Perspectives of mothers regarding infant swaddling and hip health in Riyadh, Saudi Arabia: Behavioral trends and associated determinants

Abstract

Background:

Infant swaddling that restricts physiological hip flexion and abduction has been identified as a modifiable postnatal risk factor for developmental dysplasia of the hip (DDH). Despite increasing biomechanical evidence linking improper swaddling techniques to adverse hip development, caregiver-related determinants of hip-safe swaddling practices remain insufficiently characterized in Middle Eastern populations.

Objective:

To assess maternal knowledge of DDH and safe swaddling practices and to examine socio-demographic and informational factors associated with knowledge adequacy among mothers residing in Riyadh, Saudi Arabia.

Methods:

A cross-sectional web-based survey was conducted among mothers with at least one child aged ≤ 5 years living in Riyadh. Data were collected using a previously validated questionnaire assessing DDH awareness and swaddling practices. Knowledge scores were calculated and categorized using predefined thresholds. Associations between socio-demographic characteristics and knowledge levels were examined using Pearson’s Chi-squared test.

Results:

Among 436 respondents, the mean DDH knowledge score was 67%, while knowledge of correct swaddling practices averaged 46.9%. Higher maternal educational attainment and receiving infant care information from healthcare professionals were independently associated with adequate DDH knowledge. Early DDH screening before 6 months of age was also independently associated with adequate swaddling-related knowledge. Reliance on informal information sources, including family members and social networks, was more frequently observed among participants with lower knowledge scores.

Conclusion:

Maternal awareness of DDH does not consistently translate into knowledge of appropriate hip-safe swaddling techniques. Integration of anticipatory guidance on safe infant positioning into routine pediatric preventive care may represent a modifiable pathway for reducing caregiver-related DDH risk exposures during early infancy.

Introduction

Infant caregiving practices during the early postnatal period play a critical role in musculoskeletal development, particularly regarding modifiable positioning-related risk factors. Developmental dysplasia of the hip (DDH) is a common pediatric orthopedic condition characterized by abnormal acetabular and femoral head development, potentially leading to long-term functional impairment if not identified and managed early.[1] Delayed diagnosis is associated with increased likelihood of surgical intervention and persistent functional limitations, highlighting the importance of early identification and preventive postnatal care.[2]

Among modifiable postnatal risk factors, infant positioning practices have gained increasing attention. Traditional swaddling that restricts lower limb movement with forced hip extension and adduction has been consistently identified as a risk factor for DDH.[3] Biomechanical evidence suggests that restricting physiological hip flexion and abduction during early infancy may impair acetabular development and increase the risk of hip instability.[4] In contrast, hip-safe swaddling that allows free lower limb movement is associated with more favorable hip maturation.[5] Despite this, swaddling remains widely practiced due to its perceived benefits in soothing, thermoregulation, and sleep.[6] Studies in Saudi Arabia report a high prevalence of swaddling with variability in technique and awareness of its musculoskeletal implications.[7]

Maternal knowledge and perception of DDH risk factors may vary based on access to health information and educational resources.[8] Community-based studies in Saudi populations demonstrate variable awareness of DDH risk factors, early management, and preventive practices.[9] Caregiver surveys indicate that family members and social networks are common sources of infant care advice, alongside healthcare professionals and digital media.[10] Cultural norms and nonmedical advice may further influence caregiving behaviors, including swaddling practices.[11] Although prior regional studies have evaluated maternal awareness of DDH, limited data exist on maternal perceptions of swaddling in relation to infant hip health and the role of knowledge and information sources in shaping caregiving practices in urban Saudi populations, such as Riyadh.[12]

Therefore, this study aimed to assess maternal perspectives on infant swaddling and hip health and to examine factors associated with knowledge, information sources, and caregiving practices among mothers in Riyadh, Saudi Arabia. The findings of this study provide clinically relevant insights for primary care physicians and pediatric healthcare providers by identifying gaps in maternal knowledge and caregiving practices and highlighting the need for targeted educational interventions to improve early prevention strategies and reduce the risk of DDH in infants.

Materials and Methods

Study design and participants

This cross-sectional study evaluated maternal knowledge and perceptions regarding infant swaddling and DDH in Riyadh, Saudi Arabia. We recruited mothers residing in Riyadh who had at least one child aged 5 years or younger using a non-probability convenience sampling approach. Residency in Riyadh was self-reported by participants. Eligible participants included mothers aged 18 years and above who were able to read and understand Arabic or English and consented to participate in the study. We excluded mothers without children or those who did not complete the questionnaire. A total of 436 mothers were included in the final analysis.

Ethical considerations

The Institutional Review Board (IRB) of Imam Mohammad Ibn Saud Islamic University approved the study protocol before data collection (Project No. 908/2026; Approval Date: February 10, 2026). The study adhered to the ethical principles outlined in the Declaration of Helsinki. Participation was voluntary, and electronic informed consent was obtained through the survey’s introductory page before participation. All responses were collected anonymously, and no personally identifiable information was recorded.

Sample size and sampling

We estimated the minimum required sample size using an online sample size calculator (Raosoft Inc., Seattle, WA, USA), assuming a 95% confidence level, a 5% margin of error, and a response distribution of 50%. The minimum required sample size was 385 participants. We recruited participants using a non-probability convenience sampling approach through online distribution of the questionnaire. A total of 436 eligible mothers completed the questionnaire and were included in the final analysis, exceeding the minimum required sample size.

Study instrument

We used a structured questionnaire based on a previously published and validated instrument assessing maternal swaddling practices and awareness of DDH.[7] The questionnaire was administered in both Arabic and English and comprised items evaluating socio-demographic characteristics, knowledge related to DDH, perceptions regarding swaddling practices, and awareness of appropriate swaddling techniques. We retained the original knowledge-related items assessing DDH awareness and swaddling practices. Each correct response was assigned one point, and incorrect or “I do not know” responses were assigned zero. Total knowledge scores were calculated and expressed as percentages. Based on previously applied thresholds in similar knowledge–attitude–practice (KAP) studies, participants were categorized into good (≥60%) and poor (<60%) knowledge groups.

Data collection

We collected the data between February 11 and February 19, 2026, following IRB approval. Participants completed a structured, self-administered electronic questionnaire created using Google Forms. The questionnaire was configured to accept a single response per participant to minimize duplicate submissions. The questionnaire remained accessible throughout the data collection period, and we included only fully completed responses in the final analysis.

Data analysis

We performed all statistical analyses using R software (version 4.3.1; R Foundation for Statistical Computing, Vienna, Austria). We summarized categorical variables as frequencies and percentages. We calculated knowledge scores based on correct responses and expressed them as percentages. We categorized participants into good (≥60%) and poor (<60%) knowledge groups for both DDH-related and swaddling-related knowledge domains. We used Pearson’s Chi-squared test to examine associations between socio-demographic characteristics and knowledge levels. We considered a P value of less than 0.05 as statistically significant. We excluded incomplete responses from the analysis, and no imputation for missing data was performed.

Results

Overall, 436 mothers completed the questionnaire. Most participants were aged 26–45 years, with the largest proportion in the 36–45 year age group (167; 38%). The majority were married (383; 88%) and Saudi nationals (277; 64%). Nearly half had three to four children (212; 49%), and most had at least a secondary level of education (secondary or higher: 327; 75%), while 163 (37%) were not employed. Approximately two-thirds of the mothers (288; 66%) had heard about DDH, with doctors (33%) and social media (25%) reported as the main sources of information. Additionally, 271 mothers (62%) reported that one of their children had previously undergone clinical evaluation or screening for DDH by a healthcare provider. Among those reporting prior DDH evaluation, the assessment most commonly occurred between 6 and 12 months of age (123; 43%). Nearly half of the participants (213; 49%) also reported a positive family history of the condition [Table 1]. The distribution of overall knowledge scores is illustrated in Figure 1.

Table 1.

Socio-demographic characteristics of mothers

Mothers characteristic		n=436
Mother age
18–25		88 (20%)
26–35		135 (31%)
36–45		167 (38%)
>45		46 (11%)
Marital status
Married		383 (88%)
Widowed/Divorced		53 (12%)
Nationality
Non-Saudi		159 (36%)
Saudi		277 (64%)
Number of children
1–2		157 (36%)
3–4		212 (49%)
5 or more		67 (15%)
Educational level
Below secondary		109 (25%)
Secondary		192 (44%)
University degree or higher		135 (31%)
Employment status
Healthcare worker/student		41 (9.4%)
Non-healthcare worker/student		232 (53%)
Not employed		163 (37%)
Monthly household income
>5,000 SAR		136 (31%)
SAR 5,000–10,000		213 (49%)
SAR 10,001–15,000		87 (20%)
Heard about developmental dysplasia of the hip
Yes		288 (66%)
No		148 (34%)
If yes, what was your main source of information?
Academic study or course		37 (10%)
Affected family member		76 (21%)
Doctor		123 (33%)
Friend		20 (5.4%)
Others		19 (5.2%)
Social media		93 (25%)
Reported prior DDH clinical evaluation or screening in any child
Yes		271 (62%)
No		165 (38%)
If yes, age at reported DDH evaluation
<6 months		91 (32%)
Months 6–12		123 (43%)
1–2 years		56 (20%)
>2 years		13 (4.6%)
Family history of developmental dysplasia of the hip
Yes		213 (49%)
No		223 (51%)

Values are presented as n (%)

Figure 1.

Overall mean of mothers’ knowledge of DDH. DDH = Developmental dysplasia of the hip

Mothers demonstrated varying levels of awareness regarding DDH and its management. Most participants (366; 84%) believed that the disease can be prevented. Nearly half (196; 45%) reported that a patient with congenital hip dislocation can walk, while 147 (34%) were unsure, and 93 (21%) believed the child could not walk. The majority identified non-surgical treatment as the preferred management when DDH is diagnosed early (361; 83%), and surgical treatment as the preferred option when diagnosed late (352; 81%). Regarding expected outcomes, 318 mothers (73%) anticipated a complete cure after treatment, and most (372; 85%) agreed that early treatment is better than waiting. With respect to complications of neglected DDH, uneven leg length (269; 62%) was the most frequently identified complication, followed by hip wear (262; 60%), hip pain (261; 60%), limping (231; 53%), and inability to walk (214; 49%), while 70 (16%) reported other complications [Table 2].

Table 2.

Summary of mother responses for DDH and its related management

Characteristic		n=436
Disease can be prevented
Yes		366 (84%)
No		70 (16%)
A patient with a congenital hip dislocation can walk
I do not know		147 (34%)
No		93 (21%)
Yes		196 (45%)
Preferred treatment if diagnosed early
Non-surgical		361 (83%)
Surgical		75 (17%)
Preferred treatment if diagnosed late
Non-surgical		84 (19%)
Surgical		352 (81%)
Expected outcome after treatment
Complete cure		318 (73%)
Partial cure		118 (27%)
Is early treatment better than waiting
Yes		372 (85%)
No		64 (15%)
Expected complications if treatment is neglected
Hip wear		262 (60%)
Hip pain		261 (60%)
Inability to walk		214 (49%)
Limping		231 (53%)
Uneven leg length		269 (62%)
Others		70 (16%)

Values are presented as n (%)

Figure 1 illustrates the distribution of mothers’ overall knowledge scores regarding DDH. The mean knowledge score was 67%. Most scores ranged between 60% and 85%, while a smaller proportion of participants scored below 40%.

Maternal age showed a statistically significant association with knowledge of DDH (P < 0.001). Participants aged 26–45 years were more frequently represented in the good knowledge group compared with the poor knowledge group. Educational level was also significantly associated with knowledge classification (P = 0.013), with higher educational attainment more frequently observed in the good knowledge group. Previous awareness of DDH demonstrated a significant association with knowledge level (73% in the good knowledge group vs. 55% in the poor knowledge group; P < 0.001). The primary source of information was also significantly associated with knowledge classification (P = 0.010), as a greater proportion of mothers in the good knowledge group reported doctors as their main source of information (38% vs. 26%), whereas reliance on social media was more frequently reported among mothers in the poor knowledge group (31% vs. 22%). In addition, age at reported DDH evaluation among those reporting prior clinical evaluation was significantly associated with maternal knowledge (P = 0.002), with diagnosis before 6 months more frequently reported among mothers in the good knowledge group (39% vs. 19%), while diagnosis between 6–12 months was more commonly reported in the poor knowledge group (52% vs. 39%) [Table 3].

Table 3.

Mothers’ knowledge of DDH by their socio-demographics

Mothers characteristic		DDH knowledge				P 2
		Good n=268		Poor n=168
Mother age						<0.001
18–25		63 (24%)		25 (15%)
26–35		96 (36%)		39 (23%)
36–45		93 (35%)		74 (44%)
>45		16 (6.0%)		30 (18%)
Marital status						0.2
Married		240 (90%)		143 (85%)
Widowed/Divorced		28 (10%)		25 (15%)
Nationality						0.2
Non-Saudi		105 (39%)		54 (32%)
Saudi		163 (61%)		114 (68%)
Number of children						0.2
1–2		97 (36%)		60 (36%)
3–4		136 (51%)		76 (45%)
5 or more		35 (13%)		32 (19%)
Educational level						0.013
Below secondary		80 (30%)		29 (17%)
Secondary		111 (41%)		81 (48%)
University degree or higher		77 (29%)		58 (35%)
Employment status						0.5
Healthcare worker/student		22 (8.2%)		19 (11%)
Non-healthcare worker/student		147 (55%)		85 (51%)
Not employed		99 (37%)		64 (38%)
Monthly household income						0.6
<5,000 SAR		80 (30%)		56 (33%)
SAR 5,000–10,000		136 (51%)		77 (46%)
SAR 10,001–15,000		52 (19%)		35 (21%)
Heard about developmental dysplasia of the hip						<0.001
Yes		195 (73%)		93 (55%)
No		73 (27%)		75 (45%)
If yes, what was your main source of information?						0.010
Academic study or course		28 (12%)		9 (6.5%)
Affected family member		45 (20%)		31 (22%)
Doctor		87 (38%)		36 (26%)
Friend		13 (5.7%)		7 (5.1%)
Others		7 (3.0%)		12 (8.7%)
Social media		50 (22%)		43 (31%)
Reported prior DDH clinical evaluation or screening in any child						0.11
Yes		175 (65%)		96 (57%)
No		93 (35%)		72 (43%)
If yes, age at reported DDH evaluation						0.002
1–2 years		35 (19%)		21 (21%)
<6 months		72 (39%)		19 (19%)
Months 6–12		71 (39%)		52 (52%)
>2 years		5 (2.7%)		8 (8.0%)
Family history of developmental dysplasia of the hip						0.3
Yes		137 (51%)		76 (45%)
No		131 (49%)		92 (55%)

Values are presented as n (%). ²Pearson’s Chi-squared test; significant at P<0.05. DDH, developmental dysplasia of the hip

Figure 2 shows that 382 mothers reported using swaddling, while 54 reported no usage. Among mothers who used swaddling, the most commonly reported duration was 3 months (140; 36.6%) or 4 months (110; 28.8%). Smaller proportions reported using swaddling for 2 months (62; 16.2%), more than 4 months (32; 8.4%), 1 month (23; 6%), or less than 1 month (15; 3.9%).

Figure 2.

Mothers’ perception of swaddling and their duration of use

A total of 174 mothers (39.9%) identified snug upper limbs with loose legs as the appropriate swaddling method. Most participants (341; 78.2%) reported that swaddling can damage bones and joints. Responses were divided regarding whether swaddling causes hip dislocation, with similar proportions answering yes (147; 33.7%), no (148; 33.9%), or unsure (141; 32.3%). Additionally, 330 mothers (75.7%) agreed that hip dysplasia is less common in populations where swaddling is not practiced [Table 4].

Table 4.

Summary of mothers’ responses to swaddling-related questions

Question		Response		n=436
Correct way of swaddling		Complete restriction with a band		95 (21.8%)
		Legs straight and tightly together		167 (38.3%)
		Upper limbs snug, legs loose		174 (39.9%)
Swaddling damages bones and joints		No		95 (21.8%)
		Yes		341 (78.2%)
Swaddling causes hip dislocation		I do not know		141 (32.3%)
		No		148 (33.9%)
		Yes		147 (33.7%)
Hip dysplasia is less common where swaddling is not practiced		No		106 (24.3%)
		Yes		330 (75.7%)

Values are presented as n (%)

The distribution of mothers’ knowledge of correct swaddling is presented in Figure 3. The mean score was 46.9%, with the majority of mothers falling into the poor knowledge category.

Figure 3.

Overall mean of mothers’ knowledge of correct swaddling

Maternal age showed a statistically significant association with swaddling knowledge (P < 0.001). Mothers aged 26–35 years were more frequently represented in the good knowledge group, whereas older age groups (36–45 and above 45 years) were more frequently represented in the poor knowledge group. Educational level was also significantly associated with swaddling knowledge classification (P < 0.001), with higher educational attainment more frequently observed in the good knowledge group. Previous awareness of DDH was significantly associated with swaddling knowledge level (76% in the good knowledge group vs. 62% in the poor knowledge group; P = 0.007). In addition, age at reported DDH evaluation among those reporting prior clinical evaluation was significantly associated with swaddling knowledge (P < 0.001), with evaluation before 6 months more frequently reported in the good knowledge group (52% vs. 24%) [Table 5].

Table 5.

Mothers’ knowledge of swaddling by their socio-demographics

Mothers characteristic		Swaddling knowledge				P 2
		Good n=119		Poor n=317
Mother age						<0.001
18–25		26 (22%)		62 (20%)
26–35		57 (48%)		78 (25%)
36–45		29 (24%)		138 (44%)
>45		7 (5.9%)		39 (12%)
Marital status						0.8
Married		106 (89%)		277 (87%)
Widowed/Divorced		13 (11%)		40 (13%)
Nationality						0.2
Non-Saudi		50 (42%)		109 (34%)
Saudi		69 (58%)		208 (66%)
Number of children						0.5
1–2		41 (34%)		116 (37%)
3–4		63 (53%)		149 (47%)
5 or more		15 (13%)		52 (16%)
Educational level						<0.001
Below secondary		41 (34%)		68 (21%)
Secondary		35 (29%)		157 (50%)
University degree or higher		43 (36%)		92 (29%)
Employment status						0.081
Healthcare worker/student		12 (10%)		29 (9.1%)
Non-healthcare worker/student		52 (44%)		180 (57%)
Not employed		55 (46%)		108 (34%)
Monthly household income						0.3
<5,000 SAR		40 (34%)		96 (30%)
SAR 5,000–10,000		51 (43%)		162 (51%)
SAR 10,001–15,000		28 (24%)		59 (19%)
Heard about developmental dysplasia of the hip						0.007
Yes		91 (76%)		197 (62%)
No		28 (24%)		120 (28%)
If yes, what was your main source of information?						0.2
Academic study or course		13 (12%)		24 (9.2%)
Affected family member		16 (15%)		60 (23%)
Doctor		43 (41%)		80 (31%)
Friend		3 (2.8%)		17 (6.5%)
Others		7 (6.6%)		12 (4.6%)
Social media		24 (23%)		69 (26%)
Reported prior DDH clinical evaluation or screening in any child						0.4
Yes		78 (66%)		193 (61%)
No		41 (34%)		124 (39%)
If yes, age at reported DDH evaluation						<0.001
1–2 years		4 (4.7%)		52 (26%)
<6 months		44 (52%)		47 (24%)
Months 6–12		35 (41%)		88 (44%)
>2 years		2 (2.4%)		11 (5.6%)
Family history of developmental dysplasia of the hip						0.5
Yes		62 (52%)		151 (48%)
No		57 (48%)		166 (52%)

Values are presented as n (%). ²Pearson’s Chi-squared test; significant at P<0.05. DDH, developmental dysplasia of the hip

Sources of learning swaddling practices are illustrated in Figure 4. Most mothers (202; 46.3%) reported learning from family members, followed by healthcare providers (96; 22%), social media (65; 14.9%), friends (41; 9.4%), and other sources (20; 4.6%). A small proportion (12; 2.8%) reported having no source of information.

Figure 4.

Mothers’ source of learning swaddling

Figure 5 shows that 290 mothers (66.5%) reported that they would stop using swaddling if they knew it could cause harm, while 146 (33.5%) indicated that they would continue the practice.

Figure 5.

Mothers’ perception of using swaddling if they knew it could cause harm

Discussion

The present study highlights a discrepancy between general awareness of DDH and knowledge of appropriate preventive caregiving practices. Although mothers demonstrated moderate awareness (mean score 67%), knowledge of safe swaddling techniques remained lower (46.9%), suggesting that awareness does not necessarily translate into appropriate caregiving behavior. Similar gaps between knowledge and practice have been reported in previous studies evaluating preventive infant care behaviors.[13]

These findings are consistent with previous studies conducted in Saudi Arabia, which reported moderate awareness of DDH among mothers but limited understanding of preventive practices.[8] Other regional studies have similarly demonstrated variability in caregiver awareness and knowledge of DDH.[9] Research conducted in comparable populations has also highlighted gaps between knowledge and caregiving practices.[12] However, the present study extends prior work by specifically examining the gap between disease awareness and knowledge of hip-safe swaddling techniques. In addition, it identifies information sources and timing of clinical evaluation as key factors influencing caregiving practices. Unlike earlier studies that primarily focused on awareness, this study provides insight into caregiving behavior and its determinants within an urban Saudi population.

This knowledge–practice gap may be explained by differences in caregiver health literacy and interpretation of preventive health information. Caregiver health literacy is a key determinant of pediatric health outcomes, influencing the ability to understand risks and implement recommended practices.[14] In the context of DDH, caregivers may recognize the condition but lack specific knowledge regarding modifiable postnatal risk exposures such as restriction of physiological hip flexion and abduction during swaddling. In addition, established caregiving habits, perceived benefits of swaddling, and cultural norms may limit translation of awareness into practice. Caregivers may also perceive a trade-off between infant comfort and potential musculoskeletal risk.

Our findings underscore the influence of nonmedical information pathways on caregiving practices. Nearly half of participants reported learning swaddling techniques primarily from family members rather than healthcare providers, reflecting the role of culturally transmitted norms in shaping infant care behaviors. In Saudi settings, caregiving responsibilities are often shared within extended family systems, facilitating intergenerational transmission of practices independent of formal clinical guidance.[15] Furthermore, the timing of reported DDH evaluation may reflect missed opportunities for early caregiver education. Evaluations were most commonly reported between 6 and 12 months, whereas early intervention is most effective during the first months of life when acetabular remodeling potential is highest.[16]

Although two-thirds of participants indicated they would discontinue swaddling if informed of potential harm, a substantial proportion reported willingness to continue. This may reflect an intention–behavior gap, where knowledge does not consistently translate into behavioral change. Integration of anticipatory guidance within routine pediatric visits has been shown to improve caregiver adherence to recommended practices.[17]

From a clinical perspective, these findings highlight an opportunity for pediatric primary care providers to incorporate anticipatory guidance on safe swaddling techniques into routine well-child consultations. Embedding caregiver education within preventive services may reduce modifiable positioning-related risk exposures associated with DDH. Recent evidence further emphasizes the importance of hip-safe swaddling practices in supporting healthy hip development.[18] Additional studies highlight the role of early caregiver education in improving preventive infant care practices.[19]

This study has several limitations. The use of convenience sampling and self-reported data may introduce recall and reporting bias. The online survey design may limit generalizability to populations with lower digital access. The absence of objective behavioral observation limits verification of reported practices. Additionally, the cross-sectional design precludes causal inference.

Future research should evaluate structured caregiver education programs, including antenatal counseling and digital health interventions, to improve safe infant positioning practices and reduce DDH risk during early infancy.

Conclusion

Maternal awareness of DDH did not consistently translate into knowledge of safe swaddling practices, highlighting a gap between disease recognition and behaviorally relevant preventive caregiving practices. These findings underscore an opportunity for pediatric primary care providers to integrate anticipatory guidance on safe swaddling techniques within routine preventive care encounters during early infancy to support safer infant positioning practices.

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of Imam Mohammad Ibn Saud Islamic University (Project No. 908/2026). Informed consent was obtained from all participants before participation.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

All authors contributed to the study conception and design, data collection, analysis, and manuscript preparation. All authors reviewed and approved the final manuscript.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.