SUDANESE JOURNAL OF PAEDIATRICS

2023; Vol 23, Issue No. 2

ORIGINAL ARTICLE

Knowledge, perception and acceptability of breastfeeding and bottle feeding among Saudi population

Sarah Alruwaily (1), Nazish Masud (2,3), Haya Alshaibani (1), Maha Sheikho (1), Meshael Alshoaibi (4), Asma Awadalla (1,2)

(1) Department of Pediatrics, King Abdullah Children Specialist Children Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

(2) Research Unit, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

(3) King Abdullah International Medical Research Center, Riyadh, Saudi Arabia

(4) Department of Pediatrics, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia

Correspondence to:

Sarah Alruwaily

Department of Paediatrics, King Abdullah Children Specialist Children Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.

Email: alruwailysa [at] ngha.med.sa

Received: 15 October 2022 | Accepted: 20 July 2023

How to cite this article:

Alruwaily S, Masud N, Alshaibani H, Sheikho M, Alshoaibi M, Awadalla A. Knowledge, perception and acceptability of breastfeeding and bottle feeding among Saudi population. Sudan J Paediatr. 2023;23(2):177–186.

https://doi.org/10.24911/SJP.106-1665846928

ABSTRACT

Despite the enormous benefits of breastfeeding (BF), its prevalence is suboptimal, with exclusive BF ranging between 7.3 % and 51% in the Saudi community. The aim of this study was to assess the Saudi community’s knowledge regarding BF, exposure to BF promotional messages and formula milk advertisements and acceptability of BF in public places. It was a cross-sectional study that included Saudis aged 20–55 years old between December 2019 and June 2020. It utilised a self-administered questionnaire, which asked about background information, knowledge of BF, exposure to BF-promoting messages and exposure to formula milk advertisements and acceptability of BF versus bottle feeding in public. Data were analysed using the Statistical Package for the Social Sciences (SPSS v. 22). For the analysis, a p-value <0.05 was considered significant. The sample included for analysis was 914. The mean age of participants was 33.8 ± 9 years. The majority of participants were female 823 (90%); males 87 (10%). The vast majority (94%) agreed that breast milk is more beneficial than formula milk. Nearly two-thirds (61%) were continuously exposed to messages advertising formula feeding, compared to only 35% who were exposed to messages promoting BF. The study found that 67.2% accept BF in public places. Among male participants, only 49% accepted BF in public places compared to 79% of female participants who accepted it; p-value <0.001. Acceptability of BF in public places was significantly higher among participants who had family members who breastfed (68%), compared to those who did not (50%), (p-value 0.01).

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KEYWORDS:

Breastfeeding; Perception; Knowledge; Acceptance; Public; Promotion; Formula milk; Advertisement.

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INTRODUCTION

There is no doubt about the enormous benefits of breastfeeding (BF) both for the infant and the mother. These include protection from infectious diseases, atopic dermatitis and cardiovascular and behavioural disorders [1]. It also helps mothers to return to pre-pregnancy weight, increases bonding between the mother and child and decreases maternal depression [2]. Unfortunately, the prevalence of BF is not optimal and varies between countries [3,4]. The rate of exclusive BF varies by region as well, ranging between 7.3% and 51% in Saudi Arabia [5–8].

Many local studies have explored the factors positively or negatively influencing BF. One study determined that older maternal age, multiparity, rural residence and being a housewife were positively associated with exclusive BF. Conversely, higher education, higher family income, oral contraceptive use and chronic maternal illness decrease exclusive BF [9]. Another study showed that maternal employment, caesarean section delivery and low birth weight decrease BF rates [7]. Working mothers are two-fold less likely to breastfeed exclusively than unemployed mothers [10]. Caesarean section delivery carries twice the risk of failure of exclusive BF compared to vaginal delivery [9]. The use of a pacifier is also associated with a decreased BF rate [7]. Another risk factor is the lack of BF education sessions, increasing the risk of nonexclusive BF [8]. BF Hospital Initiatives (BFHIs) are very effective in increasing exclusive BF. It has been reported that healthcare professional-led interventions during antenatal and postnatal periods increased this rate [11].

It was found that most Saudi women in Riyadh, participating in one study, have a neutral attitude toward BF and good knowledge about it. The most common perceived barrier to BF among them was embarrassment from BF in public places [12]. This study aimed to assess the knowledge and perception of the Saudi community regarding BF. Exposure to BF and formula milk advertisements and acceptability of BF in public was studied.

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MATERIALS AND METHODS

A cross-sectional survey was conducted from December 2019 to June 2020. Adult Saudi males and females between the ages of 20–50 years were included. The survey was initially planned as a self-administered hard copy. Later, however, the data collection was affected by the unprecedented lockdowns and social distancing restrictions due to the COVID-19 pandemic which led to changing the mode of data collection. Based on the 2019 General Saudi Population Census from the General Authority for Statistics, Saudi Arabia, a majority of the Saudi community uses social media: 98.07% of males above the age of 15 and 97.6% of females above 15 [13]. Therefore, the survey was distributed through social media (WhatsApp and Twitter).

Data collection tool and pilot testing

The data were collected utilising a questionnaire used in a 2015 Hong Kong survey report, translated for the current study [14]. The World Health Organisation guidelines on Translation steps were used to translate the questionnaire [15]. After the initial translation process, the questionnaire was pilot tested with 39 participants, fitting our inclusion criteria. Based on the participant’s feedback, the items which were not clear were rephrased and reworded. The final survey was validated for content by two research unit members well-versed in Arabic and English. After all comments were incorporated, the survey was ready for data collection.

The questionnaire contained multiple-choice answers. It contained four sections: demographic, knowledge, exposure and perception sections. The demographic section included gender, age, family members in the household and medical insurance. The knowledge section included items on participants’ knowledge about BF benefits compared to bottle feeding. The exposure section assessed participants’ exposure to promotional messages about infant feeding, including BF versus bottle feeding and the sources of these messages. The perception section had questions regarding exposure to BF and bottle feeding in public places, acceptability of BF in a public place and reasons for acceptability or nonacceptability of BF in public.

Statistical analysis

The data were collected using a Microsoft Excel sheet and checked for completeness. A total of 1,020 people participated in the survey. After data cleaning, the final sample included for analysis was 914. The data were analysed using IBM^® SPSS^® Statistics version 22. The initial frequencies were run for all variables. The descriptive statistics for categorical variables like type of milk, channels of information and advertisement and acceptability of BF were reported as the percentage and frequencies out of the total participants who answered the corresponding variable. The numerical variables, such as age, were reported as means and SDs. Age was further stratified into three groups, 20–29, 30–39 and 40–55 years. All the results were summarised in tables and figures as suitable. The association of demographic profile and exposure to educational material about BF with the acceptability of BF in public was assessed using a chi-square test. For predictors of the acceptability of BF in public places, logistic regression analysis was used with forward conditional modelling. The odds ratio and 95% confidence interval were reported for included variables. The p-value <0.05 was considered significant for all the tests applied.

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RESULTS

Summary of demographic profile

A total of 1,020 people participated in the survey. After the initial screening, 106 participants were excluded as they did not fulfil the inclusion criteria (36 were above 55 years old, and 70 were aged less than 20 years old). The final sample included for analysis was 914.

The mean age of participants was 33.8 ± 9 years. Participants’ age was categorised into three groups: 20–29 years old, 30–39 years and 40 years and above, with the following percentages, respectively (38%, 33% and 29%). Most participants were female, 823 (90%). Educational level was categorised into: elementary 14 (2%), intermediate 22 (2%), high school 139 (15%) and college-level 731 (81%). Fifty-three percent of participants did not have medical insurance, while 425 (47%) had medical insurance. The majority of those with insurance were not aware whether formula milk was included or not in the insurance. A majority of participants 837 (93%) have family members who had ever practiced BF (Table 1).

Exposure toward promotional material related to infant feeding

When asked whether breast milk or formula milk is more beneficial to the health of babies, 856 (94%) reported breastmilk as more beneficial compared to formula milk. In addition, participants were also asked about exposure to educational or promotional material regarding infant feeding. Almost two thirds were continuously exposed to promotional messages on formula feeding (546, 61%), compared to only 321 (35%) being exposed to educational material on BF. All participants (100%) who have been exposed to messages regarding infant feeding (breastmilk or formula milk) have been exposed through electronic media (television and radio), 72% of these messages were promoting formula milk, compared to only 28% promoting BF. The exposure through flyers, posters and booklets was 94% with better promotion of BF than formula feeding (58% and 37%, respectively). Participants exposed to infant feeding promotional messages and educational material through the internet constituted 87% (45% regarding formula milk and 42% regarding BF). A total of 59% were exposed at malls and exhibitions (49% exposure to formula milk advertisement and 11% to BF promotion). Healthcare providers were the main source for 57% of participants, 14% of them promoting formula milk in some way and 43% promoting BF. Exposure through newspapers and magazines was in 40% of participants (Figure 1a and b).

Acceptability of BF in public places

The study found that 603 (67%) of participants accept BF in public places. Reasons for accepting BF in public places were the mother and child have the right to BF anywhere (454, 76%), and BF is natural (396, 66%). Of the 182 (33%) who do not accept BF in public places, the reasons were the mother should breastfeed her child in a special area for BF (129, 74%), BF in public is inappropriate (53, 31%) and BF makes the participant and others feel uncomfortable or embarrassed (33, 19%) (Table 2).

Table 1. Demographic profile of the participants (n=914).

Variables	Category	Frequency	Percentage
Age (years)	Mean ± SD	33.8 ± 9.3
Age categories n=806	20–29 years	307	38
	30–39 years	265	33
	40 years and above	234	29
Gender n=910	Male	87	10
	Female	823	90
Educational level n=906	Elementary	14	2
	Intermediate	22	2
	High school	139	15
	University/college level	731	81
Monthly income n=870	Less than 5,000 SR	269	31
	5,000–10,000 SR	243	28
	11,000–15,000 SR	182	21
	16,000–20,000 SR	84	10
	More than 20,000 SR	92	11
Medical insurance n=898	Yes, I have	425	47
	No, I do not have	473	53
Does your health insurance include baby/child formula milk? n=577	Yes	41	7
	No	274	48
	I do not know	262	45
Do/did any of your family members ever breastfeed? n=903	Yes	837	93
	No	66	7
Are any of your family members above 60 years of age? n=903	Yes	698	77
	No	205	23
If yes, are they n=697	Male	151	22
	Female	182	26
	Both	364	52

n, Number; SD, standard deviation.

Association of demographic profile with acceptability of BF in public

There was a significant difference between male and female acceptability of BF in public places with male acceptability 49% versus female acceptability (79%, p-value <0.001).

Moreover, having a family member who ever breastfed significantly increased the acceptability of feeding the child in public places, p-value=0.004. The age of the participant, educational level or income did not show a statistically significant association with acceptance of BF in public places (Table 3).

Figure 1. Frequency of educational material for BF or promotional messages for bottle feeding and formula milk.

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DISCUSSION

Research has shown BF to be beneficial for both child and mother [16,2]. Almost all the participants in this study, 94%, agreed that the benefit of breast milk is more than formula milk. More than three quarters of participants had higher education in the current study, which could be one of the reasons for the high awareness found about BF benefits. Despite this high awareness of these benefits, BF rates have been declining for the last two decades [17]. In Gulf Cooperation Council countries, the marketing of breast milk substitutes was found to be one of the determinants of low rates of BF [18].

The current study investigated the Saudi community’s exposure to promotional messages of BF and advertisements of formula milk. Methods of promoting BF and advertising formula milk are various. The participants in our study received these messages mainly through electronic media (TV and radio). Unfortunately, 72% of this content was promotional for formula milk compared to only 28% promoting BF. More effort at a national level is needed to utilise electronic media as a target for promoting BF. In addition, in malls and exhibitions, families are getting messages promoting formula feeding more than BF. These are strategic areas for family education about BF.

Table 2. Awareness and perception related to infant feeding in public places (N=914).

Items*	N	%
Is BF or formula milk feeding more beneficial for the health of babies?
BF is more beneficial	856	94%
Formula feeding is more beneficial	4	0%
Both are equally beneficial	36	4%
I do not know/no comment/Hard to say	14	2%
What was the content of the educational material or promotional messages about BF you have encountered?
BF is beneficial to the baby’s health	203	27%
BF is beneficial to the mother’s health	137	18%
BF is beneficial to the baby’s and mother’s health	653	86%
BF promotes mother-baby bonding	521	69%
For what age group was the advertisement or promotional message about formula milk?
New-born to 6 months	153	19%
6 months and older	108	14%
All ages	416	52%
I do not know	121	15%
In which public places have you seen a mother BF her child?
A mall	313	50%
Restaurant	139	22%
Park/playground	189	30%
Public transport (bus/train/plane)	111	18%
Hospital/clinic waiting room	480	76%
Why is the presence of a mother BF her child near you in a public place (definitely acceptable) or (acceptable)?
BF is natural	396	66%
The mother and child have the right to BF anywhere	454	76%
The BF mother does not bother anyone	319	54%
BF is beneficial to the mother/child/both	299	50%
Why is the presence of a mother BF her child near you in a public place (definitely unacceptable) or (unacceptable)?
BF makes me and others feel uncomfortable or embarrassed	33	19%
BF in public is inappropriate	53	31%
The mother should breastfeed her child in a special area for BF	129	74%

*Each item was asked as a separate variable; only percentages for the category ‘yes’ are presented in the table. N, number.

Table 3. Association of participant profile with the acceptability of BF in public.

Variables	Categories	Disapprove BF		Approve BF		p-value*
		N	%	N	%
Age categories	20–29 years	62	24	198	76	0.68
	30–39 years	50	21	184	79
	≥40 years	43	21	164	79
Gender	Male	32	51	31	49	<0.001*
	Female	150	21	572	79
Higher education	No higher education	38	25	112	75	0.49
	Higher education	143	23	487	77
Monthly income	Less than 5,000 SR	51	23	176	78	0.44
	5,000–10,000 SR	45	22	159	78
	11,000–15,000 SR	46	28	117	72
	16,000–20,000 SR	18	25	54	75
	More than 20,000 SR	15	18	67	82
Medical insurance	Yes, I have	93	25	279	75	0.35
Does your health insurance include baby/child formula milk?	Yes	9	25	27	75	0.96
	No	56	23	188	77
	I don’t know	51	23	167	77
Have any family members ever breastfed?	Yes	161	22	564	78	0.01*
Family members above 60 years of age?	Yes	143	24	465	77	0.69
Have you ever encountered educational material or promotional messages about BF?	Yes, continuously	58	20	231	80	0.10
Have you ever encountered advertisements or promotional messages about formula milk?	Yes, continuously	108	22	376	78	0.02*
Have you ever seen a mother BF her child in a public place like a mall, restaurant, park, and so on?	Yes, continuously	21	18	95	82	<0.001*
Have you ever seen a child fed formula milk in a public place like a mall, restaurant, park, and so on?	Yes, continuously	143	22	513	78	0.03*
Do you recommend the following or similar statements posted in a public area: (-BF mothers and their children are welcome -The team will not disturb a BF mother -The team will help any mother BF her child)	Support idea	112	17	550	83	<0.001*

*The chi-square statistic is significant at the 0.05 level. BF, Breastfeeding; N, Number.

Our study found the percentage of participants who received messages regarding BF from healthcare professionals was only 43%, which is very low, considering the vast majority of deliveries in Saudi Arabia are in hospitals. Healthcare professionals play an extremely important role in empowering mothers both to initiate and establish exclusive BF and overcome challenges leading to the cessation of BF. Visits to the hospital for antenatal and paediatric appointments and hospital stays of mothers before and after delivery are opportunities for BF promotion. At a national level, policymakers have a pivotal role in implementing BFHI [19]. In the outpatient setting, time waiting for antenatal, paediatric appointments, or primary healthcare visits can be utilised to advocate for BF [20]. Also, a very valuable opportunity during the hospital stay of mothers before and after delivery can be utilised.

Regarding exposure to feeding of infants and children in public places, a majority reported continuously having seen a mother bottle feeding her infant compared to a smaller portion seeing a mother breastfeed in public places. These public places are mainly hospitals and clinic waiting areas. Even if formula feeding is given only outside the home, this will ultimately lead to the failure of exclusive BF [21].

One of the advantages of this study is including males, as their role in promoting BF is essential. It was found in a meta-analysis that targeting fathers in the promotion of BF increased the rate of exclusive BF at 6 months, and also increased mothers’ knowledge and improved mothers’ attitudes toward BF [22]. However, the response rate for males in the current study was low (only 10%). Among male participants, only 49% accept BF in public places, compared to 79% acceptance among female participants. Having a family member who had been breastfed was found to be associated with the acceptability of BF in public places. Education level, monthly income and age were not found to have any significant effect on the participants’ acceptability of BF in public places. Since having family members who breastfed affected the acceptability of BF among participants; and age, income and educational level did not, it appears that culture and social norms among the family are a more powerful influencer of BF acceptability than socioeconomic status.

Since BF in public was not found in our study to be highly acceptable among the community, and since embarrassment is a major barrier to exclusive BF as found in a previous study, the provision of designated BF areas in public places is urgently needed. The majority of participants who viewed BF in public as unacceptable, agreed that mothers should breastfeed their children in special areas for BF. The finding is consistent with other studies, where people think that exposing breasts in public places is not acceptable [23]. Some Asian and African countries even consider public nursing a criminal act [24]. A simple solution is the provision of areas for BF in public places such as parks and malls (BF-friendly environment), as well as in the workplace, especially with the higher rates of women’s employment in public places. In Saudi Arabia, almost all of the malls and shopping markets have female prayer areas. An additional small, designated room for nursing could be included. The idea is similar to existing changing rooms next to the restrooms.

The current study highlights the important idea of public acceptability of BF but has some limitations as well. The cross-sectional design itself can assess the association but is unable to establish the impact of intervention in an actual setting. In addition, the overall number of male participants was less in the study. The logistic regression modelling was applied to control the confounding; however, it can lack the true representation of the male acceptability of BF in the community. The other limitation of the study is an online survey, which can introduce response bias leading to over or under-presentation of the true perception of the community. The initial idea was to conduct the study face to face; however, the COVID-19 restrictions were implemented during the initial data collection phase. Therefore, the mode of data collection was shifted to e-survey.

Future studies should involve more male participants to get a more accurate perception of society as a whole. In addition, we recommend the focus of BF promotion be shifted from antenatal and postnatal mothers to fathers. Most of the existing interventions are either in the form of BF lessons for antenatal or postnatal women. The antenatal checks can be taken as an opportunity to promote BF in the presence of both partners. Any intervention for the promotion of mother and child health is incomplete without the involvement of male partners. Fathers can play a significant role in the promotion of BF. In addition, the malls and shopping areas are the most often visited leisure areas in Saudi Arabia. The promotion of BF-friendly environments is a small intervention but can go a long way in the promotion of BF.

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CONCLUSION AND RECOMMENDATIONS

The study concludes high awareness about the benefits of BF compared to formula milk. BF in public places was significantly less approved by Saudi males. Continuous exposure to advertising messages for formula feeding is more common than exposure to BF promotional messages. Electronic media should be utilised for mass media communication channels to promote BF. BF promotion efforts should target fathers as well as mothers.

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ACKNOWLEDGEMENTS

The authors would like to extend their sincere appreciation to Lina Altaf, Tala Alalula, Hamad Alghanem, Khalid Alharbi and Ahmad Almuallimi for their contribution to the research by data collection.

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CONFLICT OF INTEREST

The authors declare that there is no conflict of interest regarding the publication of this paper.

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FUNDING

The authors received no financial support for the research, authorship and/or publication of this article.

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ETHICAL APPROVAL

The study was approved by the Institutional Review Board (IRB) of King Abdullah International Medical Research Center (KAIMRC). Participants were informed about the study and their consent was obtained in a written form. Confidentiality and anonymity of all participants were kept throughout the study and afterward.

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AUTHORS CONTRIBUTIONS

SA, NM, HA and AA conceived the presented idea and designed the study methods. MA and MS took the lead in data collection. HA and MA contributed to reviewing the collected data and contributed to manuscript writing. NM conducted and verified all statistical analyses. AA supervised the entire process and closely monitored the progress of the study. All authors contributed to the writing of the manuscript and approved the final manuscript.

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