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Demographic Information
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Mother’s age:
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……………. years
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Marital status:
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Married
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Divorced
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Widowed
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Separated
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Education level:
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Illiterate
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Primary school
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Intermediate school
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High school graduate
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Bachelor’s degree
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Master’s degree
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Doctorate degree
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Family income:
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Class 1 <5,000 SAR
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Class 2 >5,000–10,000 SAR
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Class 3 >10,000–15,000 SAR
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Class 4 >15,000 SAR
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Employed
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Yes
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If yes what is your current salary…………………… SAR
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No
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Medical history
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Have you ever been diagnosed with any chronic disease:
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Yes
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If yes, what are ………………………
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No
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Did you have any medical problems that prevented you from feeding your baby:
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Yes, specify…………………………
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No
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Pregnancy history (M = male) (F = female)
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Number of pregnancies
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………………………………
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Number of live births
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M………………… F……………
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Number of miscarriages
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M…………………… F…………
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Number of children who were breastfed:
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M…………………… F…………
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How long did you wait before getting pregnant again after your last child?
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………………………………. Months
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Any complications during previous pregnancies
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………………………………
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Mode of delivery of the last child:
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Vaginal delivery
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Cesarean section
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Type of health facility:
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Public health facility
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Private health facility
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Last baby’s age: ……………. Months
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Last baby’s gender
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Male
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Female
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Birth weight of the last baby:………….. gram
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Any mother complications during the last pregnancy:
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Yes …………….
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No
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Any mother complications during the postpartum period
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Yes………….
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No
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Any mental health problems, such as postpartum depression
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Yes ………….
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No
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Did your last child have any complications at birth:
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Yes
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If yes, what was it……………
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No
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How many antenatal clinics have you attended:
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…………………..
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How many postnatal clinics have you attended:
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…………………..
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Have you attended any breastfeeding counseling?
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Yes
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No…if no, go to question 28.
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How many times have you attended breastfeeding counseling?
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…………………………
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Which of the following was discussed during breastfeeding counseling?
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Why breastfeeding is important
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Advantages and benefits of breastfeeding for both the mother and the baby
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How to breastfeed a baby, including positioning and attachment
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How to deal with pain or discomfort during breastfeeding
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How to return to work and continue breastfeeding.
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How to troubleshoot common breastfeeding problems
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While you were in the hospital for the delivery of this baby, did anyone help you with breastfeeding by talking to you or showing you how to breastfeed your baby?
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Yes
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No
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How long after your baby was born did you start breastfeeding?
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During the first hour of delivery
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2–24 hours
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>24 hours
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Not breastfed at all
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How long did you exclusively breastfeed your baby?
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………………Months
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If you stop breastfeed your baby what were your reasons for stopping breastfeeding?
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Not producing enough milk
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Going back to work
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Having pain while breastfeeding
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A medical condition that made it difficult to breastfeed
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Pressure by family or friends to stop breastfeeding
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Other (please specify):……………….
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Mother’s knowledge of EBF
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When is the best time to start breastfeeding:
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Within the first hour of delivery
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Within the first 24 hours of delivery
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Within the first 3 days of delivery
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Within the first week of delivery
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How important is it to you to breastfeed your baby?
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Not important at all
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Not very important
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Somewhat important
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Very important
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Extremely important
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Breastfeeding is not recommended for birth parents who have:
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Hepatitis C
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Tuberculosis that has been treated
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Diabetes
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HIV
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Mother’s attitude toward EBF
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A mother who is breastfeeding exclusively is most likely to:
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Have a lower risk of postpartum depression
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Lose weight more quickly after childbirth
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Have a lower risk of breast cancer
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Have a lower risk of ovarian cancer
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All of the above
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What would make you more likely to breastfeed exclusively?
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Having a strong support system
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Learning more about the benefits of EBF
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Having access to lactation support
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Feeling confident in my ability to breastfeed
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All of the above
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What would make you less likely to breastfeed exclusively?
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Having to return to work early
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Having concerns about my milk supply
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Feeling pressure from others to formula feed
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Not having enough time to breastfeed
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All of the above
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How likely are you to breastfeed your baby?
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Very unlikely
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Somewhat unlikely
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Neither likely nor unlikely
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Somewhat likely
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Very likely
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Mother’s practice toward EBF
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Have you breastfed your last child?
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Yes
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No
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How frequently did you breastfeed your last child?
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On-demand
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Regularly
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Randomly
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Perceived susceptibility:
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How likely do you think it is that your baby will get sick if you do not breastfeed exclusively?
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Very likely
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Somewhat likely
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Not very likely
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Not at all likely
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Perceived seriousness:
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How serious do you think it is for your baby to get sick if you do not breastfeed exclusively?
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Very serious
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Somewhat serious
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Not very serious
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Not at all serious
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Perceived benefits:
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How beneficial do you think it is to breastfeed your baby exclusively?
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Very beneficial
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Somewhat beneficial
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Not very beneficial
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Not at all beneficial
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Perceived barriers:
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What are the barriers that you think might prevent you from breastfeeding your baby exclusively?
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I don't have enough time to breastfeed
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I'm not sure how to breastfeed
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I'm worried about my milk supply
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I'm worried about my baby getting sick
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Other (please specify):
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Cues to action:
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What would motivate you to breastfeed your baby exclusively?
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My doctor told me it’s the best thing for my baby
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I want to give my baby the best start in life
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I want to save money on formula
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I want to bond with my baby
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Other (please specify):
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