Factors affecting breastfeeding initiation among mothers in Riyadh primary healthcare clinics: a cross-sectional study

Abstract

Background

This study examined the prevalence, timing, and factors associated with breastfeeding practices among Saudi mothers. Breastfeeding is integral to infant health, and understanding cultural and demographic influences on initiation timing is crucial for developing effective interventions.

Methods

A cross-sectional study was conducted, recruiting 449 Saudi mothers from four primary healthcare centers in Riyadh between January 2022 and January 2023. The inclusion criteria were mothers with children under the age of two. Data were collected via a validated self-administered questionnaire. The sample size calculation considered an anticipated prevalence of 43.6% based on previous research. Ethical approval was obtained from the IRB of the King Abdullah International Medical Research Center.

Results

Breastfeeding prevalence was high (86.6% of mothers), which aligns with global breastfeeding promotion efforts. However, variations were observed in the initiation timing, with only 46.0% of the patients initiating breastfeeding within the first hour. While no statistically significant factors influenced initiation, notable trends emerged. Older mothers and those with lower educational levels demonstrated higher rates of early initiation, suggesting cultural and generational influences. Working mothers faced challenges with breastfeeding continuation due to the lack of designated breastfeeding time at work.

Conclusion

This study provides insights into the prevalence of breastfeeding practices among Saudi mothers and the factors influencing them. High breastfeeding prevalence indicates a positive cultural commitment to breastfeeding, whereas variations in initiation timing and continuation underscore the need for targeted interventions such as implementing breastfeeding clinics that inhance practice and education among mothers. Workplace support and educational campaigns are recommended to enhance breastfeeding initiation, particularly among working mothers.

Background

Breastfeeding is critical for newborns due to its well-documented benefits for both infants and mothers [1]. The benefits of early breastfeeding initiation within 1 h of birth are well documented [2]. Newborns who began breastfeeding 2–23 h after birth have a 33% higher risk of dying than those who began within 1 h of birth; the risk of death for newborns who started breastfeeding more than 24 h after birth is over twice as high [3]. Exclusively breastfed infants are less prone to infections, including otitis media, pneumonia, and necrotizing enterocolitis. Breastfeeding mothers also have a reduced risk of premenopausal breast cancer, ovarian cancer, type 2 diabetes, metabolic syndrome, and retained gestational weight [4]. Exclusive breastfeeding means feeding an infant with breast milk, with no other liquids or solids except for medication or supplements [5]. For the first 6 months of life, breast milk meets all of the infant’s essential nutritional needs [6]. Despite strong evidence supporting breastfeeding, WHO data from 2007 to 2014 show that only 36% of infants aged 0–6 months were exclusively breastfed worldwide [1].

Recent research suggests that it is challenging to achieve exclusive breastfeeding, especially among working women and those with low socioeconomic backgrounds [7]. Other factors, such as maternal pre-pregnancy BMI, also influence the birth weight of infants, precipitating breastfeeding issues [7, 8]. Breastfeeding patterns in Saudi Arabia have changed considerably in recent decades owing to demographic shifts and the rising socioeconomic status [9]. Additionally, studies have shown a gradual decline in breastfeeding rates and duration, particularly among young mothers in urban areas [10,11,12], driven by early bottle feeding [12, 13] and the introduction of solid foods [14].

Studies have highlighted multiple factors affecting the choice to initiate and continue breastfeeding, including maternal obesity, smoking, mode of delivery, early skin-to-skin contact, parity, maternal education, and psychosocial factors. Cultural and social beliefs also have a substantial influence on breastfeeding behaviors. In some countries, there are traditions that involve feeding newborns supplemental foods or having an older adult family member provide a specific food or liquid [1, 15,16,17,18]. Conversely, wider pregnancy intervals, family support, and vaginal delivery are positively associated with breastfeeding. Little is known about Saudi mothers’ perceptions and practices of exclusive breastfeeding [19].

A recent cross-sectional study conducted in Taif found that the prevalence of exclusive breastfeeding among mothers was only 16.3% [19]. Additionally, a nationwide nutritional survey of 5339 Saudi children showed that the initiation of breastfeeding was delayed beyond 6 h after birth in 28.1% of infants [11]. While Saudi mothers have high breastfeeding initiation rates (over 90%), timely initiation (within the first hour) remains low in some studies [11, 20]. A study in Mecca, Saudi Arabia, found that only 38.1% of mothers initiated breastfeeding within 1 h [21]. However, research on barriers to timely breastfeeding initiation in Saudi Arabia remains limited [22].

This study aimed to assess the prevalence, timing, and factors associated with breastfeeding practices among Saudi mothers. Unlike most global studies on the general population, this study focused only on Saudi mothers who attend primary healthcare centers; it evaluated how age, education, employment status, and healthcare support impact breastfeeding among mothers. Additionally, this research highlights other concerns, such as the lack of breastfeeding support in the workplace, which is an issue often overlooked in the region. Hence, this study provides a regional perspective on breastfeeding practices that can inform future policies and interventions for Saudi mothers, especially working mothers. Counseling and education have been shown to positively impact exclusive breastfeeding rates, especially among targeted populations [23].

Methods

Study design and setting

This cross-sectional study was conducted at four major primary healthcare centers (HCSC, Iskan, NGCSC, and Dirab) in King Abdulaziz Medical City, Riyadh, from January 2022 to January 2023. Inclusion criteria were Saudi mothers with a youngest child under 2 years old, regardless of the infant’s gestational age or congenital anomalies. Mothers with chronic diseases, non-Saudi mothers, and those who reported taking immunosuppressants were excluded from the study.

Study population and data collection

A sample size of 400 participants was determined using the Open-Source Epidemiological Statistics for Public Health Website, based on the recent 2020 statistics published by the Ministry of Health on government hospital deliveries. The anticipated prevalence (43.6%) was based on previous research conducted in 2019 on the prevalence of breastfeeding in Saudi Arabia [3]. Participants were recruited using convenience sampling. They completed a self-administered questionnaire that was validated and modified from a WHO-guided instrument, which underwent a rigorous translation process to ensure linguistic accuracy. The questionnaire had six sections and 27 questions, covering demographics, breastfeeding practices, awareness, postnatal and breastfeeding clinic utilization, and factors influencing breastfeeding decisions.

To enhance the validity of the questionnaire, a pilot test was conducted on a small sample (15–20 participants) to check for clarity and adequacy; changes were made based on participants’ responses, such as improving readability and presentation of questions and their answers. Reliability was assessed using Cronbach’s alpha, with values above 0.7 indicating acceptable reliability in measuring factors influencing breastfeeding initiation. This ensured that questionnaire data reflected consistent and accurate information on breastfeeding initiation among the female Saudi population in Riyadh.

Ethical considerations

Ethical approval was obtained from the IRB of the King Abdullah International Medical Research Center, and no funding was obtained for this research. Data collection took place after obtaining informed consent from the participants, who were assured of the confidentiality of their responses and that their participation was voluntary. Questionnaire response data were collected by the authors and captured using Statistical Package for Social Sciences (SPSS) for analysis.

Statistical methods

Descriptive statistics were used to summarize participant characteristics, while inferential statistics, including the chi-square test, were used to identify significant differences and associations between categorical variables such as age, level of education, employment status, parity, and breastfeeding initiation timing. Fischer’s exact test was performed to improve the accuracy and reliability of the chi-square test results, as the assumption that all expected cell frequencies should exceed five was not met. Logistic regression was used to assess the relationship between breastfeeding initiation time and other determinants of breastfeeding practices. Regression analysis coefficients indicated the strength of the association between each determinant and the likelihood of breastfeeding initiation.

Article selection for litrature

We carried out a thorough search of the scientific literature across various electronic bibliographic databases, including PubMed, Scopus, Google Scholar, and Web of Science. The following search terms were used to screen the databases: (breastfeeding OR exclusive breastfeeding OR lactation), (Factors AND initiation of breastfeeding).

Results

Table 1 provides a comprehensive overview of the demographic characteristics of the 449 participants. The majority of participants were between the ages of 30–39 (54.6%), with a mean age of 33.41 years (SD = 7.27). Educational distribution showed that a significant proportion had attained a university or postgraduate level of education (61.5%); the predominant employment status was housewife (66.1%) and most participants were married (96.0%). The average number of deliveries per participant was 2.82 (SD = 2.10), indicating a relatively moderate level of maternal experience; 66.8% of the women were multiparous, and 31.8% were primiparous.

Table 1 Participant demographics (n = 449)

Regarding participants’ most recent childbirth experience, most received antenatal (93.1%) and postnatal care (66.1%). Most reported no complications during delivery (85.5%), and the gestational age of the youngest child was predominantly full-term (74.8%). Newborn weights largely fell within the normal range of 2.5–4.5 kg (56.3%).

Most participants (73.7%) had received breastfeeding education, indicating a high level of awareness. Additionally, 60.1% believed that they should initiate breastfeeding within the first hour, which aligns with the recommended practices for optimal infant health. Notably, only 13.4% of participants did not breastfeed their m child.

Table 2 shows the breastfeeding characteristics of the mothers who reported breastfeeding their newborns. Nearly half of the mothers initiated breastfeeding within the recommended first hour after delivery (46.0%), and breast milk was the predominant first feed (65.2%), indicating a strong preference for natural feeding methods. Most mothers practiced feeding on-demand (68.2%), while 60.0% reported using a breast pump. Breastfeeding concerns were minimal, with 72.7% of participants experiencing no problems. Furthermore, 97.2% reported no child health complications that could affect breastfeeding, reaffirming the positive trend in infant health.

Table 2 Breastfeeding characteristics among mothers who reported breastfeeding their newborn (n = 449)

Mothers largely viewed antenatal (60.4%) and postnatal care (87.7%) as highly beneficial and recognized the importance of breastfeeding within the first hour (87.7%). However, there were varied opinions on formula milk, with 27.8% strongly agreeing that it was more beneficial than breastfeeding, highlighting the need for more nuanced approaches to breastfeeding promotion.

Figure 1 shows the varying duration of breastfeeding by mothers, with the majority breastfeeding for less than 1–2 months (34.0%).

Fig. 1

Breastfeeding duration

Figure 2 depicts the reasons mothers had for delaying the initiation of breastfeeding. Notably, 33.4% of mothers did not delay initiation, while cesarean delivery (21.7%) and lack of breast milk (14.9%) were identified as significant contributors to delayed initiation.

Fig. 2

Reasons for delaying the initiation of breastfeeding among mothers

Table 3 revealed no statistically significant associations but highlighted noteworthy patterns related to breastfeeding timing initiation. Mothers aged 50–59 had the highest percentage of delayed initiation; they did not breastfeed at all in the first hour (83.3%). Mothers with the lowest educational level (illiterate or not studied) had a relatively higher early initiation rate (within the first hour) (66.7%). Regarding employment status, housewives exhibited the highest percentage of breastfeeding initiation within the first hour (48.6%). Mothers who did not receive antenatal care had a higher percentage of breastfeeding initiation within the first hour (47.1%) than mothers who did receive antenatal care.

Table 3 Factors affecting the breastfeeding initiation time

Although not statistically significant, these trends highlight areas for further investigation; they indicate a need for targeted interventions to enhance timely breastfeeding initiation among specific subgroups. Moreover, they demonstrate the need to explore the more nuanced factors that may influence breastfeeding practices. Notably, parity was significantly associated with breastfeeding initiation timing, with multiparous mothers (50.58%) more likely to initiate breastfeeding within the first hour. Mothers who breastfed their latest child showed a significant association with early breastfeeding initiation, with the highest percentage (77.78%) among those who breastfed for 19–24 months. Similarly, breastfeeding mothers had the highest early initiation rate (58.8%). Mothers who fed their babies at no specific time (51.82%) also demonstrated a significant association with timely breastfeeding initiation.

Table 4 presents the regression analysis results, showing that parity (p = 0.044) and delivery complications (p = 0.042) significantly affected breastfeeding initiation. This indicated that multiparous mothers and those with complications during childbirth were less likely to initiate breastfeeding early. However, factors such as age, education, employment status, antenatal/postnatal care, use of breast pumps, and history of breastfeeding problems were not significantly associated with early breastfeeding initiation (p > 0.05). While these factors may influence breastfeeding continuation, they do not appear to determine its early initiation.

Table 4 Logistics regression analysis for factors affecting breastfeeding initiation

Discussion

This study provides insights into the prevalence and factors influencing breastfeeding practices among Saudi mothers. Breastfeeding prevalence was high, with 86.6% of mothers reporting breastfeeding their youngest child. This finding aligns with global breastfeeding promotion efforts. However, only 46.0% of mothers initiated breastfeeding within the first hour. Factors such as age, education level, and employment status showed no statistically significant associations with initiation, but notable trends emerged. Older mothers, those with higher parity, and mothers with lower levels of education demonstrated higher rates of early initiation, suggesting cultural and generational influences. Working mothers faced challenges with the continuation of breastfeeding due to the lack of designated breastfeeding time at work.

Of the participants surveyed, 37% did not allocate time for breastfeeding at work, highlighting the need to raise awareness of breastfeeding rights in the workplace. Workplace support and educational campaigns are recommended to promote the continuation of timely breastfeeding among working mothers. The challenges faced by working Saudi mothers in continuing breastfeeding align with global findings, emphasizing the need for workplace support and policy improvement, including the provision of paid maternal leave and access to breastfeeding rooms. Some workplaces in Saudi Arabia have introduced a “breastfeeding hour” and breastfeeding rooms to support breastfeeding mothers.

Esmaeili et al. [7] found that maternal BMI impacts the birth weight of a newborn, which affects breastfeeding capacity. As suggested by Salehian and Karimi [23], accommodative practices like breastfeeding counseling and education are essential for enhancing exclusive breastfeeding practices among women, especially in low-income settings. Additionally, postpartum mental health issues such as depression should be addressed as they erode breastfeeding mothers’ self-efficacy [24]. T Socioeconomic factors, including whether a pregnancy is desired or unwanted, also impact breastfeeding, warranting targeted interventions [8, 25].

Cesarean section and lack of breast milk supply were the leading factors in delaying the initiation of breastfeeding, highlighting gaps in education and support. Better education and support through breastfeeding clinics in primary healthcare could correct misconceptions and enhance confidence in the practice of exclusive breastfeeding and it’s continuity. These findings align with studies in Saudi Arabia and other regions. Studies in Saudi Arabia [2, 3, 26] show a decline in the duration of breastfeeding, especially among young urban mothers, highlighting the need for interventions. Research in other Eastern Mediterranean countries [27, 28] has shown that various factors including maternal education, cultural beliefs, and workplace support are critical to breastfeeding practices [26, 29, 30]. For example, Al-Jawaldeh noted that the Baby-Friendly Hospital Initiative plays a key role in promoting breastfeeding, but implementation varies by region [26]. Strengthening and adapting these activities to fit different cultural and socioeconomic contexts can significantly influence a mother’s decision to initiate and sustain breastfeeding [31, 32].

This study emphasizes the need for further research on breastfeeding practices among Saudi mothers to identify critical influencing factors. Further studies should explore societal beliefs and social norms [30, 32], as well as examine workplace policies to develop targeted interventions. Analyzing past breastfeeding records can provide valuable insights into trends, outcomes, and areas needing improvement [13]. Moreover, qualitative research could provide a more detailed understanding of mothers’ experiences with breastfeeding initiation and continuation [19, 22].

Given these results, several public health interventions could be implemented to stimulate breastfeeding among mothers in Saudi Arabia. Expanding prenatal and postnatal care services to include breastfeeding education and support can increase the mothers’ awareness and confidence in breastfeeding [19, 22]. Mobile or online nursing stations in primary healthcare clinics and workplaces could support mothers who limit breastfeeding, particularly due to workplace culture [33]. Importantly, government authorities should introduce supportive work policies, such as paid maternity leave and designated breastfeeding spaces, to help working mothers breastfeed more easily. Healthcare providers, policymakers, and communities must collaborate to create a supportive environment that encourages and protects breastfeeding practices [28, 29, 32].

Socioeconomic status is a confounding variable that impacts the initiation of early breastfeeding as it determines the ability of an individual to access healthcare, education, and other support services. For instance, women with high socioeconomic status can afford lactation consultants and benefit from breastfeeding-friendly environments, increasing the likelihood of early initiation and continuing to breastfeed for longer periods. Conversely, women with a lower socioeconomic status may experience poor prenatal care and education, slowing down or hindering breastfeeding onset.

This study has several limitations. The cross-sectional design limits the ability to infer causality from the associations observed, and recall bias affects reliability. Additionally, the study was conducted in one city, which limits generalizability. The high proportion of breastfeeding among mothers could be biased due to the use of convenience sampling. Some data on socioeconomic status were also missing, as they were not answered by the participants; this limits insights into the impact of socioeconomic factors on breastfeeding and weakens conclusions about other factors like maternal age or delivery complications.

Conclusion

This study provides valuable insights into the prevalence and factors influencing breastfeeding practices among Saudi mothers. A high prevalence of breastfeeding indicates a strong cultural commitment, whereas variations in initiation timing and continuation underscore the need for more targeted interventions. Workplace support and educational campaigns are recommended to enhance the continuation of timely breastfeeding, particularly among working mothers.