Developing and Assessing the Effectiveness of a Web-based Breastfeeding Educational Resource on Exclusive Breastfeeding Rate among Saudi Women

Abstract

Background Breastfeeding is not only a very cost-effective way of feeding a baby, but it is also associated with multiple health benefits for both mothers and infants. Henceforth, the World Health Organization highly recommends early initiation of breastfeeding within an hour after birth, followed by exclusive breastfeeding for up to six months. However, the rates of early initiation of breastfeeding and exclusive breastfeeding vary around the world, and in some countries, they are well below the WHO targets. Similarly, in Saudi Arabia, the rate of early initiation of breastfeeding ranges from 26.3% in the Northern region to 62.7% in the Southern region. Furthermore, the rate of exclusive breastfeeding at six months after birth varies from 19.2% to 28%. Despite national efforts to promote breastfeeding, a decline in breastfeeding practices has been recorded, coinciding with increased use of infant formula. Introducing formula milk during hospital stays in Saudi Arabia is common practice. Several misconceptions about body shape, the safety of colostrum, and breastmilk insufficiency, coupled with rapid economic growth, have contributed to this decline and early breastfeeding cessation, even though Saudi women are offered breastfeeding education during pregnancy. Therefore, there was a need to develop an online educational intervention to motivate Saudi women to breastfeed for a longer duration. Saudi Arabia has a deep-rooted cultural heritage based on the Islamic religion, and its main language is Arabic. Hence, the cultural and linguistic aspects of the educational intervention were considered important determinants of its successful implementation. Aim The aim of this program of Higher Degree Research (HDR) was to develop and assess the effectiveness of a Web-based Breastfeeding Educational Resource (WEBBER) on exclusive breastfeeding rate during the hospital stay until one month after birth. Method The multi-method study was carried out in three phases to address the research aim. In the first phase, a systematic review was conducted to collect evidence-based information. The content of the website was based on the knowledge gaps identified in the systematic review, the WHO recommendation and the Milky Way app. In the second phase, the content of the website was finalised through a consensus development conference involving local stakeholders from the participating hospital in Saudi Arabia and university researchers. Participants of the Consensus Development Conference were asked to give feedback before the meeting, and changes were made to the content accordingly. The meeting was conducted on Zoom, and polling was used to indicate whether consensus was reached about the content, images and layout. The Persuasive System Design model informed the framework of the website development phase. The third phase was divided into two stages. In the first stage, a quasi-experimental study with a before and after intervention design was used to assess the effectiveness of the Web-based breastfeeding educational resource in promoting breastfeeding practices. An online survey was conducted to collect information about the breastfeeding practices during a hospital stay and at one month after birth before (Standard Care group) and after (Intervention group) giving access to the website. In the second stage, a semi-structured interview was undertaken to explore women’s experiences using the website. The interview was digitally recorded and transcribed verbatim using the Otter application before translating into English. The quantitative data was analysed using R language for statistical computing. A log-binomial regression model was used to adjust for any confounding factors that were identified. The qualitative data was analysed using content and thematic analysis. Results A total of sixteen studies were included in the systematic review. Data from ten studies that reported on breastfeeding knowledge demonstrated that 42.3% to 82.3% of Saudi women had good knowledge. However, several gaps in knowledge were identified including managing breastfeeding challenges. A meta-analysis of seven studies that reported on attitudes showed that most Saudi women hold positive attitudes towards breastfeeding. However, around 40% of women believed that formula milk was as healthy as breastmilk, and 59.4% believed that formula feeding was more convenient. The literature review was crucial in developing the content of the website. After making changes to the content based on feedback received from the members of the Consensus Development Conference, 100% agreement about the content, layout and images was achieved during the meeting. This confirmed the cultural and linguistic appropriateness of the content of the website, which was successfully developed using the Persuasive Systems Design model. Findings from the quasi-experimental experimental demonstrated an almost three times increase in the rate of exclusive breastfeeding at one month after birth in the intervention group that was given access to the website. Several predictors of exclusive breastfeeding were identified, including intention to breastfeed for six months or more, baby not receiving pre-made infant formula, and unemployment status of the women. Thematic analysis of the data from the semi-structured interview revealed three themes, including “Satisfying,” “Helpful,” and “Motivational.” Participants found the website “satisfying” due to its “Accessibility,” “Visual attraction,” “User-friendliness,” “Informative content,” “Trustworthiness,” and “Uniqueness.” They qualified the website as being helpful because it was perceived as a “Problem solver,” “Supportive,” and “Confidence booster.” The four sub-themes associated with “Motivational” were “Motivation to continue breastfeeding,” “Preparedness for managing breastfeeding challenges,” “Facilitating the continuation of breastfeeding,” and “Enhancement of intention to Breastfeed for a longer period.” Overall, the women’s experience of using the website was very positive. Conclusion This program of Higher Degree Research (HDR) has demonstrated the effectiveness of the Web-based Breastfeeding Education Resource in improving the exclusive breastfeeding rate during the hospital stay until one month after birth in Saudi Arabia. The Consensus Development Conference facilitated the engagement with local stakeholders, who ensured the cultural and linguistic appropriateness of the evidence-based content derived from the systematic review, WHO and Milky Way App. The Persuasive Systems Design model was successfully employed in developing the website, which was confirmed by the positive feedback from breastfeeding women who felt more motivated to breastfeed. This study has demonstrated that a women-centred online breastfeeding educational intervention can improve breastfeeding practices in Saudi Arabia.