|
Infant feeding practices of Saudi mothers in five different
regions of Saudi Arabia
Ebtissam Murshid, BDS, MS, MPH, DrPH.
College of Dentistry, King Saud University, Email:
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
Objective: A cross-sectional study was carried out to determine the infant feeding practices of Saudi mothers in five different regions of the Kingdom of Saudi Arabia.
Materials and Methods: Self administered questionnaires were randomly distributed to mothers with children aged less than 2 years attending major children's hospitals in five different regions. The questionnaire covered different demographic data such as mother's age, occupation, educational level, number of children, marital status, region, and type of feeding or nursing.
Results: In general 48.2% of the mothers preferred exclusive bottle feeding, followed by bottle and breast feeding (29.7%) with only 22.0% of the mothers preferring exclusive breast feeding. Statistical test on the effect of the different demographic factors on the mothers' preference of infant feeding were found to be highly significant, (χ2 test, P ≤ 0.01). Stepwise Logistic regression test shows that the most significant factors affecting the mothers' infant feeding practices were mothers' education and marital status.
Conclusion: Bottle feeding was the most common method of infant feeding by all the participating mothers. Medical professionals should educate mothers to increase their awareness of the importance of breast feeding.
Breast feeding is the most nutritive and immunologically
supportive way for infant health.1-4 Many studies showed that the
benefits of breast feeding not only improve the infants' health but also the
mothers' health in many different forms, such as reducing the risk of breast
and ovarian cancer and other health problems.5-7 Many organizations
such as United Nations Children Fund (UNICEF), World Health Organization (WHO)
and American Academy of Pediatrics have issued and promoted different programs
to support and encourage breast feeding in many countries around the world.3,8,9
Literature review shows that the practice of breast
feeding has declined considerably over the last few years and early
introduction of bottled milk and solid food has increased in many parts of the
world.10-16 In the Saudi society breast feeding is considered to be
the ideal and the most natural way of nursing infants due to religious and
cultural beliefs. However, during the last few decades major developmentals
have taken place in Saudi
Arabia making it one of the fastest growing
economies of the world.17 This fast progress has had different
influence on the lifestyles of many Saudi families. The developmental influence
comes into light as more mothers leave their homes either for work or to
utilize opportunities to achieve higher education. Many long-established
habits and cultural traditions are adapting to the new era. Results of
previous studies showed that breast feeding duration exceeded 2 years in some
areas of Saudi Arabia.18,19 However, recent studies showed a decline
in breast feeding between the ages of 6 and 12 months and the introduction of
bottle formula as well as solid food has become more frequent at an earlier
infant age.20,21
The common finding between the different studies was the
decline in breast feeding. Most of the authors reported that the majority of
the mothers (up to 90%) started with breast feeding but the number dropped
considerably within the first few months of the infant's age.24, 28, 29 Many reasons
were given by the mothers to explain the discontinuation of breast feeding
practices. These reasons include insufficient breast milk, lack of family
support, infant's age, short intervals between births and lack of adequate
information on breast feeding.22-26
The decline in breast feeding and the early introduction
of bottle feeding with usually different sugary content for a prolonged period
(more than 12 months of the infant age) increased the risk of early childhood
caries in many societies.30,31 It
has been reported that many children were used to feeding before/during sleep,
nocturnal/nap-time bottle feeding, and consumption of excessive amount of fruit
juices/soft drinks from container which resulted in increased nursing caries
rate among Saudi infants and toddlers.32
Therefore the aim of
this study was to evaluate the infant feeding practices of Saudi mothers and
the variables affecting their selection of feeding methods in five different
regions of Saudi Arabia.
A self-administered Arabic question- naire was distributed to major children's hospitals in
five different regions around the Kingdom of Saudi Arabia who agreed to
participate in the study targeting mothers with children aged less than 2 years
(in the nursing stage). Children were randomly selected from the booked
patients list in the well-baby care clinic over a period of 3 months. The
questions covered a variety of factors, including age, education, occupation,
marital status, number of children, and actual feeding practices. The sample
was divided into 3 groups according to the mode of feeding: exclusive breast
feeding, exclusive bottle feeding, or combined breast and bottle feeding.
A total of 1400 questionnaires were distributed as
follows: 400 in the Central region represented by the city of Riyadh, 250 in the Western region (Jeddah and
Makkah), and 250 in the Eastern region (Dammam and Dhahran), 250 in the
Southwestern region (Jazan), and 250 in the Northern region (Arar).
All responses were entered into a computer database and
analyzed using a Statistical Package for Social Sciences (SPSS version 10).
Descriptive statistics were generated on all items and cross tabulation as well
as step logistic regression to find the most significant demographic factors
that have an effect on the mothers' feeding practices. Chi-square test was
performed to evaluate the different variables.
Out of
1400 distributed questionnaires, 912 samples were received, yielding a response
rate of 65.14%. A large number of the participating mothers (48.2%) were using
bottle formula to feed their infant, followed by bottle and breast combined
(29.7%) while 22% practiced breast feeding only (Table 1).
More
than half (53.3%) of the participating mothers were between 20 and 30 years of
age and 35.1% were between 31 and 40 years. Only 6.8% and 4.6 % were more than
40 and less than 20, respectively. Bottle feeding was the most commonly used
method by the mothers in each age group followed by the combination of bottle
and breast. Breast feeding was the least commonly used in all age groups.
Younger mothers (< 20 years) breast feed their infant more than the older
mothers. The statistical test showed insignificant variations in the mothers'
feeding practices between the different age groups as P
Table 2
shows the effect of mother's educational level on the type of feeding. About
one third (38.6%) of the total participating mothers were university graduates
while high school diploma holders were 22%. In the least educated or illiterate
mothers' group, breastfeeding was preferred (42.3%) over the other two options
of feeding when compared with the more educated mothers. Bottle feeding was
used more by university and high school graduate mothers (59.4% and 46.3%
respectively). Pearson's Chi-square test showed significant variations in the
mothers' feeding practices according to their educational level, P value
< 0.01 and Chi-square was 70.302 (Table
2).
Distribution
of responding mothers is shown in Table 3. Most of the mothers from the
different regions used bottle feeding over the other two methods. The largest
group of mothers which practiced breast feeding was from the Western region
(28.4%) and the least group was from the Southwestern region (13.4%). The
statistical test showed significant variations in the mothers' feeding
practices according to their regions, P value < 0.01 and Pearson's Chi-square = 50.100 (Table 3).
Majority
of participating mothers were married (93.3%). The effect of the marital status
on the mothers' feeding practices (Table 4) showed that mothers in the married
and widow categories preferred bottle feeding (48.5% and 65.5%, respectively)
while divorced mothers preferred both bottle and breast feeding (68.8%). The
statistical test showed significant variations in the mothers' feeding
practices according to their marital status, P value < 0.01 and Pearson's Chi-square = 28.371.
The
study of the occupational effect on the mothers' feeding practices showed that
exclusive breast feeding was more among housewives (29.4%) compared with
employed wives (11.0%). Bottle feeding was more among employed wives (57.0%)
compared with housewives (42.4%). Using both feeding methods was more among
employed 32.1% and 28.2% among housewives. This variation was significant (P
value < 0.01 and Pearson's Chi-square =
44.66) as shown in Table 5.
A large
number of the participating mothers (49.0%) had one to three children and only
5.2% had more than 10 children (Table 6). Mothers with less than 10 children
preferred bottle feeding; while mothers with more than 10 children preferred
both bottle and breast methods of feeding. Mothers with one to three children
practiced breast feeding more than the rest of the mothers. The differences
were significant at P value <
0.01 and Pearson's Chi-square = 39.39 (Table 6).
Mothers
with children 4-6 months of age preferred both breast and bottle feeding 42.0%.
Whereas mothers with children between the age of seven months and two years
preferred bottle feeding. A large number of mothers with children between the
age of 1 and 2 years were still practicing breast feeding (48.8%). Statistical test showed significant
variations in the mothers' feeding practices according to the age of their
children, P value < 0.01 and
Pearson's Chi-square = 36.714 (Table 7).
Multiple
regression analysis (stepwise) identified the most significant factors
affecting the mothers feeding practices as mother's education and marital
status (Table 8). These two variables were significant (P value < 0.01). value was 0.26
and Pearson's Chi-square value = 7.595 (Table 1).
Out of the 1400 questionnaires distributed to the
mothers only 912 were returned. Some of the mothers refused to participate for
different reasons, some others did not return the questionnaires within the
collecting data period.
The results of this study support the decline in breast
feeding practices by Saudi mothers when compared with precious studies
conducted in the country.14,19,21 In general nearly half (48.2%) of
the mothers in this study used bottle formula, 29.7% used both bottle and
breast feeding, while only 22% breast fed their children.
Previous studies showed no significant relationship
between the duration of breast feeding and the mother's age.24,27
Other studies showed a positive correlation between the mothers' age and
practice of breast feeding. The older mothers practiced breastfeeding more than
younger mothers.19,21
However, results of this study showed that bottle feeding was more
commonly used among Saudi mothers in all different age groups. It is important
to highlight that breast feeding was the type of feeding used least among the
three methods of infant feeding. Breast feeding was practiced more by mothers
20 years of age and mothers between 31-40 years than older mothers. This may be
due to the enthusiasm of the young mothers to experience breast feeding.
Another explanation could be that younger mothers have more time for their
children than older mothers who most probably have other children and therefore
have more responsibilities.
Mothers' education apparently has a significant effect
on the mothers' feeding practices. The results in this study showed that the
group of less educated mothers' preferred breastfeeding over the other two
options. This is in agreement with other studies 19,24 that reported a negative correlation
between the level of the mother's education and breast feeding. Furthermore,
these authors reported that the illiteracy of the mothers was associated with
longer breastfeeding duration.19, 24, 27 The highly educated mothers
with University degree in this study preferred bottle feeding to the other two
methods. This could be explained by the desire of mothers who cherish acquiring
higher education to keep pace with speedy development of technology and
societal changes in Saudi
Arabia, as previously mentioned.
The mother's region has a positive effect on the type of
feeding. Results of this study showed that breast feeding was practiced least
in the Central region and most in the Western region. However, bottle feeding
was practiced by all the mothers from the five different regions more than the
other two methods of feeding. Comparing the result of this study with other
studies conducted around the Kingdom show significant variations. Each of the regions
had a different preference on the type of feeding according to the life style
and habits of that region.15,20,21,24,28,29 The differences between the different regions
is predictable taking in consideration the size of the Kingdom and the effect
of the bringing up of the mothers.
Mothers admitted that martial status and family support
were factors that either encouraged or discouraged them from practicing breast
feeding. This study's results show that married mothers practiced breast
feeding more than widowed or divorced mothers as is normal. But in general,
bottle feeding practices was the most common method of infant feeding among all
groups of mothers. An interesting point here is that none of the previous
studies conducted in the Kingdom or in the literature reviewed considered the
possibility of a difference in feeding practices between widowed or divorced
mothers and married mothers.
Results of this study showed that mothers' occupation
had a significant effect on the mothers feeding practices. Breast feeding was
reported more by housewives; as a result of the more time they spent with their
children. However, bottle feeding was preferred among housewives as well as
working mothers, possibly explained by the mothers' lack of knowledge or interest.
The results of this study did not agree with those of Madani who in 1994
reported no significant relationship between the duration of breast feeding and
the mother's age or working status.24
Bottle feeding was more commonly used by mothers in
general. Results showed that mothers with more than 7 children preferred breast
feeding more than mothers with less children. This could be explained by the
probability that they may have learned from the value of breast feeding through
experience, or due to the change in their economic status as a result of their
growing families.
The results of this study also showed that a large
number of the mothers (42.0%) preferred to introduce formula to their children
at a younger age (4 to 6 months), a finding in agreement with the earlier
results of other studies conducted in different parts of the Kingdom.14,19-21
It is interesting to find that 48.8% of mothers with children
between the age of one and two years were still practicing breast feeding.
Although breast feeding is encouraged for the mothers and child's health but
every effort should be made to increase the mothers' awareness of early
childhood caries as a result of prolonged nursing breast/ bottle.
It is recommended
that every effort should be made to encourage and support breast feeding. At
the same time awareness about the appropriate duration of nursing, the gradual
weaning and the appropriate cleaning and brushing methods should be explained
through media to target affected mothers. Educational health programs should
emphasize that the nursing method is beneficial to the oral health of the
children if appropriately used.
-
Bottle
feeding was the most common method of infant feeding used by all the
participating mothers.
-
Large
number of mothers was practicing nursing for prolonged period of time.
-
The
most significant variables affecting the mothers' feeding practices were their
level of education and marital status.
-
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Reprint Request to
Ebtissam Murshid, BDS, MS, MPH, DrPH.
Department of Preventive Dental
Sciences
College of Dentistry, King
Saud University
P.O. Box 434, Riyadh
11321, Saudi
Arabia
E-mail:
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
Table 1. Mothers’
age and feeding practices
|
Mothers’ age
|
Count
|
Type of feeding
|
Total
|
|
Breast
|
Bottle
|
Both
|
|
<
20
|
Count
% Within mother’s age
% Within type of feeding
|
11
26.2%
5.5%
|
19
45.2%
4.3 %
|
12
28.6%
4.4 %
|
42
100.0%
4.6%
|
|
20-30
|
Count
% Within mother’s age
% Within type of feeding
|
93
19.1%
46.3%
|
251
51.4%
57.0%
|
144
29.5%
53.1%
|
488
100.0%
53.5%
|
|
31-40
|
Count
% Within mother’s age
% Within type of feeding
|
83
25.9%
41.3 %
|
144
45.0%
32.7%
|
93
29.1%
34.3%
|
320
100.0%
35.1%
|
|
>
40
|
Count
% Within mother’s age
% Within type of feeding
|
14
22.6 %
7.0 %
|
26
41.9%
5.9 %
|
22
35.5%
8.1%
|
62
100.0%
6.8%
|
|
Total
|
Count
% Within mother’s age
% Within type of feeding
|
201
22.0%
100.0 %
|
440
48.2%
100.0%
|
271
29.7%
100.0%
|
912
100.0 %
100.0 %
|
|
P
= 0.26
Pearson’s Chi-square = 7.595
|
|
|
|
|
Table 2. Mothers’
education and feeding practices
|
Mothers’ education
|
Count
|
Type of feeding
|
|
|
Breast
|
Bottle
|
Both
|
Total
|
|
Illiterate
|
Count
% Within mother’s education
% Within type of feeding
|
52
42.3%
25.9%
|
39
31.7%
8.9 %
|
32
26.0%
11.8 %
|
123
100.0%
13.5%
|
|
Primary
|
Count
% Within mother’s education
% Within type of feeding
|
36
32.1%
17.9%
|
48
42.9%
10.9%
|
38
30.6%
10.3%
|
112
100.0%
12.3%
|
|
Intermediate
|
Count
% Within mother’s education
% Within type of feeding
|
35
28.2%
17.4 %
|
51
41.1%
11.6%
|
38
30.6%
14.0%
|
124
100.0%
13.6%
|
|
High
School
|
Count
% Within mother’s education
% Within type of feeding
|
35
17.4 %
17.4 %
|
93
46.3%
21.1 %
|
73
36.3%
26.9%
|
201
100.0%
22.0%
|
|
University
|
Count
% Within mother’s education
% Within type of feeding
|
43
12.2 %
21.4 %
|
209
59.4%
47.5 %
|
100
28.4%
36.9%
|
352
100.0%
38.6%
|
|
|
Total
Count
%
Within mother’s
education
%
Within type of
feeding
|
201
22.0%
100.0 %
|
440
48.2%
100.0%
|
271
29.7%
100.0%
|
912
100.0 %
100.0 %
|
|
P < 0.01
Pearson’s Chi-square =
70.302
|
|
|
|
|
Table 3. Mothers’
region and feeding practices
|
Region
|
Count
|
Type of feeding
|
|
|
Breast
|
Bottle
|
Both
|
Total
|
|
Central
|
Count
% Within region
% Within type of feeding
|
41
12.8%
20.4%
|
189
58.9 %
43.0 %
|
91
28.3 %
33.6 %
|
321
100.0%
35.2%
|
|
Western
|
Count
% Within region
% Within type of feeding
|
57
34.5%
28.4%
|
59
35.8%
13.4%
|
49
29.7 %
18.1%
|
165
100.0 %
18.1 %
|
|
Eastern
|
Count
% Within region
% Within type of feeding
|
37
28.5%
18.4 %
|
59
45.4%
13.4%
|
34
26.2 %
12.5 %
|
130
100.0 %
14.3 %
|
|
Southwestern
|
Count
% Within region
% Within type of feeding
|
27
16.9 %
13.4 %
|
72
45.0%
16.4 %
|
61
38.1 %
22.5 %
|
160
100.0 %
17.5 %
|
|
Northern
|
Count
% Within region
% Within type of feeding
|
39
28.7 %
19.4 %
|
61
44.9%
13.9 %
|
36
26.5 %
13.3 %
|
136
100.0%
14.9 %
|
|
Total
|
Count
% Within region
% Within type of feeding
|
201
22.0%
100.0 %
|
440
48.2%
100.0%
|
271
29.7 %
100.0%
|
912
100.0 %
100.0 %
|
|
P <
0.01
Pearson’s Chi-square = 50.100
|
|
|
|
|
Table 4. Mothers’ social status and feeding practices
|
Social status
|
Count
|
Type of feeding
|
Total
|
|
Breast
|
Bottle
|
Both
|
|
Married
|
Count
% Within social status
% Within type of feeding
|
196
23.0 %
97.5 %
|
413
48.5 %
93.9 %
|
242
28.4 %
89.3 %
|
851
100.0 %
93.3 %
|
|
Widow
|
Count
% Within social status
% Within type of feeding
|
3
10.3 %
1.5 %
|
19
65.5 %
4.3 %
|
7
24.1 %
2.6 %
|
29
100.0 %
3.2 %
|
|
Divorced
|
Count
% Within social status
% Within type of feeding
|
2
6.3 %
1.0 %
|
8
25.0%
1.8 %
|
22
68.8 %
8.1 %
|
32
100.0 %
3.5 %
|
|
Total
|
Count
% Within social status
% Within type of feeding
|
201
22.0%
100.0 %
|
440
48.2%
100.0%
|
271
29.7 %
100.0%
|
912
100.0 %
100.0 %
|
|
P
< 0.01
Pearson’s Chi-square = 28.37
|
|
|
|
|
Table 5. Mothers’
occupation and feeding practices
|
Occupation
|
Count
|
Type of feeding
|
Total
|
|
Breast
|
Bottle
|
Both
|
|
Housewife
|
Count
% Within mother’s job
% Within type of feeding
|
161
29.4 %
80.1 %
|
232
42.4 %
52.7 %
|
154
28.2 %
56.8 %
|
547
100.0 %
60.0 %
|
|
Employed
|
Count
% Within mother’s job
% Within type of feeding
|
40
11.0 %
19.9 %
|
208
57.0 %
47.3 %
|
117
32.1 %
43.2 %
|
365
100.0 %
40.0 %
|
|
Total
|
Count
% Within mother’s job
% Within type of feeding
|
201
22.0%
100.0 %
|
440
48.2%
100.0%
|
271
29.7 %
100.0%
|
912
100.0 %
100.0 %
|
|
P
< 0.01
Pearson’s Chi-square = 44.66
|
Table 6. Number
of children and feeding practices
|
Number of children
|
Count
|
Type of feeding
|
Total
|
|
Breast
|
Bottle
|
Both
|
|
1-3
|
Count
% Within number of children
% Within type of feeding
|
76
17.0 %
37.8 %
|
225
57.0 %
58.0 %
|
116
26.0 %
42.8 %
|
447
100.0 %
49.0 %
|
|
4-6
|
Count
% Within number of children
% Within type of feeding
|
65
22.7 %
32.3 %
|
128
44.8 %
29.1 %
|
93
32.5 %
34.3 %
|
286
100.0 %
31.4 %
|
|
7-9
|
Count
% Within number of children
% Within type of feeding
|
44
33.3 %
21.9 %
|
45
34.1 %
10.2 %
|
43
32.6 %
15.9 %
|
132
100.0 %
14.5 %
|
|
10 +
|
Count
% Within number of children
% Within type of feeding
|
16
34.0 %
8.0 %
|
12
25.5 %
2.7 %
|
19
40.4 %
7.0 %
|
47
100.0 %
5.2 %
|
|
Total
|
Count
% Within number of children
% Within type of feeding
|
201
22.0%
100.0 %
|
440
48.2%
100.0%
|
271
29.7 %
100.0%
|
912
100.0 %
100.0 %
|
|
P
< 0.01
Pearson’s Chi-square = 39.39
|
|
|
|
Table 7. Age of
the child and feeding practices
|
Age of children
|
Count
|
Type of feeding
|
Total
|
|
Breast
|
Bottle
|
Both
|
|
4-6 months
|
Count
% Within age of child
% Within type of feeding
|
45
31.5 %
22.4%
|
38
26.6 %
8.6 %
|
60
42.0 %
22.1 %
|
143
100.0 %
15.7 %
|
|
7-9 months
|
Count
% Within age of child
% Within type of feeding
|
23
20.4 %
22.9 %
|
52
46.0 %
11.8 %
|
38
33.6 %
14.0 %
|
113
100.0 %
16.8 %
|
|
10- 1 year
|
Count
% Within age of child
% Within type of feeding
|
35
22.9 %
17.4 %
|
12
25.5 %
2.7 %
|
44
28.8 %
16.2 %
|
153
100.0 %
16.8 %
|
|
1 – 2 years
|
Count
% Within age of child
% Within type of feeding
|
98
19.5%
48.8%
|
276
54.9%
62.7%
|
129
25.6%
47.6%
|
503
100.0%
55.2%
|
|
Total
|
Count
% Within age of child
% Within type of feeding
|
201
22.0%
100.0 %
|
440
48.2%
100.0%
|
271
29.7 %
100.0%
|
912
100.0 %
100.0 %
|
|
P < 0.01
Pearson’s Chi-square = 36.714
|
|
|
|
Table 8. The
stepwise regression analysis model with the different variables
|
Model
|
t- test
|
P values
|
|
Constant
|
9.503
|
0.00*
|
|
Mothers’ age
|
-0.0335
|
0.738
|
|
Mothers’ education
|
3.561
|
0.00*
|
|
Region
|
-1.163
|
0.245
|
|
Mothers’ marital status
|
4.334
|
0.00*
|
|
Mothers’ occupation
|
1.177
|
0.239
|
|
Number of children
|
1.524
|
0.128
|
*Significant at P ≤
0.01
|
