From 17 Mar – 6 Jun 2020, a total of 170 deliveries took place at KAAUH. We excluded 34 mother/infant pairs; 1 pair was excluded because of a preterm birth, 2 pairs involved foetal mortality/morbidity, 10 mothers refused to participate, and 21 pairs were lost to follow-up.
Table 1 shows the demographic and clinical characteristics of the study cohort; the mean age of the participating mothers was 29.5 ± 5.07 years, and the majority had a bachelor’s degree and were unemployed. A total of 90% of the mothers were healthy, 99% were non-smokers, and many were overweight (mean BMI 28.6 ± 4.9 kg/m2).
Table 1
Demographic and clinical characteristics of the study cohort
Variable
|
Distributions
|
Maternal age (years)
|
|
Less than 21
|
6 (4.4%)
|
21–24
|
33 (24.3%)
|
More than 24
|
97 (71.3%)
|
Level of education
|
|
High school degree or less
|
36 (26.5%)
|
Bachelor’s degree
|
88 (64.7%)
|
Master’s degree
|
10 (7.3%)
|
Ph.D. or equivalent
|
2 (1.5%)
|
Employment status
|
|
Employed
|
37 (27.2%)
|
Unemployed
|
99 (72.8%)
|
Employment sector
|
|
Teaching & Academia
|
24 (64.9%)
|
Corporate & Business
|
8 (21.6%)
|
Healthcare
|
4 (10.8%)
|
Other
|
1 (2.7%)
|
Average monthly income in SR
|
|
Less than 10000 SR/month
|
57 (41.9%)
|
10000–30000 SR/month
|
73 (53.7%)
|
More than 30000 SR/month
|
6 (4.4%)
|
Chronic diseases
|
|
No
|
123 (90.4%)
|
Yes
|
13 (9.6%)
|
Smoking status
|
|
No
|
135 (99.3%)
|
Yes
|
1 (0.7%)
|
All participants were full term, with a mean gestational age of 39.3 ± 1.4 weeks, and the mean parity was 1.7 ± 1.6 child. During pregnancy, the mothers visited the ANC clinic an average of 5.7 ± 3.4 times and the health educator clinics an average of 0.04 ± 0.1 times. The mean length of hospital stay was 2.5 ± 1.7 days, and the mean birth weight was 3.08 ± 0.4 kg. Regarding breastfeeding advice during admission, both the doctors and nurses/midwives had low scores, with scores of 0.2 ± 0.4 and 0.6 ± 0.4, respectively.
Figure 1 shows the feeding status of the study cohort, and approximately 1/3 of the individuals exclusively breastfed their newborns within the first 2 weeks post-partum; however, this rate dropped to 19% at 6–8 weeks. However, bottle feeding was performed by two-thirds of the mothers within the first 2 weeks: 23.5% performed bottle feeding once only/day, 55.3% performed bottle feeding half of the time, and 21.2% performed bottle feeding only. The bottle-feeding rate increased to 80.9% at 6–8 weeks, representing 51% of the feedings.
Table 2 shows the mothers’ beliefs and satisfaction about breastfeeding. Interestingly, despite the high score regarding their knowledge that breastmilk is the best source for infants’ nutrition, this factor was not correlated with breastfeeding within the first 2 months post-partum, and this correlation was also not significant for formula milk.
Table 2
Mothers beliefs and satisfaction about breastfeeding promotion
Variable
|
Likert scale 0–10 (strongly disagree – strongly Agree)
|
Correlation with breastfeeding status at 10–14 days post-partum
|
Correlation with breastfeeding status at 6–8 weeks post-partum
|
Breast milk is the best source of nutrient for infants < 6 months of age
|
9.3 ± 1.1
|
0.1623
|
0.1288
|
Formula milk is the best source of nutrient for infants < 6 months of age
|
3.9 ± 2.9
|
-0.1286
|
-0.1986
|
Planning to exclusively breastfeed for 2 months
|
7.2 ± 3.4
|
-0.0887
|
-0.1065
|
Planning to exclusively breastfeed for 6 months
|
7.2 ± 3.1
|
0.3291
|
0.2714
|
Having an encouraging and supportive family for breastfeeding
|
8.1 ± 2.3
|
-0.0227
|
-0.0226
|
Having an encouraging and supportive work environment for breastfeeding
|
5.4 ± 3.6
|
0.2204
|
0.2712
|
Satisfied about breastfeeding counselling practices in the hospital
|
5.7 ± 3.6
|
-0.0310
|
0.0758
|
Willing to receive additional advice/attend follow-up visits on breastfeeding
|
6.8 ± 3.6
|
0.1279
|
0.0922
|
Regarding the factors associated with feeding status, as shown in Table 3, maternal age and the mode of delivery were strongly and statistically significantly associated with bottle feeding However, other demographic and clinical factors were not associated with feeding status within the first two weeks post-partum. In 6–8 weeks, maternal age was strongly and statistically significantly associated with breastfeeding and the mode of delivery. Other demographic and clinical factors that showed significant associations were employment status, the absence of chronic diseases and previous breastfeeding experience (Table 4).
Table 3
Factors associated with feeding status at 10–14 days
Factors
|
Breastfeeding
|
P-Value
|
Bottle –feeding
|
P-Value
|
No
|
Yes
|
Once only/day
|
2–4 times/day
|
All the feedings
|
Maternal age (years)
|
|
|
|
|
|
|
|
Less than 21
|
2 (1.47%)
|
4 (2.94%)
|
.236
|
0 (0%)
|
2 (2.3%)
|
0 (0%)
|
.035*
|
21–24
|
23 (16.91%)
|
10 (7.35%)
|
3 (3.53%)
|
18 (21.18%)
|
2 (2.35%)
|
More than 24
|
60 (44.12%)
|
37 (27.21%)
|
17 (20.00%)
|
27 (31.76%)
|
16 (18.82%)
|
Level of education
|
|
|
|
|
|
|
|
High school or less
|
21 (15.44%)
|
15 (11.03%)
|
.394
|
7 (8.24%)
|
9 (10.59%)
|
5 (5.88%)
|
.518
|
Bachelor’s degree
|
57 (41.91%)
|
31 (22.79%)
|
12 (14.12%)
|
34 (40.00%)
|
11 (12.94%)
|
Master’s degree or above
|
7 (5.15%)
|
5 (3.68%)
|
1 (1.18%)
|
2 (2.35%)
|
2 (2.35%)
|
Employment status
|
|
|
|
|
|
|
|
Employed
|
27 (19.85%)
|
10 (7.35%)
|
.117
|
4 (4.71%)
|
18 (21.18%)
|
5 (5.88%)
|
.298
|
Unemployed
|
58 (42.65%)
|
41 (30.15%)
|
16 (18.82%)
|
29 (34.12%)
|
13 (15.29%)
|
Monthly income
|
|
|
|
|
|
|
|
< 10000 SR
|
32 (23.53%)
|
25 (18.38%)
|
.286
|
7 (8.24%)
|
17 (20.00%)
|
8 (9.41%)
|
.405
|
10000–30000 SR
|
50 (36.76%)
|
23 (16.91%)
|
13 (15.29%)
|
27 931.76%)
|
10 (11.76%)
|
> 30000 SR
|
3 (2.21%)
|
3 (2.21%)
|
0 (0%)
|
3 (3.53%)
|
0 (0%)
|
Chronic diseases
|
|
|
|
|
|
|
|
No
|
76 (55.88%)
|
47 (34.56%)
|
.593
|
17 (20.00%)
|
43 (50.59%)
|
16 (18.82%)
|
.739
|
Yes
|
9 (6.62%)
|
4 (2.94%)
|
3 (3.53%)
|
4 (4.71%)
|
2 (2.35%)
|
(BMI) (Mean ± SD)
|
28.9 ± 4.8
|
28.0 ± 5.0
|
.286
|
29.5 ± 4.7
|
28.5 ± 4.7
|
29.6 ± 5.1
|
.584
|
Smoking status
|
|
|
|
|
|
|
|
No
|
84 (61.76%)
|
51 (37.50%)
|
.331
|
20 (23.53%)
|
47 (55.29%)
|
17 (20.00%)
|
.207
|
Yes
|
1 (0.74%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
1 (1.18%)
|
Mode of delivery
|
|
|
|
|
|
|
|
C/S
|
0 (0%)
|
1 (0.74%)
|
.049*
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
.550
|
Instrumental
|
1 (0.74%)
|
4 (2.94%)
|
0 (0%)
|
1 (1.18%)
|
0 (0%)
|
NSVD
|
84 (61.76%)
|
46 (33.82%)
|
20 (23.53%)
|
46 (54.12%)
|
18 (21.18%)
|
Epidural anaesthesia
|
|
|
|
|
|
|
|
No
|
69 (50.74%)
|
43 (31.62%)
|
.640
|
17 (20.00%)
|
38 (44.71%)
|
14 (16.47%)
|
.845
|
Yes
|
16 (11.76%)
|
8 (5.88%)
|
3 (3.53%)
|
9 (10.59%)
|
4 (4.71%)
|
Previous breastfeeding experience
|
|
|
|
|
|
|
|
Failure
|
37 (27.21%)
|
16 (11.76%)
|
.075
|
8 (9.41%)
|
23 (27.06%)
|
6 (7.06%)
|
.547
|
None
|
30 (22.06%)
|
15 (11.03%)
|
6 (7.06%)
|
15 (17.65%)
|
9 (10.59%)
|
Success
|
18 (13.24%)
|
20 (14.71%)
|
6 (7.06%)
|
9 (10.59%)
|
3 (3.53%)
|
Pacifier use
|
|
|
|
|
|
|
|
No
|
46 (33.82%)
|
26 (19.12%)
|
.722
|
11 (12.94%)
|
28 (32.94%)
|
7 (8.24%)
|
.324
|
Yes
|
39 (28.68%)
|
25 (18.38%)
|
9 (10.59%)
|
19 (22.35%)
|
11 (12.94%)
|
Table 4
Factors associated with feeding status at 6–8 weeks post-partum
Factors
|
Breastfeeding
|
P-Value
|
Bottle –feeding
|
P-Value
|
No
|
Yes
|
once only/day
|
2–4 times/day
|
All the feedings
|
Maternal age (years)
|
|
|
|
|
|
|
|
Less than 21
|
6 (4.41%)
|
0 (0%)
|
.041*
|
1 (0.91%)
|
5 (4.55%)
|
0 (0%)
|
.083
|
21–24
|
30 (22.06%)
|
3 (2.21%)
|
5 (4.55%)
|
18 (16.36%)
|
7 (6.36%)
|
More than 24
|
74 (54.41%)
|
23 (16.91%)
|
11 (10.00%)
|
33 (30.00%)
|
30 (27.27%)
|
Level of education
|
|
|
|
|
|
|
|
High school or less
|
32 (23.53%)
|
4 (2.94%)
|
.174
|
6 (5.45%)
|
18 (16.36%)
|
8 (7.27%)
|
.593
|
Bachelor’s degree
|
70 (51.47%)
|
18 (13.24%)
|
10 (9.09%)
|
33 (30.00%)
|
27 (24.55%)
|
Master’s degree or above
|
8 (5.88%)
|
4 (2.94%)
|
1 (0.91%)
|
5 (4.55%)
|
2 (1.82%)
|
Employment status
|
|
|
|
|
|
|
|
Employed
|
32 (23.53%)
|
5 (3.68%)
|
.296
|
1 (0.91%)
|
22 (20.00%)
|
9 (8.18%)
|
.011*
|
Unemployed
|
78 (57.35%)
|
21 (15.44%)
|
16 (14.55%)
|
34 (30.91%)
|
28 (25.45%)
|
Monthly income
|
|
|
|
|
|
|
|
< 10000 SR
|
44 (32.35%)
|
13 (9.56%)
|
.087
|
7 (6.36%)
|
19 (17.27%)
|
18 (16.36%)
|
.552
|
10000–30000 SR
|
63 (46.32%)
|
10 (7.35%)
|
10 (9.09%)
|
35 (31.82%)
|
18 (16.36%)
|
> 30000 SR
|
3 (2.21%)
|
3 (2.21%)
|
0 (0%)
|
2 (1.82%)
|
1 (0.91%)
|
Chronic diseases
|
|
|
|
|
|
|
|
No
|
97 (71.32%)
|
26 (19.12%)
|
.015*
|
16 (14.55%)
|
47 (42.73%)
|
34 (30.91%)
|
.346
|
Yes
|
13 (9.56%)
|
0 (0%)
|
1 (0.91%)
|
9 (8.18%)
|
3 (2.73%)
|
(BMI) (Mean ± SD)
|
28.6 ± 4.8
|
28.6 ± 5.2
|
.964
|
27.5 ± 3.7
|
28.7 ± 5.1
|
29.0 ± 4.9
|
.592
|
Smoking status
|
|
|
|
|
|
|
|
No
|
109 (80.15%)
|
26 (19.12%)
|
.513
|
17 (15.45%)
|
56 (50.91%)
|
36 (32.73%)
|
.333
|
Yes
|
1 (0.74%)
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
1 (0.91%)
|
Mode of delivery
|
|
|
|
|
|
|
|
C/S
|
0 (0%)
|
1 (0.74%)
|
.020*
|
0 (0%)
|
0 (0%)
|
0 (0%)
|
.254
|
Instrumental
|
2 (1.47%)
|
3 (2.21%)
|
0 (0%)
|
2 (1.82%)
|
0 (0%)
|
NSVD
|
108 (79.41%)
|
22 (16.18%)
|
17 (15.45%)
|
54 (49.09%)
|
37 (33.64%)
|
Epidural anaesthesia
|
|
|
|
|
|
|
|
No
|
92 (67.65%)
|
20 (14.71%)
|
.431
|
16 (14.55%)
|
46 (41.82%)
|
30 (27.27%)
|
.369
|
Yes
|
18 (13.24%)
|
6 (4.41%)
|
1 (0.91%)
|
10 (9.09%)
|
7 (6.36%)
|
Previous breastfeeding experience
|
Failure
|
48 (35.29%)
|
5 (3.68%)
|
.013*
|
7 (6.36%)
|
25 (22.73%)
|
16 (14.55%)
|
.938
|
None
|
37 (27.21%)
|
8 (5.8%)
|
6 (5.45%)
|
17 (15.45%)
|
14 (12.73%)
|
Success
|
25 (18.38%)
|
13 (9.56%)
|
4 (3.64%)
|
14 (12.73%)
|
7 (6.36%)
|
Pacifier use
|
|
|
|
|
|
|
|
No
|
60 (44.12%)
|
12 (8.82%)
|
.441
|
9 (8.18%)
|
36 (32.73%)
|
15 (13.64%)
|
.077
|
Yes
|
50 (36.76%)
|
14 (10.29%)
|
8 (7.27%)
|
20 (18.18%)
|
22 (20.00%)
|
Multiple causes have been proposed for breastfeeding cessation in the literature. However, we asked the mothers about the most common causes and allowed them to list others if applicable. The most common causes for breastfeeding cessation within the first two months post-partum included insufficient or a lack of breastmilk (37% and 51%, respectively), followed by maternal fatigue (12%) at both 2 weeks and 6–8 weeks post-partum. Other causes were less frequently reported, such as cracked nipples/painful breasts, the acclimation of infants to other foods and a lack of support. The other causes that were listed by the mothers were sleep deprivation, the mothers’ medication intake (pain killers, antibiotics, OCPs), latching difficulty, a lack of experience, the mothers being busy performing other household duties, and infant satiety with formula milk.