Bridging the gap between mother’s needs to breastfeed and institutional policies: A mixed methods study exploring factors influencing breastfeeding.

Abstract

Previous studies on factors influencing breastfeeding practices in the Arab Gulf countries, including the Kingdom of Saudi Arabia, have mostly provided quantitative findings that mainly assessed mother-related factors, such as their knowledge, attitudes, and practices, in addition to demographics. This highlighted the need for in-depth exploration of barriers to breastfeeding in the Kingdom of Saudi Arabia beyond the mothers themselves, such as those created by institutional and socio-cultural factors. Methods This research adopted a mixed methods approach and a socio-ecological framework specifically adapted for the Saudi context. The research consisted of three parts, the first of which was a systematic review of breastfeeding practices and associated factors in the Arab Gulf region. The second was a cross-sectional study involving primary data collection among healthcare professionals to identify their awareness, knowledge, and views on the Baby-Friendly Hospital Initiative (BFHI). The third and final study utilised semi-structured interviews among Saudi mothers in Riyadh city to explore barriers to breastfeeding practices, and to understand the mothers’ needs for support in relation to breastfeeding. Data were analysed thematically before findings from the quantitative and qualitative studies were integrated using the socio-ecological framework. Results The systematic review identified a broad range of factors that influenced breastfeeding practices. These were categorised according to the socio-ecological framework. In the quantitative study, healthcare professionals (n=109) participated in the survey, with approximately 50% aware of the policies favourable to breastfeeding in their workplaces. Knowledge regarding the Ten Steps to Successful Breastfeeding (TSSBF) was assessed using a questionnaire based on the literature review, the hospital self-appraisal and monitoring tool (World Health Organization, 2009) and the implementation guide to the revised Baby-Friendly Hospital Initiative (WHO, 2018). The majority of participants (71%) were knowledgeable about TSSBF. 98% of participants held positive views about BFHI and agreed that it increased breastfeeding rates; 85% found that the initiative was time-consuming; 93% agreed that there was no access to ongoing lactation and breastfeeding support; and 73% of participants expressed positive attitudes towards infant breastfeeding. In the qualitative study, two main themes emerged: firstly, barriers to breastfeeding; and secondly, mothers’ needs for breastfeeding support. Barriers to breastfeeding included lack of knowledge and practical demonstrations before and after birth, physical problems such as C-section delivery and sore nipples, as well as lack of privacy, family size and employed status. Family and socio-cultural barriers identified as potentially important influences on breastfeeding practices among Saudi mothers were: inadequate family support, conflicting views and advice about BF, criticism of the BF mother, and visitors from social networks, in addition to the cultural norms of beauty and taboo topics of women’s reproductive health. Barriers within the health system concerned inadequate information before the birth, and help with BF before discharge from hospital, and postnatally. Other barriers were the availability of formula milk and healthcare professionals’ insensitivity to mothers’ needs. The findings indicated that action was needed in different layers of the socio-ecological framework to broaden awareness of the importance of breastfeeding and provide society-wide support for breastfeeding. Furthermore, healthcare professionals need to be able to implement the TSSBF in full, including immediate and uninterrupted skin-to-skin contact and support for mothers to with initiation of BF as soon as possible after birth, and rooming-in. Conclusion This study which provides insights into a variety of barriers that influence breastfeeding practices among Saudi women. Even though participants held positive views about breastfeeding, a considerable number felt disincentivised to breastfeed their infants. This phenomenon was shaped in a large part by the social nexus formed by mothers’ husbands, family members and social networks, healthcare professionals, hospital practices, and policies, which together influenced mothers’ decisions and capabilities to breastfeed. The study has highlighted the important role that hospitals can play in ensuring that mothers receive correct and thorough education on breastfeeding, as well as adequate practical support from appropriately trained healthcare professionals. Overall, this research project contributes to the existing body of breastfeeding literature by providing new insights into the potential influence of traditional cultural customs in Saudi Arabia and highlighting that implementation of the BFHI may require a range of additional actions depending on the country context and culture.