2%), six months (5.0% vs. 26.4%)
and 12 months (1.2% vs. 15.4%). A previous
study in the same locality demonstrated that
compared to non-working mothers, working mothers
were more likely to bottle feed their infants
and start weaning early and were less likely
to continue breastfeeding for 12 months(26).
Another study reported the same finding(12),
however Madani et al, reported no significant
relationship between duration of breastfeeding
and working status(19).
The higher the maternal education, the lower
is the breastfeeding rate and the higher the
mixed feeding rate throughout the first year
of life. This is in agreement with previous
studies in Saudi Arabia that reported an inverse
association between the level of maternal
education and breastfeeding as well as its
duration(12,20,22-25). Highly educated mothers
are more likely to be employed which adversely
affects breastfeeding.
Mothers' age is not found to be associated
with infant feeding patterns. This is in agreement
with previous studies(12,19,25). However other
previous studies in Saudi Arabia reported
that younger women had a shorter duration
of breastfeeding then their older counterparts(16,22-24).
We found that gestational age and birth weight
have a significant effect on feeding pattern.
Breastfeeding is significantly higher among
full term infants and normal weight infants
throughout the first year of life. Forman
et al.,(27) reported the same finding. This
can be attributed to the high likelihood of
admission to neonatal care units with poor
suckling of the neonates. In their review
of literature, Nascimento and Issler(28) concluded
that despite being highly desirable, little
success in breastfeeding preterm infants is
generally observed, particularly in special
care neonatal units.
Breastfeeding is significantly lower among
infants delivered by caesarean section, throughout
the first year of life. The evidence available
from previous studies on the relationship
between caesarean section and breastfeeding
is inconclusive. Many studies from around
the world have suggested that caesarean delivered
women are less likely to breastfeed than those
who delivered vaginally(28-30). This appears
to be the case for women who have operations
under general anesthesia, as they feel tired,
depressed and less mobile thereby unable to
begin breastfeeding early. The difficulties
appear to persist so that even when breastfeeding
is successfully established, less caesarean
delivered women continue to breastfeed compared
to those who delivered spontaneously(31).
In contrast, an earlier study found that although
mothers giving birth by caesarean had a later
first breastfeeding than those who delivered
vaginally, there is no relation between delivery
type and duration of breastfeeding(32).
In conclusion maternal socio-demographics
are not predictors of feeding pattern at the
age of two months and their significant impact
becomes evident after that, while infant factors
and mode of delivery exerted their significant
effect on feeding patterns throughout the
whole of infancy.
Al-Jassir et al,(20) concluded that the practice
of breast feeding is increasing, but at the
same time the fraction of mothers that breastfeed
exclusively is declining. There is a need
for strengthening the breastfeeding drive,
while stressing that breast milk alone is
sufficient for the first six months of life
with appropriate supplementation after this
age. Sustaining breastfeeding once it has
been initiated and established is theoretically
considered an easy task to accomplish, especially
with the findings indicating that the most
significant factors affecting the outcome
of breast feeding are modifiable by health
education. Mothers of preterm or low birth
weight infants and those delivered by caesarian
section need information and support to make
informed decisions about their infants' feeding.
Vaccination sessions are an opportunity for
breastfeeding education with special emphasis
to mothers at risk of stopping breastfeeding.
Legislation is needed to permit working lactating
women to breastfeed their infants in the workplace,
or enjoy a longer paid maternal leave or at
least part time work.
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