The breastfeeding initiation rate, defined as the proportion of infants who received any breastfeeding whatsoever within the first 48 hours, was found to be 100%, which is similar to a study of health care workers in the same area (south western Saudi Arabia). Other Saudi Arabian studies have reported breastfeeding initiation rates ranging between 92 and 98%[9, 11, 12]. Only 119 of the participants (31%) complied with the WHO recommendations of starting breastfeeding within one hour of delivery.
Sustained exclusive breastfeeding up to six months without any supplement was reported by only 8.3% of participants. This figure is better than what has been reported by other Saudi Arabian and US studies. However, it is lower than the figure from a Ugandan study (49.8%) and from a health care workers’ study (15.9%).
The most important reason given by the participants for initiating breastfeeding was their Islamic religious background (56.6%), which is practiced by all of them. It is most likely related to the Islamic teaching in the Holy Quran which states “And mothers shall breastfeed their children for two whole years, for those who desire to complete the appropriate duration of breastfeeding”. This finding is different from the health care workers’ study where the main reason was the child health (43.7%), followed by religious background (17.2%). It is worth mentioning that 55% of the health care workers in the study population were non-Muslim.
The breastfeeding was stopped at a mean age of 8.7 ± 7.8 months. The most common reason given for stopping breastfeeding was insufficiency of breast milk (44% of the participants), which is similar to other studies[12, 19]. In fact, about 5% of women actually had physiologic insufficient milk supply, although up to (50%) or more reported that they perceived insufficient milk for their baby[20, 21]. Thus, insufficient milk supply was considered to be more perceived than ‘real’. The next most important factor for early cessation of breastfeeding was work-related problems (38.5%). It is somewhat less than what was reported by the health care workers (45.7%).
The effect of these two factors is likely to be the reason that most of the participants shifted to formula feeding by six month (91.7%). It also could explain, to some extent, the high rate of using readymade liquid formula while in hospital (66.7%). Such practice is to the contrary of WHO recommendations in the ten steps initiative for successful breastfeeding, and to the recommended practice of baby friendly hospitals[23, 24]. This practice might be attributed to the willingness of the mother to train their baby to use formula from a young age due to the pressures of work environments unsuitable for breastfeeding.
It has been found that hospitals and work places without facilities for breastfeeding can undermine breastfeeding. Cohen and Mrtek showed that women employed by business establishments which were "breastfeeding friendly" were able to maintain a breastfeeding regimen for at least six months; rates comparable to those of women who were not employed outside the home.
Inadequate comprehensive maternity leave policies, lack of child care facilities at or near the workplace, rigid time schedules that do not allow for nursing breaks, lack of facilities providing privacy for breast-pumping and absence of facilities for refrigeration of pumped breast milk are among factors that affect breastfeeding prevalence among working mothers[26, 27]. The maternity leave for working mothers in Saudi Arabia is very well outlined; she is entitled to 60 days leave with full salary and up to 3 years at 25 percent of her salary.
To breastfeed future children was the intention of the majority of participants (90.1%). It is similar to an earlier report from Saudi Arabia. Such an attitude is one of the strongest predictors of breastfeeding initiation and duration.
Only a small number of participants (1.3%) disagreed with the idea of feeding colostrum or claimed ignorance of its benefits; similar to what was reported from other part of the country. This finding was contrary to what was reported by Singh et al. in 1997, where 77% of mothers from the District of Rajasthan, India, discarded colostrum and to what has been reported recently from other parts of India, where 15 to 60% of studied women still discard colostrum[31, 32].
Low rates of knowledge regarding the appropriate duration of exclusive breastfeeding (28.9) and the time when complementary food should be introduced (30.7%), in conjunction with very low rates of attending classes related to breastfeeding issues during pregnancy (8.6%) are important factors in limiting breastfeeding prevalence. It also indicates the crucial role of health care providers and peer support to pregnant women and breastfeeding mothers. Such support, as well as face-to-face and pre- and postnatal classes, has been proven to be effective in reducing early cessation of breastfeeding and was a very effective way to promote breastfeeding prevalence[33, 34].
Our study population, consisting of only female school teachers, may have limitations in not being applicable to other working Saudi women. Other factors which may limit generalization of our findings include cultural differences between this Educational District and other Saudi provinces and the inclusion of women whose youngest children were aged two months and five years, since this may affect accurate recall in responding to the questionnaire.