Barriers of exclusive breastfeeding among mothers attending primary health-care centers in Jazan, Saudi Arabia

ABSTRACT

Background:

Exclusive breastfeeding (EBF) describes infants who were only breastfed for 6 months. Many Saudi mothers have suboptimal breastfeeding practices. Therefore, this study aims to assess breastfeeding knowledge and determine barriers to EBF among mothers attending primary health care centers in Jazan City.

Methods:

A descriptive cross-sectional study was done that included all mothers attending the PHC centers. Data were collected through a self-administered questionnaire.

Results:

Most study participants understand breastfeeding’s health benefits for babies and mothers, but most believe that synthetic milk is the best alternative for working mothers to feed their babies. A percentage of 66.7 of mothers practiced breastfeeding during the first 6 months of the child’s life. EBF shows a significant relationship with knowledge and barriers. Sixty percent of mothers have never had any information about breastfeeding; the primary source was from their mothers and only 31.4% from hospital staff. Most respondents disagreed with statements of barriers to EBF, which elicits an unexpected response.

Conclusions:

Most participants have good knowledge concerning breastfeeding benefits for both mother and infant and disagreed on the mentioned barriers for EBF that include lack of breastmilk, deficiency of information, and working conditions.

Introduction

Breastfeeding is the natural process of providing infants with the essential nutrients needed for average growth and development. Exclusive breastfeeding (EBF) is defined as “infants who were only breastfed since birth; no formula, no water, or liquid supplement.” it is recommended until 6 months of age, with continued breastfeeding by the side of proper complementary foods up to 2 years of age.[1]

Breastfeeding should be initiated during the first hour after birth, as Colostrum is immediately formed after delivery and WHO highly recommends it as the most excellent milk for the newborn.[1] It confers numerous benefits to the infant and mother.[1]

Exclusively breastfed infants for 6 months have less morbidity from a gastrointestinal infection[2] and promotion of EBF could reduce the prevalence of chronic child undernutrition.[2]

Raising breastfeeding practice to a near-universal level could reduce 823,000 annual deaths in children younger than 5 years and 20,000 yearly deaths from breast cancer.[3]

Despite various global initiatives on breastfeeding, data showed that EBF rate has declined over the last decade and has become a concern worldwide due to the valuable benefit of breastfeeding.[4,5]

Mothers need to be supported for their children to be optimally breastfed through the adoption of many policies that were stated by WHO to protect, promote, and support breastfeeding, such as the International Labour Organization’s provision of supportive health services with infant and young children, adoption of the International Code of Marketing of Breast-milk Substitutes, feeding counseling during all contacts with caregivers and young children, such as well-child and sick child visits, and immunization and during antenatal and postnatal care. Implementation of community support, including community-based health promotion, mother support groups, and education activities, is also a valuable strategy that helps and supports mothers for EBF.[6]

Most Saudi mothers have suboptimal breastfeeding practices, as shown in a study conducted in Riyadh, which concluded that only 13.7% of the mothers successfully breastfeed their infants.[7] Several barriers affect breastfeeding; these barriers are linked with single mothers, young mothers, lower income, smoking, full-time employment, and cesarean section. Negative attitudes of mothers, their partners, family members, and health-care professionals could also limit breastfeeding.[8]

Early cessation of breastfeeding among Saudi mothers is mainly due to insufficient breast milk and work-related obstacles, such as busy working hours, absence of privacy at the workplace, and work regulations that do not allow attending children with their mothers.[9]

Women felt that factors that made EBF easier were a desire to have a healthy baby, feeling that breast milk was enough to satisfy the baby and family support. Breast pain and the perceived need to give the baby water and other herbal fluids due to heat or religious practices made EBF difficult. Some women reported that EBF increases workload, and it is time-consuming.[10]

Fortunately, mothers can still safely breastfeed if tested positive for COVID-19. The breastmilk itself does not have any traces of COVID-19, and babies will continue to benefit from the nutrition they get from the breastmilk.[6]

Prevalence of breastfeeding among mothers in the Jazan region was high, but EBF was still below WHO feeding recommendations. Reduced amount of milk was the main reason leading mothers to shift to other alternatives feeding their babies. Another cause that hinders mothers from breastfeeding is being out to work.[11]

The prevalence of EBF of infants at 6 months of age was also low in other parts of Saudi Arabia; it was positively associated with the mother’s awareness of the recommended duration of EBF and negatively associated with mothers with Saudi nationality, babies born with low birth weights, cesarean deliveries, and among working mothers.[12]

The most mentioned barriers to breastfeeding in Jeddah in nearly one-third of women included false ideas about small amounts of breast milk produced by lactating women, lack of knowledge about breastfeeding and easiness of usage, and liberal availability of formula within the community after birth. Surprisingly, more educated women and those with higher incomes show less knowledge about breastfeeding.[13]

Previous studies concluded that technical support, workplace environment, and high maternal breastfeeding knowledge were significantly associated with the longer duration of EBF. At the same time, barriers to EBF were a grandmother’s lack of support for EBF, breast engorgement, and receiving formula samples at discharge from hospitals after delivery.[14,15]

Baby-friendly support, counseling regarding breastfeeding during antenatal care and hospitalization for delivery, and special training of health staff provided through health facility services significantly improved EBF practice.[4,16]

Several studies showed that grandmothers play a dominant role in infant feeding practices; most women described the grandmother (i.e., mother of study participant or mother-in-law) as a critical influencer of feeding practices, either through providing advice on the early introduction of foods or actively feeding the infant during the first 6 months, with or without the mother’s consent.[4,17]

Early initiation and duration of EBF are greatly affected by breastmilk substitutes displayed directly to consumers via print advertisements and mass media and indirectly via free supplies, incentives, and promotions to and through health workers, facilities, and policymakers.[18]

Objectives: This study aims to determine barriers to EBF and assess breastfeeding knowledge among mothers attending primary health-care centers in Jazan, Saudi Arabia.

Materials and Methods

Study design: Study area

This is a descriptive cross-sectional study conducted at primary health-care centers in Jazan City, Southwestern Saudi Arabia, from February 2018 to December 2018 to answer the following research questions:

• (1)To what extent do mothers know the benefits of breastfeeding?
• (2)What are the mothers’ perceived breastfeeding barriers?
• (3)Do mothers’ knowledge and perceived barriers differ by their sociodemographic factors?
• (4)Is there any correlation between mothers’ knowledge and perceived barriers?

Four primary health-care centers in Jazan city were selected for the study out of the 9 centers in the city with average daily mothers’ attendance of about 180 mother–infant pairs representing different geographic areas and social backgrounds (coastal area, mountain area, plane, and high social).

Study population

All the mothers attending with their babies to the selected PHC were enrolled in the study (total coverage).

Sample size

The sample size was estimated at 400 women calculated according to the formula:

Based on the values, n = 0.5.

Desired marginal error = 0.05 and z or (confidence level 95%) = 1.96, expected nonresponsive rate 10% and design effects 1.5.

Inclusion criteria

Only the current child was included in this study for all mothers with healthy infants aged from 0 to 2 years.

Exclusion criteria

Babies who were ill or had a congenital malformation were excluded from participation in the study.

Data collection

Data were collected using a self-administered questionnaire on participants’ sociodemographic characteristics, breastfeeding knowledge, and EBF barriers for all mothers who attended with their babies to the PHC for vaccination during the study period.

The survey asked about EBF, breastfeeding only with no other food or liquid, including water, except for drops or syrups of vitamins, mineral supplements, or medicine.

Mothers were asked about their intention to breastfeed their infants (preplanned) and previous successful experience with EBF. The survey also explored the sources of mothers’ information and motivation for breastfeeding as a possible factor influencing their plans and practice and asked for barriers that could hinder EBF.

Instruments

Three-part questionnaires consisted of the following:

• (1)The sociodemographic data,
• (2)the breastfeeding knowledge, and
• (3)the perceived breastfeeding barriers.

The sociodemographic data covered mother information, maternal history, previous breastfeeding experience, and housekeeper availability.

The researchers developed breastfeeding knowledge questions based on the WHO and UNICEF breastfeeding recommendations for optimal infant feeding. Likert’s scale categorized responses to the knowledge questions.

The perceived breastfeeding barrier questions were chosen based on most identified barriers in the literature. The total score was calculated by summing the individual scores and high scores indicating more mothers’ barriers. Three experts validated the content validity of the questionnaire: two expert pediatricians and one talented community physician.

A pilot study was conducted to validate the questionnaire on 30 Saudi mothers from the target population to assess all study questions’ reliability and cultural unity, followed by a series of modifications performed in the form after reviewing in a state of rewording only that helped refine the questionnaire.

Data management and analysis plan

Data were coded, entered, and analyzed using the Statistical Package for Social Sciences version 16 for Windows. These data were presented using descriptive statistics that include frequencies, percentages, means, and standard deviations. Inferential statistics were also used to examine the significance of comparison and correlation between the study variables using many tests like the T-test and ANOVA test. A P < 0.05 was used as a significance level.[17,19]

Ethical issues

An informed written consent was obtained from all participants. Data confidentiality and privacy was maintained throughout the research.

Ethical approval was obtained from the Jazan Directorate of Health Affairs, Research Ethics Committee on 02/April/2018G, Registry no 063.

Results

Response rate

The overall response rate was 94%, expressing a high response rate because the questionnaires were given to respondents one by one.

Respondent’s demographic information

Mothers’ age group 26–30 years represents the sample’s highest rate (30.6%). A percentage of 66.9 of the study sample were Saudi mothers, 73.0% of them have secondary and university education, 75.8% of the mothers have one to three children, 54.7% of babies were male babies, and 45.3% were female, 61.4% were less than 12 months, and all had a nearly similar order distribution. A percentage of 76.4 have an acceptable standard of living, as shown in Table 1.

Table 1.

Demographic data of the respondents

Variable	Frequency n=360	Percentage
Mother age
<20 years	21	5.8
20-25 years	94	26.1
26-30 years	110	30.6
31-35 years	81	22.5
36-40 years	40	11.1
>40	14	3.9
Mother nationality
Saudi	241	66.9
Non-Saudi	119	33.1
Mother education
Illiterate	23	6.4
Primary school	28	7.8
Intermediate school	46	12.8
Secondary school	106	29.4
Graduate/Postgraduate	157	43.6
Baby gender
Male	197	54.7
Female	163	45.3
Baby age
<6 months	109	30.3
6-12 months	112	31.1
13-18 months	62	17.2
19-24 months	67	18.6
Child order in the family
First	88	24.4
Second	94	26.1
Third	76	21.1
Other	96	26.7
Family standard of living
Below the level	28	7.8
Acceptable l	275	76.4
Above the level	36	10.0
Mother work
Housewife	237	65.8
Working mother	91	25.3
Student	24	6.7
Number of children
1 Child	93	25.8
2-3 children	180	50.0
4-6 children	64	17.8
More than 6 children	17	4.7
Having housemaid
Yes	39	10.8
No	314	87.2

Mother’s information and practice about EBF

The majority of mothers (59.7%) had no information about breastfeeding; those who knew the primary source were from their mothers. A percentage of 92.8 of the respondents breastfed their babies, with only 7.2% didn’t do it at all. Sixty percent decided to practice breastfeeding during pregnancy, while 34.2% agreed after birth. Sixty percent of the studied group practiced EBF during the first 6 months of the child’s life without using any other food, while 27% did not do that. Only 28.9% of the mothers continued EBF for 6 months, 6.7% for 5 months, 11.7% for 2–4 months, and 19.4% less than 2 months, as shown in Graph 1.

Graph 1.

The mother’s source of information and practice about breastfeeding. BF: Breastfeeding

Descriptive statistics of mother’s knowledge

Regarding the extent of mothers’ knowledge about the benefits of breastfeeding, most participants agreed with 14 from 21 statements measuring mothers’ knowledge about breastfeeding and breast milk. They disagreed with five false information, indicating that most study participants understand breastfeeding’s health benefits for babies and mothers with good awareness and a high level of breastfeeding. They agreed that breast milk is the optimum food; mothers should keep EBF for up to 6 months; it is more comfortable to digest, cheaper than artificial milk, protects children from constipation, diseases, and obesity; the child who feeds with breast milk acquires movement skills earlier. Breastfeeding strengthens the emotional relationship between child and mother, protects mothers from breast cancer, helps uterine contractions, and protects them from postpartum hemorrhage. However, they still agreed that synthetic milk is the best alternative for working mothers to feed their babies, reflecting a gap of knowledge about the best infant feeding choice as shown in Table 2.

Table 2.

Mother’s knowledge about breastfeeding

Variable	Agree		Strongly agree		Not sure		Disagree		Strongly disagree
	n	%	n	%	n	%	n	%	n	%
Breast milk is the optimum food for the infant	299	83.1	31	8.6	6	1.7	7	1.9
BM is better than synthesis milk for the infant	266	73.9	41	11.4	11	3.1	22	6.1	4	1.1
No benefits of breastfeeding for the infant after 6 months	93	25.8	38	10.6	47	13.1	109	30.3	59	16.4
Breastfeeding strengthens the emotional relationship between the child and the mother	291	80.8	46	12.8	4	1.1	5	1.4	3	0.8
BM is easier to digest than the synthesis milk	273	75.8	58	16.1	14	3.9	3	0.8	1	0.3
BM is cheaper compared to synthesis milk	296	82.2	43	11.9	8	2.2	1	0.3	1	0.3
BF protects from diseases	245	68.1	66	18.3	36	10.0	1	0.3
BF protects the mother from B cancer	227	63.1	61	16.9	61	16.9	1	0.3
BF protects the child from obesity	179	54.7	80	22.2	66	18.3	7	1.9	1	0.3
BF protects the mother of osteoporosis	121	33.6	68	18.9	127	35.3	15	4.2	14	3.9
The mother should keep exclusive BF up to 6 months	134	37.2	87	24.2	53	14.7	48	13.3	22	6.1
BF helps uterus contractions and protect from postpartum hemorrhage	233	64.7	66	18.3	40	11.1	3	0.8	7	1.9
Children who depend on breast milk have less constipation	205	56.9	89	24.7	46	12.8	6	1.7	2	0.6
Children who feed with BM acquire movement skills quicker	179	49.7	84	23.3	68	18.9	15	4.2	4	1.1
SM best alternative for working mothers’ baby	104	28.9	130	36.1	41	11.4	55	15.3	21	5.8
BM has a lack of iron	15	4.2	33	9.2	97	26.9	123	34.2	81	22.5
Children who feed on BM are more exposed to obesity than those feed with SM	79	21.9	33	9.2	59	16.4	117	32.5	62	17.2
The mother who uses SM lose a lot of mother’s pleasure	143	39.7	63	17.5	42	11.7	65	18.1	29	8.1
SM is a healthy food as the BM	19	4.4	53	14.7	39	10.8	143	39.7	94	26.1
Children who feed with SM healthier than those on BM	18	5.0	25	6.9	44	12.2	148	41.1	113	31.4
SM children are cleverer than those of the BM	10	2.8	17	4.7	67	18.6	127	35.3	120	33.3

BF: Breastfeeding, BM: breastmilk, SM: synthetic milk

Descriptive statistics of breastfeeding barriers

In response to perceived breastfeeding barriers, most respondents disagreed with the 16 barrier statements as shown in Graph 2. This was an unexpected response.

Graph 2.

Barriers of breastfeeding. BF: Breastfeeding

Analysis of variance

The association between mothers’ knowledge and perceived barriers and the effect of sociodemographic factors was analyzed. The study found that Saudi mothers have less understanding about breastfeeding than non-Saudi mothers; the difference is statistically significant (P = 0.007). In contrast, it had no significant effect on the obstacles of breastfeeding.

Baby gender and housemaid factor have nothing to do with the mother’s knowledge or the barriers to breastfeeding, as shown in Table 3.

Table 3.

T-test analysis for mother’s nationality, baby gender, and having housemaid with knowledge and barriers

Dependent variables	Demographic variable	n	Mean	Sig. (two-tailed)
Mother’s nationality
Knowledge	Saudi	229	8.2192	0.007
	Non-Saudi	118	7.6458	0.007
Barriers	Saudi	167	17.0659	0.095
	Non-Saudi	84	14.5357	0.085
Baby gender
Knowledge	Male	188	7.9521	0.777
	Female	158	8.0089	0.776
Barriers	Male	140	15.7714	0.479
	Female	109	16.7982	0.477
Housemaid
Knowledge	Yes	39	7.8103	0.508
	No	312	8.0199	0.477
Barriers	Yes	27	18.5926	0.284
	No	224	16.1205	0.249

The study revealed that maternal age has a significant relation with knowledge, but not significant toward barriers, while mother education has no significant association with both knowledge and barriers. Baby order shows a significant relation toward both knowledge and barriers. The standard of living shows no significant relation toward knowledge but is highly influential with barriers. Baby’s age has no significant association with knowledge and barriers. The mother’s work shows a significant association toward knowledge but not significant with barriers. The number of children factor reveals significant relation with knowledge but not significant with barriers as shown in Table 4.

Table 4.

One-way ANOVA test for some demographic factors with knowledge and barriers variables

Dependent variables	Sum of squares	Df	Mean square	F	Sig.
Mother age
Knowledge
Between groups	44.369	5	8.874	2.612	0.025
Within groups	1185.600	349	3.397
Total	1229.970	354
Barriers
Between groups	256.786	5	51.357	0.399	0.850
Within groups	32,339.759	251	128.844
Total	32,596.545	256
Mother education
Knowledge
Between groups	12.570	4	3.143	0.903	0.462
Within groups	1217.399	350	3.478
Total	1229.970	354
Barriers
Between groups	510.195	4	127.549	1.002	0.407
Within groups	32,086.349	252	127.327
Total	32,596.545	256
Baby age
Knowledge
Between groups	6.001	3	2.000	0.567	0.637
Within groups	1209.202	343	3.525
Total	1215.203	346
Barriers
Between groups	45.756	3	15.252	0.119	0.949
Within groups	31,586.648	246	128.401
Total	31,632.404	249
Baby order
Knowledge
Between groups	30.512	3	10.171	3.091	0.027
Within groups	1145.227	348	3.291
Total	1175.740	351
Barriers
Between groups	1183.423	3	394.474	3.188	0.024
Within groups	30,685.256	248	123.731
Total	31,868.679	251
Standard of living
Knowledge
Between groups	3.494	2	1.747	0.514	0.598
Within groups	1134.518	334	3.397
Total	1138.012	336
Barriers
Between groups	1682.701	2	841.351	6.997	0.001
Within groups	28,737.799	239	120.242
Total	30,420.500	241
Knowledge
Between groups	36.820	2	18.410	5.430	0.005
Within groups	1176.459	347	3.390
Total	1213.278	349
Barriers
Between groups	694.214	2	347.107	2.721	0.068
Within groups	31,508.186	247	127.564
Total	32,202.400	249
Number of children
Knowledge
Between groups	46.363	3	15.454	4.551	0.004
Within groups	1181.680	348	3.396
Total	1228.043	351
Barriers
Between groups	866.136	3	288.712	2.285	0.079
Within groups	31,464.940	249	126.365
Total	32,331.075	252

The study showed that attending a training course about the importance of breastfeeding has no effect on breastfeeding knowledge and barriers, while the time of decision for practicing breastfeeding has significant results for both breastfeeding knowledge and barriers. Also, it showed that mothers who practiced EBF during the first 6 months of their child’s life without using any other food show a significant relationship with breastfeeding knowledge and barriers as shown in Table 5.

Table 5.

T-test analysis of information and practices with the knowledge and barriers variables

Dependent variables	Demographic variable	n	Mean	Sig. (two-tailed)
Information about BF
Knowledge	Yes	140	7.8257	0.100
	No	213	8.1587	0.099
Barriers	Yes	94	17.3723	0.341
	No	159	15.9686	0.331
The decision to take breast milk or synthetic milk
Knowledge	During pregnancy	217	7.7982	0.000
	After birth	123	8.4943	0.001
Barriers	During pregnancy	140	14.9786	0.013
	After birth	99	18.6364	0.013
An experience of EBF during the last 6 months
Knowledge	Yes	208	7.8212	0.002
	No	134	8.4448	0.002
Barriers	Yes	135	15.0222	0.015
	No	107	18.5701	0.015

EBF: Exclusive breastfeeding

The source of breastfeeding information has no significant relation with both knowledge and barriers. The period that mothers practiced EBF during the first 6 months of the child’s life without using any other food shows a significant relationship with knowledge but not significant with barriers, as shown in Table 6.

Table 6.

One-way ANOVA test for the source of information and practice with knowledge and barriers

Dependent variables	Analysis of variance	Sum of squares	Df	Mean square	F	Sig.
Source of information
Knowledge	Between groups	6.923	4	1.731	0.530	0.714
	Within groups	1103.318	338	3.264
	Total	1110.241	342
Barriers	Between groups	357.688	4	89.422	0.703	0.590
	Within groups	30,511.112	240	127.130
	Total	30,868.800	244
Duration of exclusive breastfeeding
Knowledge	Between groups	82.379	3	27.460	10.032	0.000
	Within groups	703.434	257	2.737
	Total	785.812	260
Barriers	Between groups	664.141	3	221.380	1.840	0.142
	Within groups	20,696.808	172	120.330
	Total	21,360.949	175

Discussion

The majority of the study participants know breastfeeding’s health benefits for babies and mothers, as shown in Table 2, comparable to similar studies in Saudi Arabia showing that two-thirds (62%) had good knowledge regarding breastfeeding’s health benefits for mothers and babies.[20]

The study concluded that maternal age was positively correlated with mothers’ knowledge, indicating that older mothers have more understanding about breastfeeding; this result supported previous Saudi Arabian studies.[12] Baby order shows a considerable relation toward both knowledge and barriers, while the standard of living shows no significant association toward breastfeeding knowledge but is highly influential with barriers. The study detected that most participants practiced breastfeeding (92.8%), and only 7.2% did not. Sixty-six percent practiced EBF during the first 6 months of the child’s life, and 27.2% did not do that. Sixty percent of the participants decided to practice breastfeeding during pregnancy while 34.2% agreed after birth. Only 28.9% of the mothers continued EBF for 6 months, 6.7% for 5 months, 11.7% for 2–4 months, and 19.4% less than 2 months, as shown in Graph 1, comparable to previous studies that reported prevalence of 26.9% EBF at Jazan.[11] Another study reported that only 13.7% of all infants were exclusively breastfed at 6 months.[15]

A review of the EBF rate in Saudi Arabia reported that rates range from 0.8% to 43.9%.[5] Prior research studies in Tabuk, Saudi Arabia, have presented that EBF was practiced by 31.4% of mothers for the first 6 months of their infant’s life.[12] Approximately 59.7% of mothers reported that they did not receive information about breastfeeding. The grandmother was the most common source of breastfeeding information reported by participants (93.3% compared to similar studies.[17]

Prior studies in Saudi Arabia showed that approximately 45% of mothers reported not receiving breastfeeding information. In contrast, only 31.1% received information from hospital staff and 10.7% from a training course. Education in the postpartum ward was the most common location reported by participants (44.6%), whereas only 29.9% received information during antenatal care and 16.9% at well-baby clinics.[7] Regarding breastfeeding duration, it was found that there is a positive correlation to the mothers’ knowledge; that was reported similarly by previous studies in Saudi Arabia, which stated that there is a reasonably good relationship between knowledge related to breastfeeding and actual practice. The analysis showed no relation between attending a training course about the importance of breastfeeding and participant knowledge and breastfeeding barriers. There is a meaningful relationship between the time of the decision to practice breastfeeding and knowledge of breastfeeding. It was found that the most common defect of knowledge cited by the studied group was that they believe that synthetic milk is the best choice for working mothers for their infant feeding.

Most respondents disagreed with the 16-item statements as barriers, as shown in Graph 2, which grabs attention to unexpected responses. Prior studies in Saudi Arabia reported that employment was negatively associated with breastfeeding.[12] Other studies concluded that the most common perceived barriers for EBF among Saudi mothers were embarrassment from lactation in public places (83.2%),[8] lack of knowledge, returning to work or school, contraception, and insufficient milk.[8,21,22]

Maternal work and understanding of the benefits of EBF were the most common maternal–infant factors that acted as an obstacle and a facilitator for EBF, respectively; thus, interventions targeted toward maternal–infant factors will significantly enhance and optimize EBF and, ultimately, improve maternal–child health outcomes.[22]

Limitations of the study

This study is a cross-sectional design with a minimal sample size. There is a need for other studies using other designs like a cohort study to discover the root causes for the low rate of breastfeeding practice to increase the prevalence and awareness of mothers and the whole community about the value and benefits of breastfeeding.

Conclusion

The study concluded that Saudi mothers at Jazan city have good knowledge of EBF comparable to many previous Saudi Arabia studies with a high percentage of practicing breastfeeding initially but not preserved and the only defect in understanding was that synthetic milk is the best choice for working mothers for their infant feeding, reflecting the knowledge gap concerning the expressed breast milk, which is the best option for their infant feeding; this finding would be helpful and valuable for conducting a suitable strategies and programs at hospital or community level for encouragement for EBF.

It is recommended that breastfeeding practices in the Kingdom of Saudi Arabia be studied nationally and extensively using more appropriate research designs like cohort studies to present more accurate and valid results. Breastfeeding promotion programs should work hard to raise maternal awareness about the importance of EBF and the option of using the expressed breast milk for working mothers. Breastfeeding remains the most cost-effective way to reduce the risk of mortality, obesity, hypertension, eczema, and type 2 diabetes in later life.[21]

Grandmothers greatly influence EBF and feeding practices, so programs that seek to affect EBF should include grandmothers in their interventions to achieve maximum impact.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Author contributions

G.A.G. conceived and designed the study, drafted and revised the manuscript, and critically reviewed results. M.M.E. conceived the idea, provided research materials, wrote the initial and final draft of the article. S.M.S. designed the work and critically reviewed the manuscript. A.A.M. collected the data and assisted in result interpretation. A.A.A. collected data and assisted in result interpretation. A.O.A. analyzed and interpreted data, drafting the work. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.