Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. FACTORS ASSOCIATED WITH BREASTFEEDING IN WESTERN OF SAUDI ARABIA A thesis presented in partial fulfilment of the requirements for the degree of Master in Human Nutrition At Massey University Palmerston North, New Zealand Anwaar Shahbar 2014 I ABSTRACT Background information: The recommendation for optimal breastfeeding duration in the Kingdom of Saudi Arabia (KSA) is based firstly on the Quran and then the World Health Organisation (WHO) recommendation. The rate of initiation of breastfeeding in Saudi Arabia is over 90%, with the early introduction of infant formula. Objective: To investigate breastfeeding practices at birth and one month postpartum and its association with the BFHI status of the hospital where delivery occurred, and with women’s intentions, self-efficacy, knowledge and attitudes, previous experience, support, and discouragement for breastfeeding. Study design: Longitudinal study with data collection at baseline and follow-up at one month postpartum. Method: Women were recruited from two private hospitals in Jeddah, one of these hospitals has baby friendly hospital policies (BFHI). A semi-quantitative questionnaire was used for collecting data by face-to-face interviews with women in the hospital after giving birth and by a phone interview at one month postpartum. SPSS was used for statistical analysis. Results: One hundred and two women completed the baseline survey, and 77 women completed the study at one month (36 from the BFHI and 41 from the non-BFHI). At baseline, 77% women at the BFHI hospital had introduced breast milk as first nutritive substance, while only 7% of women in the non-BFHI II hospital did. However, at one month postpartum, mixed-feeding was the most common feeding method (58%), and there was no difference in feeding method between women in both hospitals. All Egyptian women in the sample (n= 10) were fully breastfeeding at one month, and Saudi women were more likely to use mixed-feeding. Breastfeeding attitudes, self-efficacy, and previous experience were related to breastfeeding practice at one month. Considering all variables, logistic regression found that breastfeeding self-efficacy was the only variable associated with breastfeeding practice at one month, and women with a higher score were more likely to be exclusively, fully, or predominantly breastfeeding at one month (p= 0.001). Conclusion: The BFHI was found to be effective in making breast milk the first nutritive substance infants received, and in encouraging early breastfeeding initiation. Breastfeeding self-efficacy was the strongest predictor of breastfeeding intention and practice at one month. III ACKNOWLEDGEMENTS First and the foremost I would like to thank Allah for everything he gave to me starting with having the opportunity to continue studying for my Master’s degree and being able to successfully complete my thesis. I also would like to thank my supervisor Dr Janet Weber for her support, advice, and patience with me. Thanks to my cooperative supervisor, Professor Suhad Bahijri, for helping me get the ethical approval from the Saudi Ethics Committee. Many thanks to my second cooperative supervisor, Dr Muneera Balahmar, for her assistance in getting permission from the Ministry of Health to collect data in Saudi Arabian hospitals, and for her advice and help whenever problems occured. Thanks and appreciation for Dr Modia Batterjee for her help and advice. Thanks to Professor Patrick Morel for his kindness and assistance with statistical issues, that drove me crazy. I really appreciate support from my friends Angela, Belinda, Elizabeth, Rifana, and help from my sister-in-law Huda and cousin Omnia. I would like to acknowledge King Abdullah, King of Saudi Arabia and the Saudi government for providing me with a scholarship and supporting me financially. I am so grateful to my parents, who were very supportive and always encouraging me. I love you Mom and Dad. IV Special thanks to my brother Mohammad, who made sacrifices for me and came to New Zealand with me and never left me alone. To my husband, Amjad. I am really glad to have you in my life and no words are enough to explain how much I LOVE YOU. You were very supportive, and were always there whenever I needed you to cheer me up and make me happy. My mother, father, brothers, and husband, God protect you for me and never deprive me of your presence in my life. V TABLE OF CONTENT ABSTRACT ................................................................................................................... I ACKNOWLEDGEMENTS ........................................................................................... III TABLE OF CONTENT.................................................................................................. V LIST OF TABLES ........................................................................................................ IX LIST OF FIGURES ...................................................................................................... XI LIST OF ABBREVIATIONS........................................................................................ XII CHAPTER 1 : INTRODUCTION ................................................................................... 1 1.1. Introduction ........................................................................................................ 1 1.2. Baby Friendly Hospital Initiative (BFHI) .............................................................. 4 CHAPTER 2 : REVIEW OF THE LITERATURE ........................................................... 6 2.1. Definitions of breastfeeding ................................................................................ 6 2.2. Breastfeeding patterns in Saudi Arabia .............................................................. 8 2.2.1. Initiation of breastfeeding in Saudi Arabia ................................................................. 9 2.2.2. Timing of breastfeeding initiation in Saudi Arabia ...................................................... 9 2.2.3. Exclusive breastfeeding in Saudi Arabia .................................................................... 10 2.2.4. Introduction of formula in Saudi Arabia ................................................................... 13 2.2.5. Introduction of solids in Saudi Arabia ....................................................................... 14 2.2.6. Duration of breastfeeding in Saudi Arabia ................................................................ 16 2.2.6.1. Changes in duration overtime in Saudi Arabia .................................................. 16 2.2.7. Intention of breastfeeding in Saudi Arabia ............................................................... 17 2.2.8. Summary ................................................................................................................... 18 2.3. Reasons and factors associated with discontinuing exclusive or any breastfeeding .......................................................................................................... 18 2.3.1. Lactation factors ........................................................................................................ 19 2.3.2. Psychological factors ................................................................................................. 19 2.3.3. Nutritional factors ..................................................................................................... 20 2.3.4. Medical factors .......................................................................................................... 21 2.3.5. Self-weaning factors .................................................................................................. 23 2.3.6. Life-style factors ........................................................................................................ 23 2.3.7. Social factors ............................................................................................................. 24 2.4. Factors associated with breastfeeding patterns in Saudi Arabia ....................... 25 VI 2.4.1. Age and parity ............................................................................................................ 25 2.4.2. Delivery mode and contraceptive pills ...................................................................... 26 2.4.3. Baby birth weight ....................................................................................................... 26 2.4.4. Marital status ............................................................................................................. 27 2.4.5. Mother’s occupation ................................................................................................. 27 2.4.6. Parent’s education ..................................................................................................... 28 2.5. Sources of breastfeeding information ............................................................... 28 2.6. Beliefs and attitudes about breastfeeding ......................................................... 31 2.7. Baby Friendly Hospital Initiative (BFHI) ............................................................ 34 2.8. The Theory of Planned Behaviour (TPB) .......................................................... 37 2.9. Summary .......................................................................................................... 39 CHAPTER 3 : METHODS ........................................................................................... 41 3.1. Sample selection .............................................................................................. 41 3.2. Instrument ........................................................................................................ 42 3.2.1. Attitudes scale ........................................................................................................... 44 3.2.2. Breastfeeding Self-Efficacy Scale (BSES) .................................................................... 46 3.2.2.1. Translation of BSES ............................................................................................. 47 3.2.2.2. Pretesting of BSES ............................................................................................... 48 3.2.3. Pretesting ................................................................................................................... 48 3.3. Ethical consideration ........................................................................................ 48 3.4. Data collection .................................................................................................. 49 3.5. Data management ............................................................................................ 50 3.5.1. Coding ........................................................................................................................ 50 3.6. Data analysis .................................................................................................... 53 CHAPTER 4 : RESULTS ............................................................................................ 55 4.1. Baseline sample description ............................................................................. 55 4.1.1. Infant feeding in hospital ........................................................................................... 59 4.1.1.1. First food given to infant .................................................................................... 59 4.1.1.2. Changes in feeding method while in hospital .................................................... 59 4.1.2. Problems initiating breastfeeding ............................................................................. 64 4.1.3. Support for breastfeeding while in the hospital ........................................................ 64 4.1.4. Breastfeeding practice while in hospital ................................................................... 65 4.1.5. Breastfeeding plan for the coming 12 months .......................................................... 66 VII 4.1.6. Knowledge ................................................................................................................. 70 4.1.7. Sources of breastfeeding information ...................................................................... 74 4.1.8. Attitudes .................................................................................................................... 76 4.1.9. Breastfeeding Self-Efficacy Scale (BSES) ................................................................... 78 4.1.10. Questions about previous child............................................................................... 79 4.1.10.1. Previous breastfeeding practice ...................................................................... 79 4.1.10.2. Breastfeeding problems with previous child ................................................... 80 4.1.10.3. Breastfeeding support with previous child ...................................................... 82 4.1.10.4. Reasons for stop breastfeeding or introducing formula.................................. 83 4.1.11. Comparisons between previous breastfeeding practice and new intentions ........ 85 4.2. One month postpartum questionnaire ............................................................... 85 4.2.1. Feeding method and plans at one month ................................................................. 87 4.2.1.1. Exclusive or full breastfeeding ........................................................................... 89 4.2.1.2. Predominant breastfeeding ............................................................................... 89 4.2.1.3. Mixed-feeding .................................................................................................... 90 4.2.1.4. Exclusive formula feeding .................................................................................. 93 4.2.2. Breastfeeding encouragement and discouragement at one month ......................... 94 4.2.3. Problems initiating breastfeeding and feeding method at 1 month ........................ 96 4.2.4. Association between ethnicity and feeding method at 1 month ............................. 97 4.2.5. Association between feeding methods at one month and demographic characteristics ..................................................................................................................... 97 4.2.6. BSES and attitudes and feeding method at 1 month ................................................ 98 4.2.7. Logistic regression ................................................................................................... 100 CHAPTER 5 : DISCUSSION .................................................................................... 102 5.1. Sample characteristics and relationship to breastfeeding ............................... 103 5.2. Theory of planned behaviour (TPB) ................................................................ 108 5.2.1. Breastfeeding Self-Efficacy Scale (BSES) ................................................................. 108 5.2.2. Attitudes and knowledge ........................................................................................ 110 5.2.3. Subjective norms: support and discouragement .................................................... 112 5.2.4. Intentions ................................................................................................................ 114 5.3. Baby Friendly Hospital Initiative (BFHI) .......................................................... 115 5.4. Strengths and limitations ................................................................................ 118 VIII 5.4.1. Limitations ............................................................................................................... 118 5.4.2. Strengths .................................................................................................................. 118 CHAPTER 6 : CONCLUSION ................................................................................... 119 REFERENCES ......................................................................................................... 121 APPENDICES .......................................................................................................... 130 1. Feeding pattern in Saudi Arabia .................................................................... 130 2. English version of baseline questionnaire ..................................................... 136 3. Arabic version of baseline questionnaire ...................................................... 149 4. 1 month postpartum questionnaire (English version)................................... 162 5. 1 month postpartum questionnaire (Arabic version) .................................... 167 6. Information sheet (English version) .............................................................. 172 7. Information sheet (Arabic version)................................................................ 175 8. Participants consent form (English versions) ................................................ 177 9. Participants consent form (Arabic version) ................................................... 178 10. Comparison between demographics of opted out women and followed-up women ................................................................................................................... 179 11. Type of help received while in hospital ..................................................... 180 12. Information during pregnancy ................................................................... 181 IX LIST OF TABLES Table 2.1: WHO breastfeeding definitions .................................................................................... 6 Table 2.2: The New Zealand’s Ministry of Health breastfeeding definitions................................ 7 Table 2.3: Timing of first breastfeeding ...................................................................................... 10 Table 2.4: Exclusive breastfeeding rates on different region of Saudi Arab ............................... 12 Table 2.5: Mixed-feeding rate on different region of Saudi Arabia ............................................ 15 Table 4.1: Subjects distribution in both hospitals by their nationalities .................................... 56 Table 4.2: Age of participants ..................................................................................................... 56 Table 4.3: Education level, occupation, and family income of participants ............................... 57 Table 4.4: Parity, delivery mode, baby’s gender and number of children of participants ......... 58 Table 4.5: Infant feeding in hospital ........................................................................................... 60 Table 4.6: Reasons for introducing formula while in hospital .................................................... 63 Table 4.7: Problems associated with initiating breastfeeding .................................................... 64 Table 4.8: Help received to breastfeed while in hospital ........................................................... 65 Table 4.9: Breastfeeding practice at time of first interview in hospital ..................................... 66 Table 4.10: When mothers plan to introduce solids .................................................................. 68 Table 4.11: When mothers will stop breastfeeding .................................................................... 69 Table 4.12: Reasons for intent to stop breastfeeding before 2 years ........................................ 70 Table 4.13: How women know when to breastfeed ................................................................... 70 Table 4.14: How women know that their baby is getting enough milk ...................................... 71 Table 4.15: Association between knowledge about WHO recommendation regarding complementary feeding and plans to introduce solids .............................................................. 72 Table 4.16: Important factors when making decisions about breastfeeding ............................. 74 Table 4.17: Sources of breastfeeding information during pregnancy ........................................ 75 Table 4.18: Baseline attitudes scale ............................................................................................ 76 Table 4.19: Women’s attitudes toward breastfeeding ............................................................... 77 Table 4.20: Breastfeeding self-efficacy scale results .................................................................. 79 Table 4.21: Feeding practice with previous child ....................................................................... 80 Table 4.22: Problems associated with initiating and continuing breastfeeding previous child . 81 Table 4.23: Problems initiating breastfeeding with new and previous babies ........................... 82 Table 4.24: Support received breastfeeding previous child ....................................................... 83 Table 4.25: Reasons for introducing formula or stopping breastfeeding for previous child ...... 84 Table 4.26: Age, education level, occupation, and family income of participants ..................... 86 Table 4.27: Parity, delivery mode, and number of children ....................................................... 87 Table 4.28: Breastfeeding practice at 1 month .......................................................................... 88 Table 4.29: Feeding plans up to 12 months ................................................................................ 88 Table 4.30: Exclusive or full breastfeed mothers descriptions at 1 month ................................ 89 Table 4.31: Predominant breastfeed mothers descriptions at 1 month .................................... 90 Table 4.32: Mixed-feeding descriptions at 1 month ................................................................... 92 Table 4.33: Exclusive formula feeding mothers descriptions at 1 month .................................. 93 X Table 4.34: Breastfeeding support from discharge from the hospital until 1 month postpartum ..................................................................................................................................................... 95 Table 4.35: Association between parity and having problems initiating breastfeeding ............. 96 Table 4.36: Feeding practice at 1 month in relation to ethnicity ................................................ 97 Table 4.37: Association between BSES scores and feeding method at 1 month ........................ 98 Table 4.38: Response to BSES scale items ................................................................................... 99 Table 4.39: Forward stepwise logistic regression...................................................................... 101 XI LIST OF FIGURES Figure 4.1: Timing of starting breastfeeding among infants whose first feed was breast milk . 61 Figure 4.2: Timing of starting breastfeeding among infants who were first fed formula .......... 62 Figure 4.3: Feeding methods planned up to 12 months ............................................................. 67 XII LIST OF ABBREVIATIONS American Academy of Paediatrics AAP Baby Friendly Hospital Initiative BFHI Breastfeeding Self-Efficacy Scale BSES Breastfeeding Self-Efficacy Scale Short Form BSES-SF International Medical Centre IMC Iowa Infant Feeding Attitude Scale IIFAS Kingdom of Saudi Arabia KSA Ministry of Civil Service MCS New Zealand Ministry of Health NZMOH Oral Rehydration Salts ORS Saudi Arabia Ministry of Health SAMOH Saudi Germany hospital SGH Soliman Fakeeh SF Statistical Package for Social Science SPSS Theory of Planned Behaviour TPB United Nations Children’s Fund UNICEF United States of America USA World Health Organisation WHO