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Prevalence and Knowledge towards Breastfeeding of Mothers Attending the Well-Baby Clinic at Primary Health Centers in Makkah Al-Mukarramah, 2018

Haneen Omar Taher

Family Medicine Resident, Joint Program Makkah, Saudi Arabia

Abstract: BACKGROUND: Breastfeeding offers a lot of benefits to both the mother and infant. The World Health Organization (WHO) even recommended breastfeeding as an effective way in promoting infant nutrition. However, despite of advancing medical technology, breastfeeding practice is continually declining in Saudi Arabia as caused by a variety of factors. AIM: The aim of this research is to assess the knowledge on breastfeeding, its prevalence, and the socio-demographic factors affecting the knowledge of mothers attending a well-baby clinic in primary health care centers in Makkah. Methodology: The researcher conducted a cross-sectional survey to working mothers attending a well-baby clinic in primary health care centers in Makkah. Mothers of childbearing age and of any nationality were included in this study. A self-administered questionnaire involving three main sections, namely: socio-demographic information, level of knowledge, and attitude of mothers was utilized for data collection. Results: Majority of the respondents score correctly in 19 out of 20 knowledge items concerning breastfeeding practice. Relating the socio-demographic characteristics of participants towards their breastfeeding knowledge, the average knowledge score was found to range from 13 to 14, suggesting that the sampling population have an average knowledge on breastfeeding and its benefits. Mothers with infant delivered via spontaneous vaginal delivery and with housemaid were reported to have higher mean knowledge scores and are deemed to have better knowledge towards breastfeeding. Likewise, those who breastfed until 6 months, those who stopped breastfeeding after 12 months, and those who introduced supplemental food between 4 and 6 months garnered a higher mean knowledge scores. On the other hand, mothers who consulted their doctor on choosing artificial milk as well as those whose milk had been changed more than once had gotten a lower mean knowledge score. Conclusion: The result of self-administered questionnaire suggests that the sampling population have an average knowledge on breastfeeding and its benefits. Factors such as nationality, occupation of the mother, and mode of infant delivery were not significantly associated to breastfeeding practice. On the other hand, experiencing the SVD or CS mode of infant delivery and having housemaids can aid in the dissemination of breastfeeding knowledge.

Keywords: prevalence, knowledge, breast, feeding, mothers, well-baby clinic, primary health centers, 2018

Received September 14, 2019; Revised October 12, 2019; Accepted November 10, 2019

Citation: Haneen Omar Taher, Prevalence and Knowledge towards Breastfeeding of Mothers Attending the Well-Baby Clinic at Primary Health Centers in Makkah Al-Mukarramah, 2018. American Journal of Medical Sciences and Medicine, 7 (4). 147-155. January 2019. doi:10.12691/ajmsm-7-4-2

1. Introduction

1.1. Background

Breastfeeding provides enormous benefits to both the mother and the infant. Initiation of breastfeeding within 1 hour of giving birth is deemed necessary as colostrum is secreted during that period. On the other hand, the oxytocin released by mothers during breastfeeding aids in uterine contraction and reduction of maternal blood loss. Aside from that, mother-infant interaction can be established early with the help of breastfeeding [1].

The Eastern Mediterranean Regional Office of World Health Organization reported high rates of early breastfeeding in the Middle East and North Africa. However, low rates of exclusive breastfeeding for infants under 6 months of age had been previously reported from this region [2]. This is affected not only by knowledge on breastfeeding but also by factors such as education, occupation, and socio-economic status of the parents [3].

Saudi Arabia is a country as to which Islam plays a great role in its culture and tradition. A teaching in the Holy Quran stated: “And mothers shall breastfeed their children for two whole years, for those who desire to complete the appropriate duration of breastfeeding” (4). However, the practice of breastfeeding is reported to be in declining trend in Saudi Arabia despite of advancement in health services [5].

In a study conducted by Amin and colleagues [6], they found that majority of mothers who initiate breastfeeding are who are housewives. Working mothers find it difficult to initiate breastfeeding due to lack of flexible work schedule and lack of childcare facilities at workplace. Despite that, work environment can play a crucial role in the promotion of breastfeeding.

1.2. Rationale

Breastfeeding offers a lot of benefits to both the mother and infant. The World Health Organization (WHO) even recommended breastfeeding as an effective way in promoting infant nutrition. However, some mothers, especially those in the working sector, face several barriers in breastfeeding. In relation to that, there is insufficient published data in Saudi Arabia that clarifies the issues and concerns of working mothers toward proper breastfeeding practice. In this case, the researcher found interest in providing women and their families with expert care and support on breastfeeding, particularly in Jeddah as to which the researcher currently resides.

1.3. Aim of the Study

The aim of this research is to assess the knowledge on breastfeeding as well as its prevalence among mothers attending a well-baby clinic in primary health care centers in Makkah. In addition, this study aims to determine the socio-demographic factors affecting their knowledge on breastfeeding.

Similarly, this study may serve as an avenue in the promotion of breastfeeding education in Makkah .

1.4. Objectives

1. To assess the knowledge regarding breastfeeding among mothers attending the well-baby clinic at primary health care centers in Makkah 2018.

2. To determine the factors associated with knowledge of breastfeeding among mothers attending the well-baby clinic at primary health care centers in Makkah 2018.

3. To estimate the prevalence of breastfeeding among mothers attending the well-baby clinic at primary health care centers in Makkah , 2018.

2. Literature Review

2.1. Prevalence of Breastfeeding Practice

An assessment of the breastfeeding practices in the first 6 months of 578 infants was performed at King Abdulaziz Medical City (KAMC), Riyadh, Kingdom of Saudi Arabia (KSA). About 95% of the infants involved in this study were introduced to breastfeeding. Majority of the mothers also introduced milk formula and fluids during the first 6 months of nutrition practice, with a percentage of 83.4 and 94, respectively. In addition, about 89.2% of the mothers had begun complementary feeding, frequently by the age of 4-6 months. About 1 out of 2 mothers introduced formula milk as due to inadequate milk produced during lactation period. Aside from that, about 1 out of 10 mothers experienced breast problems while feeding the infant [7]. Al-Frayh and Wong [8] studied the infant-feeding practices in 6,623 randomly selected families living in Riyadh, KSA. Out of 4,796 infants included in this study, bottle feeding was introduced to about 59.6% of infants at the age of less than 3 months. In addition, 31.3 and 9.3 of the infants were exclusively breastfed and bottle fed, respectively, whereas about 59.4% of the infants were both breast- and bottle fed. Majority of the infants were given solid food beginning at the age of 3 months. The researchers found out that older mothers are more inclined to breastfeeding as compared to younger mothers who tend to use complementary food. A retrospective study on the prevalence, duration and current recommendations on breastfeeding in Iran was investigated by Olang and colleagues [9]. This was done on 63,701 infants aged less than 2 years of age in 30 urban and rural provinces of Iran. About 90% of the infants were breastfed at 1 year of age, however, this declined to 57% at the age of 24 months. At 4 months of infant age, the exclusive breastfeeding rates were 58 and 56 percent in rural and urban areas, respectively. Four hundred and sixty-six hospitals were qualified as baby friendly hospitals in accordance to their policy questionnaire. Breastfeeding rates were checked every 4 years and funded by the Iran Ministry of Health.

Moreover, Al-Ayed and Qureshi [10] determined the breastfeeding practices of 347 mothers who attended a well-baby clinic in King Khalid University Hospital, Riyadh, KSA. Based from their results, 25.9% of the participants had their infants exclusively breastfed whereas 34.9% of the infants were exclusively bottle fed. On the other hand, 136 infants were fed with both breast milk and formula milk. At the age of 3 to 6 months, about 88.6 and 90.1 percent of the breastfed and bottle-fed infants, respectively, were introduced to weaning foods. Bottle feeding was preferred due to insufficient breast milk, infant refusing breast milk, as well as work-related problems.

2.2. Factors Associated with Breastfeeding

A study was conducted by Al-Binali [11] wherein the breastfeeding knowledge, attitude and practice among 384 teachers in Abba Female Educational District in southwestern Saudi Arabia. In terms of knowledge on breastfeeding, about 89.3% of the respondents stated that colostrum is good for the infant. On the other hand, 225 of the participants reported that their Islamic religious background played a key role in initiating breastfeeding. In addition, about 68% of the teachers intends to attend breastfeeding classes in preparation for future pregnancy. Three hundred and forty-nine teachers reported that they also provide formula milk as supplement to breast milk. However, breastfeeding was stopped at an average age of 8-9 months because of certain factors such as insufficient breast milk and work-related problems. Moreover, a cross-sectional survey was conducted among 4872 mothers in order infant feeding patterns. In terms of breastfeeding information, about 9 in every 20 mothers responded that they learned information on breastfeeding from medical staff. About 92% of the mothers fed colostrum to newborn infants, however, 76.1% of the respondents had begun bottle-feeding at the age of 3 months. Almost half of the mothers responded that insufficient milk was the main reason for the introduction of bottle feeding. On the other hand, 50.1% of the participants began introducing solid foods to infants at age between 4 and 6 months [12].

Breastfeeding and weaning practices were studied 8,566 households in Riyadh as well as in two rural areas outside Riyadh. Out of 8,566 households, 6131 women had given birth within the last 5 years prior to survey. Two thousand five hundred and twenty-six mothers were breastfeeding at the time the survey was conducted and 82% of which are aged less than 6 months old. About 34 and 10 percent of the infants and children aged less than 2 years old were exclusively breastfed and bottle-fed, respectively, whereas, the remaining 56 percent were introduced to both breastfeeding and bottle feeding. Mothers living in urban areas began supplementation with solid food at an average age of 4.8 months while those living in rural areas supplemented the infant with solid food at an average of 6.4 months. Child reaching suitable age, insufficient breast milk produced by mother, and mother being sick were the main factors for weaning in both urban and rural areas [13].

Alwelaie and others [14] investigated the breastfeeding knowledge and attitude among 848 Saudi women in three hospitals, namely King Fahd Medical City, Riyadh Military Hospital, and King Abdulaziz Medical City from July 7-22, 2009. Six in every 10 women were aged between 21-30 years old and about half of the participants have earned a college or higher education. Based from the results of this study, about 54.2% of the respondents had received breastfeeding education during their stay in the hospital for delivery. Mixed feeding was the preferred mode of infant feeding by about 48.5% of the respondents whereas 36.8% of them chose exclusive breastfeeding as their planned method of infant feeding during the first few weeks of birth. In terms of attitude towards scientific facts, about 22% of the women believed that infants should be breastfed exclusively for the first 6 months whereas 51% of them responded that formula milk is not a good choice as compared to breast milk. The probable determinants of early initiation and exclusivity of breastfeeding among 641 Saudi mothers in Al Hassa, KSA. Multistage sampling method was utilized in the selection of mothers from 4 urban and 6 rural primary health care centers. About 77.8% of mothers began initiating breastfeeding within the first 24 hours of childbirth. In addition, 76.1% of the respondents breastfed exclusively after childbirth. However, a decline to 32.9 and 12.2 percent were observed at age 2 and months, respectively. Multivariate logistic regression showed that rural, less educated, and low-income mothers with 3 or more children were more expected to breastfeed their infants exclusively. Maternal education and employment status serve as the 2 major factors that significantly influenced early initiation and exclusivity of breastfeeding [15].

Multilevel analysis on nonexclusive breastfeeding for infants aged less than 6 months old in 5 Southeast Asian countries were investigated by Senarath and others [16]. The rates of exclusive breastfeeding in these countries were 15.5, 30.7, 33.7, 38.9, and 60.1 percent for Vietnam, Timor-Leste, the Philippines, Indonesia, and Cambodia, respectively. First-born infants, working mothers, and higher maternal age were considered as individual factors in nonexclusive breastfeeding. High risk of nonexclusive breastfeeding was found in communities with trained delivery assistance in the Philippines, poor maternal education in Vietnam and Cambodia, as well as higher percentage of wealthier households in Indonesia.

Four groups of children, such as privileged urban children, children from average urban population, less privileged urban children, and children from rural areas, were considered by Serenius and colleagues [17] in order to determine the pattern of breastfeeding and weaning in Saudi Arabia. About 90% of the children from the rural areas were breastfed from age 1-3 months. However, a decline in breastfeeding was observed as the child grows, regardless of study group. On the other hand, privileged children were introduced to solid food earlier as compared rural children. At the age of 1 month, water was introduced to 83% of the urban low privileged children whereas cereals and juice were introduced to only 1 and 2% of the participants. In terms of length of breastfeeding, the median duration for children to mothers aged less than 23 years old was 11.7, 3.4, 5.5 and 1.7 months for rural, urban low, urban average, and urban privileged children, respectively.

On the other hand, Shawky and Abalkhail [18] studied the maternal factors associated with the duration of breastfeeding among 400 mothers attending primary health care in Jeddah, Saudi Arabia. About 4 in every 10 mothers had not attended school whereas 13.8% of the participants were smokers. Majority (94%) of the mothers involved in this study reported that they initially breastfed their babies. However, a decline was experienced as the infant starts to grow, then reaching 40% at the age of 12 months. Respondents who are at higher risk of discontinuing breastfeeding are those who delivered via caesarean section and those used oral contraceptives.

The patterns of breastfeeding on 1019 mothers in Taif, Saudi Arabia were studied by Madani, et al. [19] from January to April 1990. Based from the data gathered, about 98% of the participants provided their infants with breast milk at birth. Six hundred and thirty-five mothers had breastfed their infants within 6 hours of delivery whereas 68.9% of them provided supplemental liquids during the first 3 days of infant’s life. Major reasons as to why the mothers introduced supplemental liquid include: (a) following the advice of the medical team and (b) mothers thinking that breastfeeding is not enough for the baby. However, about 50.1% of the respondents stated that they feed their babies whenever they cried during day or night. About 94.4% of the mothers experienced breastfeeding at nighttime. Aside from that, 3 in every 4 mothers sleep in the same bed or room with their infants. Ogbeide and colleagues [20] investigated the factors affecting breastfeeding as well as the profile of 704 parents in Al Kharj Health Center, KSA between November 2000 to February 2001. They found out that about 2/3 of the respondents are engaged in combination of breastfeeding and bottle feeding as mode of infant feeding, followed by exclusive breastfeeding and bottle feeding in 27.3 and 6.7 percent, respectively. Different factors were also found to be related to exclusive breastfeeding: (a) advice on breastfeeding, (b) husband’s educational attainment, (c) use of contraception, and (d) whether milk sample was provided at discharge from hospital. Aside from that, several factors, such as mother’s age, age of most recently born infant, number of children previously fed, and duration of previous breastfeeding, were positively correlated to breastfeeding.

The pattern of infant feeding in King Abdulaziz University Hospital was also studied by Fida and Al-Alama [21] from October 2001 to September 2002. Among the 128 participants, 106 of them breastfed their infants. In the first 6 months, about 90% of infants were breastfed. However, this declined to 72% afterwards as due to inadequate milk supply, lifestyle, and working schedule. In terms of breastfeeding information, 56% of the participants received knowledge from their relatives, whereas 10.9% of the respondents were informed by medical personnel. Breastfeeding mothers believed that they are more satisfied with their preferred mode of infant feeding as compared to bottle feeding mothers.

In Jordan, three hundred and forty-four women with children aged 6-36 months were interviewed by Khassawneh and colleagues [22] to determine their knowledge, attitude and practice of breastfeeding. Exclusive breastfeeding, exclusive bottle feeding, and mixed feeding were reported by 58.3, 30.3, and 11.4 percent of the participants. Two in every 3 respondents practiced breastfeeding for more than 12 months whereas the remaining 1/3 practiced it for 6-12 months. The researchers found that unemployed women were more inclined to breastfeeding as compared to employed women. For working mothers, breastfeeding is negatively impact by short maternity leaves.

3. Methodology

3.1. Study Design

Cross-sectional.

3.2. Study Area

The study area was the Makkah region where there are wide number of primary health care centers serving local patients. According to PHC lists distributed by health organization, there are 85 PHCCs divided into 7 sectors belonging to Makkah region – 37 within Makkah and 48 outside of Makkah.

3.3. Study Population

Mothers attending the well-baby clinic at primary health care centers in Makkah Kingdom of Saudi Arabia during the study period of 14 January – 1 February 2018 .

3.4. Selection Criteria

Mothers of childbearing age, of any nationality, and attending a well-baby clinic at primary health care centers in Makkah were included in this study, whereas, women who have contraindication to breastfeeding their children as well as those who refuse consent were followed as the exclusion criteria.

3.5. Sample Size

The number of mothers in reproductive age is about 415,801, in accordance to the general statistics authority in Kingdom of Saudi Arabia. The sample size was calculated using Raosoft calculator, following the criteria: confidence level (95%), prevalence (50%), error (10%). The calculated sample size was (97) cases during the period of 14 January – 1 February 2018. Ten percent was added to the sample size in case of possible drop out.

3.6. Sampling Technique

The PHCCs in Makkah consist of seven inner sections and under each one fixed number of PHCCs. The patients under study were selected using multistage clustered and simple random sampling technique.

The first step was a clustered sample where one section was chosen (Al-Zaheer sector). The second step was simple random sample from the selected sector, and the researcher picked two centers randomly (Al-Zaheer PHCC and Al-Nawaryah PHCC). The third stage was a systematic random sample on the mothers based on inclusion criteria. The total population was divided by required sample size in order to decide the factorial randomly (415,801.453 / 97 = 4). The cases were numbered, and every fourth case will be enrolled in the study based on inclusion criteria.

3.7. Data Collection Tool

A self-administered questionnaire involving three main sections, namely: socio-demographic information, level of knowledge, and attitude of mothers was utilized for data collection. Factors such as age, marital status, currant BF practice, job title, educational level, and income were included in the socio-demographic information. In the level of knowledge section, frequency of feeding, benefit of colostrum, initiation of solid food, time of weaning, etc. were considered. Lastly, the third section encompassed the attitude of the mothers on certain concerns such as intention to breastfeed newborn, plan to attend classes in future pregnancy, and the like. The data gathered was translated and validated by 3 consultants.

3.8. Data Collection Technique

The researcher was given official acceptance papers from health affairs to manager of Al-Zaheer and Al-Nawaryah PHCCs in order to conduct the research. The questionnaire was distributed daily at early morning and recollected at the end of the workday during the 3-week study period. The researcher distributed the questionnaire hand by hand to the participant and explained the research and the questionnaire briefly. The researcher received a written consent from each participant together with information gathered from the study.

3.9. Study Variables

In this research, the dependent variables include the level of knowledge and attitude among working mothers as well as barriers encountered during breastfeeding. The independent variable is the socio-demographic information about the participants.

3.10. Data Entry and Analysis

The data gathered was entered by using Statistical Package for the Social Sciences (SPSS).

Analysis using one-way analysis of variance, Levene’s test for equality of variances and t-test for equality of means were performed to determine the correlation between breastfeeding knowledge and demographic characteristics.

3.11. Pilot Study

Pilot study was conducted on 10% of the sample size from the population. It was carried out at Al-Nawaryah PHCC, which is the same sector involved in the sampling as due to similarity to the target group using the same questionnaire. The deficit was identified and modified accordingly. The collected data within the pilot study was not included in the main study.

3.12. Ethical Considerations

The approval of the research committee as well as the permission from Makkah joint program of family and community medicine and from the Directorate of Health Affairs of the commercial city of Makkah PHCCs were obtained prior to research. All information was kept as confidential and the results was submitted to the department as feedback. Likewise, a written consent was obtained from every participant prior to data gathering. Lastly, all supervisors, helpers, and participants were acknowledged in this study.

3.13. Relevance and Expectations

This study was conducted to assess the knowledge and prevalence of breastfeeding among mothers attending a well-baby clinic in PHCCs in Makkah. After this study, the researcher is expected to know whether mothers understand the benefits of breastfeeding in details and the proper way to save the breast milk on purpose to feed their infants.

3.14. Limitations

This study was limited by time constraint and barriers on communication skills.

3.15. Budget, Fund or Grant

This research is a self-funded study.

4. Results

4.1. Background Characteristics

The socio-demographic characteristics of the participants were assessed as shown in Table 1. One hundred mothers with age ranging from 18 to 47 years old were considered in this study. The average age of the respondents (N = 97) was 31.02 ± 6.99 years old. In terms of nationality, majority (91.9%) of the participants were of Saudi nationality, whereas the remaining 8.1% were non-Saudi nationals. More than half (58.2%) of the mothers were housewives while the remaining 36.7 and 5.1 percent worked on a full time and part-time job, respectively. Around two-third (68%) of the mothers interviewed delivered their infants via spontaneous vaginal delivery, while the nearly one-third (32%) remainder underwent caesarean section mode. Nearly one-fourth (24.5%) of the respondents had infants with age between 12 to 24 months old while nearly one-third (31.6%) had greater than 24 months old infants. The 43.9% remaining participants had infants of less than 12 months age. In addition, more than half of the respondents (56.6%) have housemaids.

Table 1. Socio-demographic characteristics of the participants

4.2. Assessment on Breastfeeding Knowledge

The knowledge of the respondents in relation to breastfeeding was also determined in this study (Table 2). Majority of the participants agreed that breastfeeding helps to grow good teeth (97%) and breastfeeding should continue until 2 years of infant age (92%). About 87% believed that colostrum is the first milk produced by the mother and is deemed useful for the infant. After 6 months of age, 83% of the mothers thought that supplementary food should be added to breastfeeding. Almost three-quarters (76%) of the respondents agreed that the baby who breastfeeds frequently urinates in enough quantities whereas 78 of them think that the stomach of baby has been filled as indicated by burping after breastfeeding. Seven in every ten participants had confidence in breastfeeding as it aids in protecting the mother from breast cancer, reducing the risk of infant respiratory infection, and helping in the contraction of uterus. Two-thirds of the mothers interviewed agreed that the breastfeeding should be done at least 10-20 minutes for each feeding (67%), it benefits the spacing of pregnancy (66%), it helps the mother to return to its normal weight before giving birth (66%), and it should be continued until the infant reached 6 months of age (66%). On the other hand, around two-thirds of the respondents believed that breastfeeding protects against congestion and fullness of mother’s breast (65%), protects against allergies (62%) and reduces the risk of diarrhea (61%). Aside from that, they also thought that colostrum is difficult to digest and must be eliminated (62%), the infant can be provided with natural and artificial breastfeeding as supplementary feeding commenced (61%), as well as the infant should be breastfed as he or she wished (59%). Lastly, only less than 40% of the respondents agreed that breastfeeding protects the mother from osteoporosis. Overall, most of the participants had 19 correct answers out of the 20-kownledge items concerning breastfeeding as (Table 2).

Table 2. Responses of the Mothers attending PHCCs in Makkah Al-Mukarramah to Knowledge Items towards Breastfeeding (N = 100)

4.3. Association of Breastfeeding Knowledge and Other Factors

The knowledge score on breastfeeding practices of the respondents in relation to socio-demographic characteristics was then determined in this study (Table 3). Both Saudi and non-Saudi nationalities had score of 14 on the average. Participants having full-time and part time jobs had a close mean scores of 14.72 and 14.40, which were found to be slightly higher to the mean score of housewives (13.35). The respondents with infant delivered via spontaneous vaginal delivery (SVD) had a mean score of 14.15, which is slightly higher as compared to those who delivered via caesarean section (CS) with a mean score of 13.35. A higher score of 14.84 was also recorded for those with housemaid in comparison to those without housemaid (13.23). Overall, upon evaluating the knowledge scores of the respondents towards breastfeeding practices with respect to their demographic characteristics, the mean average mean score ranges from 13 to 14.

On the other hand, Levene’s test for equality of variances and t-test for equality of means were employed to determine the association of socio-demographic characteristics of the participants towards their knowledge in practice of breastfeeding. Based from these analyses, factors such as mode of delivery (P=0.010) and presence of housemaid (P=0.010) were found to have significant correlation at 95% CI towards breastfeeding practices. Specifically, SVD mode of delivery and having housemaid were deemed to have a better knowledge on breastfeeding. This suggests that experiencing to deliver an infant through vaginal birth is strongly associated with breastfeeding, and having housemaids can disseminate valuable knowledge on breastfeeding towards the mother of infants. However, other factors such as nationality and occupation of mother were found to have no significant correlation (P>0.05) towards breastfeeding knowledge according to Levene’s test for equality of variances.

The scores on breastfeeding knowledge of mothers attending well-baby clinic was also determined as shown in Table 4. Those who breastfed until 6 months have an average score of 14.43 while those who did not had a score of 13.36. Aside from that, those who stopped breastfeeding after 12 months had a mean of 16.53, which is higher to those who discontinued after 2 years with score of 13.60. The average score of mothers who introduced supplemental food before 4 months and between 4 and 6 months are 12.25 and 12.82, respectively. On the other hand, mothers who consulted their doctor on choosing artificial milk had a lower score of 13.10 than those who did not, with a mean of 15.93. Likewise, the respondents whose milk had been changed more than once got a mean of 12.32, which is lower compared to those who did not (15.60).

Table 3. Knowledge score on breastfeeding practices for various socio-demographic characteristics

Table 4. Scores on breastfeeding knowledge of mothers attending well-baby clinic at primary health centers in Makkah Al-Mukarramah

Based from the results of Levene’s test for equality of variances and t-test for equality of means, there is no significant difference in breastfeeding knowledge in terms of breastfeeding until 6 months (P=0.018), discontinuing breastfeeding during the 1st or 2nd year (P=0.019), consultation with doctor when choosing artificial milk (P<0.01) and when milk been changed more than once (P<0.01). Those who did not consult their doctors on choosing artificial milk (mean score=15.93) and those who had changed their milk more than once (mean score=15.60) were reported to have higher knowledge on breastfeeding according to statistical analysis. Among the mentioned factors, only the introduction of supplemental food before 4 months or between 4-6 months was found to be significantly different when assessed against breastfeeding knowledge (P=0.949).

5. Discussion

The knowledge of breastfeeding and its prevalence among mothers attending a well-baby clinic in primary health care centers in Makkah was determined in this study. Breastfeeding knowledge was found to have no significant correlation to the occupation of mother and nationality. However, a study conducted by Al-Jassir et al. [12] revealed that fewer Saudi mothers had received breastfeeding education as compared to non-Saudi mothers (p < 0.05). Other factors such as SVD or CS mode of delivery (P=0.010) and presence of housemaid (P=0.010) were found to have significant correlation towards breastfeeding practices. In Jordan, Khassawneh and colleagues [22] found out that women who had caesarean delivery were likely to practice breastfeeding, unlike those who had vaginal birth delivery. Aside from that, the result of the self-administered questionnaire showed that housewives practice breastfeeding as compared to mothers who were employed. A study conducted by Al-Ayed and Qureshi [10] revealed that 93 out of 251 housewives performed a mixture of breastfeeding and bottle feeding, followed by exclusive bottle feeding and breastfeeding with 32.2 and 30.6 percent. However, 44.4% of the working mothers interviewed bottle fed their infants, which is slightly higher as compared to housewives who exclusively bottle fed their babies. Likewise, only 12.2% of the working mothers breastfed their infant exclusively.

On the other hand, mothers who have housemaids have better knowledge on breastfeeding as compared to those who did not have housemaids. The presence of housemaid in the house also play a good role in breastfeeding knowledge by disseminating valuable knowledge on breastfeeding towards the mother of infants. Al-Binali [11] found that most mothers lived with their husband and children; however, their husbands are working as employees. As such, the housemaids can assist the mother in taking care of the infant while her husband is working. Majority of the participants in this study believed that colostrum is the first milk produced by the mother and is deemed useful for the infant and less than two-thirds of them agreed that colostrum is difficult to digest and must be eliminated. Comparable result was reported by Al-Binali [11] wherein about 89.3% of the interviewed respondents believed that colostrum is good for the infant. However, a study conducted by Amin and colleagues in 2011 revealed that more than half of the mothers believed that as colostrum should be discarded before initiating breastfeeding.

This study showed that about 92% of the respondents agreed that breastfeeding should continue until 2 years of infant age. After 6 months of age, 83% of the mothers thought that supplementary food should be added to breastfeeding. Two-thirds of the mothers interviewed agreed that the breastfeeding should be done at least 10-20 minutes for each feeding, it benefits the spacing of pregnancy, it helps the mother to return to its normal weight before giving birth, and it should be continued until the infant reached 6 months of age. Aside from that, nearly 60% of them thought that the infant can be provided with natural and artificial breastfeeding as supplementary feeding commenced, as well as the infant should be breastfed as he or she wished.

In a related study conducted by Alwelaie and others [14], 173 out of 786 respondents agreed that babies should be exclusively breastfed for the first 6 months. Madani and co-workers [19] discovered that one-half of the participants interviewed have breastfed their babies based on demand while 4 out of 10 infants were breastfed on a scheduled basis. Likewise, nearly half of the participants breastfed their infants for about 10 minutes or less per feed. Shawky and Abalkhail [18] found that the there is a decline in the percentage of mothers who breastfeed their infant from birth (94%) until the infant reached the age of 6 months (54%) As the infant reached 12 months old, the mothers who performed breastfeeding declined further to 40%. Al-Binali et al. [11] assessed the knowledge of female schoolteachers in Abha Female Education District on breastfeeding. More than half of the respondents agreed that breastfeeding should be given on demand. Moreover, more than one-fourth of the participants thought that complementary food should be introduced at the age of 6 and 24 months, with a percentage of 28.9 and 29.2, respectively. On the other hand, 108 mothers agreed that breastfeeding should be done exclusive until the infant reached the age of 6 months, whereas about 33.9% of them agreed that it should be done until 24 months of age. In terms of breastfeeding attitude, majority of them practiced breastfeeding because of their Islamic religious background. About 94% of the participants intends to breastfeed their future children. Likewise, 261 of them plans to attend classes in case of future pregnancy. However, less than 10% of the mothers attended breastfeeding classes during pregnancy, practiced exclusive breastfeeding for 6 months, and did not have a regular follow-up during pregnancy.

Moreover, a related study on breastfeeding was conducted by Amin and colleagues in 2011 [15]. Based from their data, 397 of the mothers surveyed breastfed their infant at 6 months of age. However, majority of them had supplemented the diet of infants with fluid or food while breastfeeding. On the other hand, less than 50% of the respondents agreed that juices and other fluids should be given as the infant approached the age of 3 months. About 72% of the participant thought that the breastfeeding duration should be at 2 years and should be given on demand.

Furthermore, an investigation on the breastfeeding and weaning practices in Saudi Arabia by Al-Mazrou and others [13] revealed that 82.4% of the participants breastfed their infants in less than 6 months after births. However, this number declined to 62.6% as the infant reached 1 year old. Even so, this even decreased further to only 5.7% as the infant approached 24 months of age. Regardless of residence and the parent’s literacy, the major reasons as to why parents begin weaning the infants were (a) infant reaching suitable age, (b) mother having insufficient milk, (c) mother becoming pregnant, (d) mother being sick, and (e) mother using contraceptives. Majority of the participants agreed that breastfeeding helps to grow good teeth (97%). Seventy-eight of them think that the baby’s stomach has been filled as indicated by burping after breastfeeding. Seven in every ten participants had confidence in breastfeeding as it aids in protecting the mother from breast cancer, reducing the risk of infant respiratory infection, and helping in the contraction of uterus. On the other hand, less than two-thirds of them believed that breastfeeding protects against congestion and fullness of mother’s breast, protects against allergies and reduces the risk of diarrhea. In a related study conducted by Alwelaie and others [14], more than half of the participants agreed that breastfeeding reduces the ear infection incidents, whereas 1 in every 2 respondents believed that it minimizes the probability of getting diarrhea and respiratory diseases. Interestingly, about 51% of the women thought that infant formula is not as good as breastmilk and almost 59% of them thought that breastfeeding strengthens the bond between them and the infant. A study conducted by Amin and colleagues [15] revealed that more than half of the mothers believed that breastfeeding protects women from breast cancer. On the other hand, less than 50% of the respondents agreed that breastfeeding should be continued even if the infant has diarrhea and can decrease infant’s respiratory infections. Almost three-quarters of the respondents agreed that the baby who breastfeeds frequently urinates in enough quantities. In 2004, Marild and others assessed the protective effect of breastfeeding against urinary tract infection (UTI) [23]. They found out that a higher duration of exclusive breastfeeding can lower the risk for UTI, even after weaning. Breastfeeding after birth was found to have the highest protective activity for UTI. Although age has no effect on lowered risk for UTI, the protective effect of breastfeeding decreases until the infant approached 7 months of age. In this study, less than 40% of the respondents agreed that breastfeeding protects the mother from osteoporosis. Okyay and colleagues [24] conducted a study on whether prolonged breastfeeding is an independent risk factor for postmenopausal osteoporosis. They discovered that women with breastfeeding period of greater than 1 year per child had the highest risk for osteoporosis. However, increased number of pregnancies was attributed to have a protective effect for osteoporosis

6. Conclusion

This study was conducted to determine the knowledge on breastfeeding among mothers who attended a well-baby clinic in primary health care centers in Makkah, Saudi Arabia. The result of self-administered questionnaire showed that the majority of the respondents correctly answered 19 out of the 20-kownledge items concerning breastfeeding. Relating the socio-demographic characteristics of participants towards their breastfeeding knowledge, the average knowledge score was found to range from 13 to 14. This suggests that the sampling population have an average knowledge on breastfeeding and its benefits.

Levene’s test showed that factors such as nationality and occupation of the mother were found to have no association with breastfeeding practice. On the other hand, factors such as mode of delivery and presence of housemaid were found to have significant correlation towards breastfeeding practices. The mean score of mothers who experienced SVD mode of delivery and having housemaid were higher compared to CS type and having no housemaid, implying that they are deemed to have a better knowledge on breastfeeding. Experiencing to deliver an infant through vaginal birth is strongly associated with breastfeeding, and having housemaids can disseminate valuable knowledge on breastfeeding towards the mother of infants. Further validation of these results in other large population may facilitate the truthfulness on the association of these factors to overall knowledge on breastfeeding practice and its benefits. Other than that, this can help in upgrading the knowledge of parents on breastfeeding.

7. Recommendations

More population-based studies must be conducted to evaluate the knowledge of parents on breastfeeding. In addition, the attitude and practice of mothers on breastfeeding must be monitored in order to foster a meaningful knowledge on breastfeeding practice.

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