Patterns and determinants of breastfeeding and complementary feeding practices of Emirati Mothers in the United Arab Emirates

The first two years of life are critical stages for a child's growth and development. Exclusive breastfeeding for six months and continued breastfeeding with safe, appropriate and adequate feeding is recommended as a global health policy in both developing and developed countries [1]. Healthcare standards are considered to be generally high in the United Arab Emirates due to increased government spending during strong economic years. Improved standards of living and health services have led to changes in morbidity and mortality rates. The infant mortality rate declined significantly in the UAE. Mortality rate for infants under five in the UAE decreased from 17 per 1000 live birth in 1990 to 8 per 1000 in 2008 [2]. Infectious diseases have gradually declined, and chronic non-communicable diseases (NCD’s) are being more prevalent.

It was noted that nutrition-related chronic diseases have increased dramatically in recent years and within a very short period of time; they are the major causes of morbidity and mortality in the UAE (Ministry of Health Report, 2009). Musaiger [3] reported that in addition to changes in lifestyle and physical activities in Middle Eastern countries, the decline in exclusive breastfeeding and high dependence on bottle-feeding are also important factors associated with the increase in the prevalence of obesity. The World Health Organization (WHO) [4] reported that promotion of breastfeeding may contribute to the prevention of childhood obesity. Since breastfeeding represents one of the earliest nutritional experiences of newborns, the first few months after birth may be a critical window for the development of obesity later on in life [5]. In the past few years, several systematic reviews indicated that increases in diseases such as diabetes, obesity and CVD are likely to be caused by a decrease in the practice of breastfeeding [6–8]. The same studies also revealed that these chronic diseases extend beyond infancy and affect the overall health of a nation. This would suggest that obesity prevention begins with breastfeeding.

It should be noted that in Middle Eastern countries, especially in Islamic societies, breastfeeding has a religious basis. Mothers continue to nurse their children for at least two years [9]. However, modernization as well as the aggressive promotion and marketing campaigns of infant formula and other baby food have influenced the traditions of breastfeeding. This resulted in the increased use of bottle-feeding, and mothers ignored the Quranic recommendations of breastfeeding for two years [10, 11]. In the UAE, limited research reported suboptimal infant feeding practices. Mixed feeding was the norm, and many mothers introduced solid food, liquid food or formula to their infants as early as one month about 50% of the mothers stopped breastfeeding before their infants reached the age of three months, and 40% did not even attempt to breastfeed [12]. In 1992, the National Nutrition Survey in the UAE [13] showed that 42% of mothers gave their children the bottle during the first month, 21% during the second and 9% during the third month. Al Mazroui et al. [14] reported that 70% of infants received non-milk supplements during the first month. In another study in Al Ain, 76.1% of infants were given milk supplements before the end of their first month, and only 28% of the mothers exclusively breastfed their infant [15]. In a recent study in the UAE, the exclusive breastfeeding rate was 76.5% on day one, 48.4% at one month and 13.3% at six months [16]. It is worth mentioning that the UAE is a multiethnic, multicultural community. As a consequence, the results of these studies varied and reflected the different breastfeeding practices of all residents, who were from different nationalities, ethnic groups and cultures. These studies did not give an accurate depiction of the breastfeeding practices of local Emirati mothers, about whom the policy makers in the UAE are mostly concerned.

The aim of this study is to evaluate breastfeeding and complementary feeding practices of Emirati mothers in the UAE, and to compare them to the guidelines and recommendations of the World Health Organization.

This study was conducted in the MCH (Maternal and Child Health) and Primary Health Care centers (PHC) centers in Abu Dhabi, Dubai and Al Ain. These centers are homogenous as they are governmental clinics that render maternal and child health services for Emirati mothers for free. Almost all Emirati mothers with children less than five years old visit these centers for the vaccination program for their infants. A multi-stage cluster sampling technique was used to collect data. In the first stage cluster sampling, a list of the MCH centers within each city was obtained and enumerated with four out of ten centers from each city being selected using simple random sampling. Then a convenient sample of 200 subjects was selected from the four centers from each city with sizes proportionate to sizes of the clinic. Sampling was based on the number of eligible mothers visiting the MCH centers. The researcher visited the MCH centers a fixed number of times at different times and days and recruited all eligible mothers. Mothers meeting the inclusion criteria (i.e., Emirati (UAE nationality) with infants less than 2 years of age were interviewed in each city. None of the mothers refused to be interviewed. Each mother signed an informed consent form before they started face to face interview.

The UAE have embraced the WHO recommendations, and the Ministry of Health issued an infant feeding policy which recommends six months of exclusive breastfeeding. However, translation of these policies into action in the UAE would require immense planning and strong implementation programmes and strategies. Despite many efforts and plans to promote breastfeeding in the UAE, there are no clear national targets, strategies or action plans to protect, promote and support appropriate feeding practices of infants and young children. The UAE should plan an infant feeding policy in the context of WHO/UNICEF Global Strategy for Infant and Young Child Feeding (IYCF) [19]. IYCF reported that once a strategy and an action plan are put in place, then countries will be able to proceed steadily and measure their progress towards established targets.

There are several limitations that need to be considered when interpreting the results of this study. One important limitation of this study is recall bias due to the retrospective nature of the data collection, possibly resulting in over or under estimation of actual breastfeeding practices. Although recall biases cannot be avoided, the author conducted all interviews to ensure consistent technique and interpretation of the answers. It should be also noted that epidemiological studies of this kind do not establish causality but may suggest associations.

Another limitation of this study is the representation of all the Emirati women who had babies and breastfeeding during the period of research. The generalisability of the results is limited by the element of convenience sampling – samples were drawn at the MCH and PHC clinics, which increase the likelihood of some types of people being selected rather than others. However, (a) strong attempts were made to match the demographic characteristics of the general population of mothers, and (b) a large proportion (more than 90%) of Emirati mothers do use the clinics for following up with the vaccination programs of their infants, as required by the Ministry of Health.

The findings in this study showed that initiation time of the first breastfeed of the whole population studied was high (98%). Although this high initiation rate is encouraging compared to Western countries, the premature introduction of supplementary feeds, the early cessation of breastfeeding and failure to exclusively breastfeed are great concerns. Despite the efforts of the Ministry of Health and the Health Education programs on breastfeeding, many participants still introduced either prelacteal fluids or supplementary food before the infant reached six months of age.

A number of socio-demographic variables were associated with the initiation and duration of breastfeeding in this study. In general, multiparous mothers were likely to initiate and exclusively breastfeed for longer periods than primiparous mothers. The association of parity with breastfeeding initiation, exclusivity and duration was investigated in several studies and similar results were reported [20–22]. However, education as a predictor differs between developing and developed countries. Educated mothers in most developed countries have returned to breastfeeding [23, 24] while in developing countries, mothers with high education have increasingly switched to bottle feeding or mixed feeding [25, 26].This finding has been explained by Abada et al. [27] that higher education in developing countries is associated with the adoption of modern ideas, often leading to the abandonment of traditional practices such as breastfeeding.

Although the majority of Emirati mothers, in this study, breastfed their infants, only 25% of them were exclusively breastfed for six months. Similarly, low levels of exclusive breastfeeding were recorded in other countries [28–30]. Higher rates of exclusive breastfeeding have been reported in New Zealand [31] and Norway [32], where 42% of the infants were exclusively breastfed for 4 months. However, even in these countries, exclusive breastfeeding declined to 7% at six months of age. This means that there still exists a need for encouraging mothers to continue exclusive breastfeeding till the infants are 6 months old.

Providing children with water as early as one month of the infant’s age, is a normal practice in UAE as well as many other communities [33–35]. Emirati mothers justified this practice by stating that the UAE have a hot climate, and infants need to be hydrated. Early supplementation with formula milk and other liquids was also noted in this study. It should be mentioned that breast milk alone can maintain adequate water balance in young infants and supplementary fluids are not needed even in warm climates [36, 37].

Caesarean delivery, contraception and nipple problems were reported in this study as influencing variables associated with breastfeeding practices. These factors have previously been shown to hinder breastfeeding and disrupt lactation [38–40].

Multiple logistic analysis of breastfeeding patterns indicated that rooming in, number of breastfeeds at night and breastfeeding on demand were the most significant predictors influencing breastfeeding patterns. Rooming in encourages demand and night feeding, and this allows frequent and close contact between the mother and the baby [41]; it also encourages the establishment of longer duration of exclusive breastfeeding [42, 43].

Timely introduction of solid foods remains an important factor for healthy infant growth. The premature introduction of complementary food was of great concern in the present study. Despite the efforts of the UAE national health education programs, many participants still introduced complementary food before the baby reached six months of age. Musaiger [9] revealed that weaning foods are introduced very early in all Arabian Gulf countries. This was attributed to high purchasing power and the wide availability of commercial baby foods. Research suggested that complementary foods offered to infants before 6 months of age tend to displace breastmilk without conferring any growth advantage over exclusive breastfeeding [44]. Early introduction of other foods or drinks is an area of concern mainly because it marks the end of exclusive breastfeeding which has protective effects [45].

In the present study, the most frequently reported reason for starting weaning and terminating breastfeeding was that the mother became pregnant (32.9%). This reason was also recorded by other studies for discontinuing breastfeeding [46–48] The belief that the breast milk of pregnant women could be harmful or no longer nutritious is widely common among Gulf women [9] and women from other communities [49, 50].

Other participants, in this study, stated that they stopped breastfeeding and started formula feeding because they believed that their breastmilk was insufficient and infant refused to suck. There seems to be a widespread perception of lactation insufficiency reported by other studies, and accordingly, the infant is given supplements at a very early age [42, 51]. The mother’s concern about milk insufficiency could be explained by her poor understanding of the proper techniques to increase breastmilk. Contrary to this belief, most mothers are able to produce breastmilk in quantities adequate for the proper growth of their infants, even in societies where the mother’s diet is poor [38]. Daly and Hartmann [52] revealed that maternal milk production is finely tuned to the demand of the infant. Therefore, frequent and exclusive breastfeeding is critical for stimulating optimal milk production.

The results of this study suggest an urgent need to target breastfeeding education campaigns at young, primiparous, which either completed high school or higher education. Those mothers were identified by this study as the most vulnerable group who are at risk of not exclusively breastfeeding. So proper advice and breastfeeding management are required to increase awareness of exclusive breastfeeding benefits and to ensure that the problems Emirati mothers face during breastfeeding do not lead to the cessation of breastfeeding.

The promotion of breastfeeding can be a potential component of the primary public health strategies to decrease public health problems in the UAE, such as obesity and NCD’s and their related risk factors. This will contribute to improving the health, nutrition and well-being of both infants and mothers.

Moreover, the findings of this study should be the foundation of future studies that investigate the feeding patterns in the UAE, and eventually assist in creating a national infant feeding policy. There is a need for a larger more detailed study following women from before birth until they stop breast feeding their babies, the thoughts and feelings of the mother and her social networks at each stage of the process should be explored.