In this local multi hospital-based sample of pregnant and newly delivered women, we reported that Jordanian women are highly knowledgeable about the benefits of breastfeeding, aware of the WHO recommendations, exhibit a positive attitude towards breastfeeding and the majority plan on breastfeeding their infants for at least 6 months.
Decision towards BF practice is affected by multiple factors including knowledge, awareness, attitudes and motivation. In our cohort, when participants were asked about the benefits of breastfeeding, most of them volunteered to report that breast milk significantly contributes to a better infant’s immunity and less risk of infections even before directly asking them to answer that question. Several other studies that focused on assessing women’s knowledge about the benefits of BF concluded that women have excellent fund of knowledge regarding certain aspects of breast milk benefits mainly its impact on immunity and good infant health outcomes [18]. Moreover, Raissian et al. reported that prenatal intention was considered a strong factor associated with a better infant’s health even if infants were not breastfed [19]. When compared to studies that explored BF knowledge and attitude in other Arab countries, our findings were very promising. The major gap in women’s knowledge about BF in certain Arab cultures is related to their perception that breast milk might not contain adequate nutritional supply, and this is the major reason to start supplementing with infant formula. This perceived belief has been highlighted in previous studies from the Middle East region [20, 21]. This misconception was found to be less obvious in mothers with older age and with a previous experience with breastfeeding [22]. In their analysis from Lebanon, Osman et al. reported that certain cultural beliefs, such as” breastmilk contains inadequate nutrients and might result in infantile colic or even causing harm to infants”, have a major negative impact on breastfeeding and were associated with early introduction of formula. The authors concluded that culture-specific counseling should be implemented to improve breastfeeding practice[20]. Some knowledge related studies about BF in the Arab world targeted college students in healthcare sections and reported variable results according to the item tested [23, 24]. For example, in Egypt, analysis of breastfeeding knowledge and attitude among nursing students revealed unexpectedly low scores highlighting the importance of implementing programs that focus on breastfeeding during the undergraduate study programs [23]. A quite similar finding was identified among Syrian and Lebanese students enrolled in health-related undergraduate studies by Hamade et al.[24].
With a positive attitude, women acquire a great motivation, and this will be reflected on their intentions and practices. Our finding of a positive association between positive attitude and planning to BF is consistent with several studies from USA and UK [25, 26]. Therefore, it is believed that promoting the best BF practices should start long time before delivery and should be included in the antenatal education and care. However, the attitude towards BF might be negatively influenced by local hospital set-up in resource limited countries like Jordan and other nations in our region. The BFHI was established by the WHO and UNICEF in the early 1990's to improve the rate of EBF [8]. However, there has been no consistency about its impact on the rate of EBF among different institutions and countries. With the busy clinic schedule and labor wards, the lack of health care education together with the absence of baby friendly units in our hospitals could have contributed to this trend. Such limited resources act against the BFHI particularly step number 5 which talks about providing enough support for lactating mothers to overcome all obstacles against successful initiation and maintain BF [8]. In addition, although our participants indicated their preference to have their babies receive colostrum as their initial feeding, a good percentage preferred to have their infants stay in the newborn nursery and agreed with using infant formula at times. This finding is a clear example of an educational gap in applying steps number 4 and 7 of the BFHI which encourage skin-to-skin care and initiating BF immediately after birth and reinforce the practice of rooming-in together[8]. Similarly, Ogbonna 2009 and Shaker 2004 have reported that lack of consistent education by the hospital staff was a strong barrier to EBF[22, 27]. Other reports concluded that the education process is an ongoing task and should continue after home discharge to avoid early cessation of BF [28].
On the other hand, decisions about plans for infant feeding practice might start a while before conception, and so targeting young adults to be involved with breastfeeding education might help improving this practice in certain cultures. This finding was studied by Hamade et al. among Syrian and Lebanese undergraduate students. The authors in that analysis identified some knowledge gaps and misperceptions that act as barriers against BF intentions. The factors reported by their study participants were related to inadequate milk supply, dietary restriction on lactating mothers, and the negative impact of breastfeeding on body shape. Accordingly, this study concluded that implementing culture specific educational programs for school adolescent students and during undergraduate studies is key in promoting a better BF practice[24].
Besides its association with a positive women’s attitude, we reported that the intention to breastfeed was significantly determined by the support women receive towards BF practice. Research has repeatedly found that women's pre-birth BF intention is a good predictor of the actual duration of BF [7]. Regardless of women’s beliefs and planning, BF practice is highly dependent on the amount of support they receive from their husbands, health care providers, relatives, friends, work environment and hospital staff [11]. In our cohort, husband’s support was a major predictor for BF, while limited support and counseling by the obstetric care provider was reported by most of our participants as a major concern. Our findings are consistent with several other studies including systematic reviews and meta-analysis reports [29, 30]. In their systematic review of professional support interventions for breastfeeding, Hannula et al. reinforced the importance of providing obstetric professionals with educational tools to support BF which would in turn improve the women’s self-efficacy and power to ensure better BF behavior [30]. In their recently published study, Van Dellen 2019 et al. examined the association between BF practice and a comprehensive evidence based intervention named “Breastfeeding Support Program, BSP” that combines antenatal and postpartum support and education, and concluded that BSP promotes longer duration and higher exclusivity of BF among their participants [31]. Besides obstetric care providers, neonatal care providers including neonatologists and nurse practitioners should frequently receive enough education and reminders to support BF to ensure compliance with step number 2 of the BFHI [8]. Studies have shown that discussing the benefits of breastmilk during prenatal consults performed by the neonatologist for pregnant women with potential premature delivery would result in a higher rate of providing breastmilk for infants admitted to the NICU during and after hospital stay [32]. Additionally, the strong association between husband’s support and intention to breastfeed among the women in our culture reflects a strong adherence to step number 3 of BFHI and makes us believe that husbands should attend the antenatal and postnatal educational sessions about BF as their influences might have a great impact on their wives’ intentions [8].
One of the main challenges in promoting EBF practice is related to maintaining BF for the recommended period rather than its initiation after birth[28]. The effect of women’s education and employment status on BF practice has been inconsistent [33]. The rate of employed women in our studied population was 30%. The majority of them answered “Going back to work after short maternity leave with limited support and space to breastfeed our infants while at work” as the major reason against EBF. Our finding regarding women’s concern about breastfeeding in the work environment is in agreement with several other reports from the region [14, 21, 34]. The short maternity leaves and the lack of supportive measures in the workplace such as the lack of day care centers and the inability of having multiple breaks during the daytime to breastfeed their infants discourage mothers from EBF and push them to introduce infant formula. On the other hand, Wallenborn 2019 analyzed US data from Infant Feeding Practices Survey II and reported that work environment support was strongly associated not only with a higher BF rate, but also with a positive self-efficacy and a longer duration of BF[35]. Although breast pumps are not widely available, there has been an increasing interest of using them among Jordanian women and this might be a cornerstone solution to help employed mother feeding their infants expressed milk while they are away at work.
Despite the challenges that might interfere with BF, our report’s finding of high women’s knowledge and positive attitude are promising determinants for improving the BF practice in Jordan. This study is not without limitations. The participants in our study who were selected from two different convenient groups represent the inhabitants of our region who mostly belong to the middle socioeconomic group only. A population-based study including random selection from higher and lower socioeconomic groups will give more accurate data to represent the whole Jordanian population. Also, being a cross sectional study, it is important to mention that the reported rates in this study reflect women’s planning towards BF and might not reflect the actual rate of BF given the potential limitations that women might encounter against BF with time. Another point which might be considered among the limitations is the non-adherence of our questionnaire to the standard scales about knowledge and attitude which have been tested for validity and reliability. However, this might actually be a point of strength about our study since we modified those reference scales and created customized scales that seem more applicable and easily presented among our study participants.