Abstract
Background:
Understanding women’s breastfeeding perceptions and experiences is increasingly recognized as a vital tool to provide effective support that would encourage the extension of the breastfeeding period.
Objective:
To identify and explore the perceptions and views that influence the feeding and weaning decisions of Emirati mother.
Methods:
A qualitative study using indepth interviews was undertaken with a convenience sample of 45 Emirati mothers who had infants aged between 6 months and 2 years. Participants were interviewed in the health centers in 3 cities in United Arab Emirates. Data were recorded through field notes and analyzed thematically using grounded theory analysis.
Results:
The following themes emerged: influences of others on the decisions to breastfeed, sources of information, infants’ behavior and participants’ views and decisions about when to introduce supplementary feeding, knowledge of and attitudes toward current World Health Organization recommendations, and mothers’ perception of the benefits of breastfeeding. Grandmothers in this study played an important role in the breastfeeding practices of Emirati mothers. They supported breastfeeding, however, some encouraged giving the infants prelacteal feeds for a variety of reasons: colic, hunger, promoting growth, and hydration. Fathers, according to the mothers, either supported or ignored breastfeeding practices.
Conclusion:
Health promotions and health care facilities failed to deliver the message of exclusive breastfeeding. Mothers in our study were resorting to the expertise of the grandmothers and receiving information and advice about child feeding from them. The findings highlight the need for successful intervention programs to be implemented for mothers and grandmothers through health care providers.
Introduction
The decision to breastfeed is largely a matter of individual choice and rational decision making. However, the decisions and experiences are constructed and practiced within the social milieu in which the mother lives. 1 Breastfeeding knowledge and attitudes are socially learned within the family since family members often have frequent and on-going interaction with the mother, providing her with practical information about breastfeeding and complementary feeding. 2,3
Extended families are the norm in Islamic societies, and the mother receives help and guidance from her family. Breastfeeding knowledge is rooted in the culture and passed from mother to daughter in the form of practices and concepts. Since in Islamic culture, the mothers are required by the Quran to breastfeed their infants for 2 years, “Mothers shall give suck to their children for two full years for those who desire to complete the term” (Quran, 2:233). Greiner had reported that breastfeeding seems to be a natural and instinctive behavior in traditional societies. 4
However, the breastfeeding tradition does not mean that women necessarily conform to what health experts would recommend as best for both baby and mother, particularly in terms of duration and exclusivity. When new information challenges a mother’s culturally based beliefs, she may mistrust the information, which may challenge the traditional knowledge and even clash with the world picture in which it is embedded.
Breastfeeding has been strongly encouraged throughout the United Arab Emirates (UAE).The Ministry of health in 1991 adopted the recommendation of the World Health Organization that mothers should exclusively breastfeed their infants for 6 months. Breastfeeding promotion strategies are increasing, with a government requirement that maternity units become “Baby Friendly.” There are 9 hospitals in UAE recognized as Baby Friendly. However, still breastfeeding practices in UAE are suboptimal. 5–8
It should be noted that no research was found related to social and cultural attitudes of Emirati women nationals with respect to breastfeeding and weaning. Such earlier studies as have been carried out include expatriates, who form a majority of the de facto population and do not share the same culture or history. 5–8 Hauck and lrurita reported that it is important to support mothers in their decisions in order to empower them to deal with the later challenges of mothering. 9 Hence, mothers should have a positive perception of their own breastfeeding experience. 10 So understanding women’s perceptions and experiences is increasingly recognized as a vital tool in providing effective support by health professionals to extend the breast feeding experience. 11–13 The purpose of the current qualitative research was to explore the perceptions and experiences of the Emirati mothers about different feeding practices.
Methods
A qualitative methodology was employed in this study in order to identify and explore the range of factors which influence feeding decisions in the UAE. A multistage cluster sampling technique was used to collect data. In the first stage cluster sampling, a list of the Public Health Centers (PHC) and Maternal and Child Health (MCH) centers within each city was obtained and enumerated with 4 of 10 centers from each city being selected using simple random sampling. A purposive convenience sample of 15 Emirati mothers who had infants aged more than 6 months but less than 2 years was selected from each city. They were interviewed in the MCH and Public Health Centers (PHC) in Abu Dhabi, Dubai and Al Ain, all by the same researcher. Their ages ranged between 20 and 42 years with a mean age (±standard deviation) of 31 ± 5.3 years, their educational level ranged from elementary to secondary in Al Ain and Abu Dhabi, while 3 mothers had university degrees in Dubai and 2 in Abu Dhabi. All the mothers in Al Ain were housewives and only 2 were in paid employment in Abu Dhabi and 4 in Dubai. All the mothers in this study initiated breastfeeding.
The mother was interviewed after explaining to her the purpose of the research and signing the consent form. The interview lasted about 30 to 45 minutes. Face-to-face in depth interviews with open-ended questions were used to allow participants to express freely their perceptions of the breastfeeding education and programs and practices in the MCH centers and hospitals and to tell their stories about the factors and influences that shaped their infant feeding decisions. Other questions arose automatically to direct the interview. The contents of the discussion focused on the breastfeeding practices, decisions, and perceptions of the mothers. All were encouraged to explain their beliefs about breastfeeding, the reasons for weaning, and the influences on their decisions. The agenda of questions included prompts such as “What influenced your breastfeeding decision?”, “What is your opinion about WHO guidelines?” and “Tell me how you feel about breastfeeding in public,” which were used to stimulate mothers’ own accounts.
Tape recordings have the advantage of capturing data more faithfully than written notes and can make it easier for the researcher to focus on the interview. However because of cultural constraints, the interviews were not taped (the interviewees were very much intimidated by the presence of the tape recorder and did not approve it); instead, field notes were taken during the interviews. To minimize the weaknesses of note-taking as a method of data recording—not reporting or missing out some details of the interview—field notes were taken during the interviews. Moreover, the field note book had a wide margin in which the researcher recorded the date, place, and start and end time of the interview and also personal thoughts, feelings, and interpretations separated from the main data. This helps to isolate personal bias and to use personal thoughts as analytically useful information. The interview notes were reviewed immediately after the interview ended for accuracy and context and to make sure that all remembered information had been recorded. At the end of each day, notes were examined, and missing details added and the notes were rewritten clearly with all the personal ideas and the researcher’s reflections and interpretations written in the margin. In assessing these field notes, we need to be aware of the possibility of selectivity on the part of the interviewer, as she was relying on memory and jotted notes and of the filtering processes that took place between what the interviewee actually said and the original field notes as well as after the event as further details were recalled.
Field notes were analyzed using grounded theory. 14,15 Analysis begins with identification of the themes emerging from the raw data, a process referred to as “open coding.” 16 All the data are examined in turn, document by document, line by line, and word by word. Words, phrases that appear to be similar can be grouped into the same category. These categories may be gradually modified or replaced during the subsequent stages of analysis that follow. The categories are then compared and contrasted between interviews to generate themes. These themes form the basis of our analysis and discussion. Nonverbal encouragement maintained motivation for the respondents to continue the interview.
Ethical Considerations
Ethical approval was granted by both the Board of Ethics Committee of the Faculty of Medicine at UAE University and the Ethics Committee at The University of Teesside, United Kingdom. The objectives of the study, the questionnaire, and the methodology were carefully reviewed by the Board of Ethics Committee in the Faculty of Medicine in UAE University. After getting their approval to conduct the study, authorities in the Ministry of Health issued letters allowing the researcher to collect data from the MCH and PHC centers in the 3 cities.
The purpose of this study was explained to every participant, and that the respondents have the right to decline and stop the interview at any time. The participants were assured of confidentiality and anonymity, and care was taken to ensure that no information collected was accessed by anyone except the researcher. The respondents were asked to sign a printed consent form.
Results
A number of themes were identified that appeared to influence the infant feeding decisions, grouped into 5 main themes: Influences of others on the decisions to breastfeed, and mothers’ concerns about the quality of their mothering. Sources of information—family, health care facilities and practices, advertisement. Infants’ behavior and participants’ views and decisions about when to introduce supplementary feeding. Knowledge of and attitudes toward current World Health Organization (WHO) recommendations. Mothers’ perceptions of the benefits of breastfeeding.
It is worth noting that the names of that mothers whose quotes were reported were given fictional names to assure anonymity.
Family Influences
All mothers in this study had initiated breastfeeding and identified reasons for doing so. The infant feeding culture of the mother’s family was counted as an important factor influencing breastfeeding. The study population has a tradition of breastfeeding. This was clearly stated by some mothers who explained that they and their siblings were breastfed and in turn they breastfed their infants. So breastfeeding was a natural progression. “I breastfed my baby the same as my mother had breastfed me.” (Nora, 28, Al Ain)
However, mothers are vulnerable and have little trust in themselves or their babies, and they seek advice intentionally and unintentionally from those who are around them—mothers, mothers-in-law, and husbands. In UAE culture, most married women live in the same house complex with her husband’s family. Everybody was trying to help me and give me advice about breastfeeding and how to care for my baby since this is my first baby (Mariam, 18, Dubai). I am not comfortable with the way my mother-in-law is interfering with my infant feeding and giving him yansun and hilba (Hala, 19, Al Ain). It is hard to argue with my mother-in-law (Samira, 23, Abu Dhabi).
The pressure exerted from the older female members on the mothers by imposing their opinions, experiences, advice, and technique onto the mother with respect to breastfeeding has a great influence on the mothers’ breastfeeding practices and decisions. In some cases whenever the mothers faced a breastfeeding problem, it was noted that some grandmothers and mothers-in-law would say, Give him bottle or give him cereals. He is hungry and you don’t have enough milk.
However, if the respondents believed they themselves were right or if they noticed that the advice did not work with their babies, they stopped following the advice without discussing it. A mother from Al Ain who had an infant having severe diarrhea blamed her mother-in-law who gave her son cereal pudding with egg. She said “enough is enough; I will never let her interfere with my child feeding anymore.” It seems that mothers with previous successful breastfeeding experience are empowered by it, but women who perceived that the advice had endangered their babies gained self-confidence and the experience empowered them in their turn.
Grandmothers had great influence on the mother’s decision to initiate breastfeeding and were very supportive of the mother doing so. Grandmothers often serve as a support for the mother and child in the first few months after delivery. It is culturally expected that the mothers will learn from grandmothers’ experience. However, grandmothers may not necessarily have an adequate knowledge of infant feeding, leading potentially to conflict.
Some grandmothers supported exclusive breastfeeding and discouraged the mother from giving prelacteal feeds, while others advised the mother to start giving her child prelacteal or solid feeds, for a variety of reasons. Fatima’s mother from Al Ain stopped her from giving her daughter formula milk and encouraged her only to breastfeed her: However, Salma (26, Al Ain) said, My mother and husband encouraged me to breastfeed my baby and not to give him any drinks while my mother in-law gave my baby water and she even told me to give him formula milk since he is crying a lot because my milk was not enough for him. My mother allowed me to give formula milk while my mother-in-law pressed me to continue breastfeeding. My mother in-law gave my child water and grippe water so not to cry. She even gave him formula milk while I was away. The nurse at MCH center told me not to give my child any liquids and only breastfeed him. However, when I came back home, my mother-in-law ignored that and gave my daughter hilba and yanson drinks to prevent colic pains. I am not comfortable with the way my mother-in-law gave cerelac to my daughter. But it is very hard to argue with her about it, as she would be very disappointed. The father did not care about how I feed my baby as long as the baby does not cry (Salma, 26, Al Ain).
Sources of Information
Mothers were asked about their main source of information about breastfeeding. The majority stated that the main source was their family (especially grandmothers). Some mothers in Al Ain stated that they had some information from the leaflets and brochures in the maternity clinics and wards. Only a few mothers in Dubai and Abu Dhabi stated that their source of information was the health workers, except for those who delivered in Baby Friendly Hospital (BFH). One mother from Dubai stated that, I read magazines and got information from the internet about the benefits of breastfeeding.
The support of health care providers has been shown to influence breastfeeding rates, and successful breastfeeding depends in part on the support of the staff who are directly involved with breastfeeding mothers. 17 –19 In UAE, the health care professionals were urged to support breastfeeding through the prenatal clinics and maternity wards. Public health activities are aimed at promoting, protecting, and supporting breastfeeding through encouraging the adoption of BFH initiatives (BFHI).
Support was high for breastfeeding mothers in the health care systems in Al Ain. (The 2 major governmental hospitals in Al Ain are BFHI). All mothers in Al Ain reported that health care personnel had informed them about breastfeeding. I was taught all about breastfeeding and how to express my breast milk at the hospital, said Nada, 23, from Al Ain.
Some mothers in this study were not satisfied with the information they had received about the breastfeeding complications they would face and how to avoid them. They said that they were informed only about breastfeeding techniques and benefits. Nobody had told me how to avoid cracked nipples or treat it … they are hurting me a lot while breastfeeding. (Fayza, 20, Dubai) My daughter is not sleeping all night … she is crying always and I am breastfeeding her all night. I am feeling tired … I think she is hungry.
Some mothers remarked that in the advertisements for commercial infant cereal products, they mention that these food products could be given to the infant when he is 4 months old I gave my child ‘Cerelac’ when he was 4 months since they say that on the package (Iman, 30, Abu Dhabi).
Infants’ Behavior and Participants’ Decisions About Supplementary Feeding
Some mothers said that the decision to introduce solids to the baby was led by some physical characteristic or behavioral of the infant—baby reaching 4 months of age, reaching a good weight or size (the baby is big), or when the baby started teething “Ï think when the baby teethes then he is ready to eat solid food” (Hamda, 29, Dubai). Increased saliva production whenever the baby sees food “When my baby sees me eating he drawls and opens his mouth and stretches his hand” (Nora, 35, Abu Dhabi) is another perceived cue from the child to start solid food. Some mothers were alert to watching perceived signs of hunger—interpreted differently by mothers and their relatives—and this might trigger early weaning. That the baby had a “hunger cry” was the most frequently mentioned and acknowledged reason for giving prelacteal feeds. My mother-in-law told me that my baby is crying because he is hungry and she told me to give him formula milk (Salma, 27, Al Ain). My mother advised to give my daughter hilba and yansoon, so she will not have colic pains and sleeps better (Samira, 23, Abu Dhabi).
Mariam from Abu Dhabi had noticed that her baby did not breastfeed as often as before when she gave him cereals at the age of 4 months, and she said that her baby stopped breastfeeding at 9 months. Exclusive breastfeeding was rarely practiced; most participants started giving their babies other feeds from the age of 2 to 4 months. “I gave my son hilba and yansoon for colic pains”.
A mother from Dubai said that she started “Introducing her infant to the taste of adult family food when he reached 4 months so he gets used to the taste of the grown-up food” (Rawdah, 30, Dubai).
Another mother from Abu Dhabi expressed her pleasure when her baby started tasting the adult food and that her daughter loved the taste and wanted more. Sleeping all night is another reason stated by the mothers for starting solids or giving formula milk. Saleema said, “My son slept all night when I gave him a bottle before bedtime.”
Knowledge of and Attitudes Toward Current WHO Recommendations
It appeared from the analysis that mother’s knowledge of the exclusive breastfeeding recommendations was not fully understood. They were confused about exclusive breastfeeding, they perceived it as not giving solid food but thought that water, prelacteal drinks, and juices were allowed. Most of the mothers from Dubai did not know until what age exclusive breastfeeding is recommended. Nobody told me about exclusive breastfeeding (Rawdah, 30, Dubai). I don’t know for how long I am supposed to exclusively breastfeed my baby (Hamda, 29, Dubai).
Moreover, most of these mothers, as well as those in Abu Dhabi, had a vague, incomplete understanding of the recommendations. Most of the participants in all the cities agreed that exclusive breastfeeding until 4 months of age was more acceptable and easier to follow since most of them had added solid or liquid feeds at this age: “Why wait until 6 months” (Samira,25, Abu Dhabi). Almost all of them expressed the idea that the age of 4 months is good for introducing solids “because the baby is big enough” and “the milk is not enough” and one even said, “This is what is written on the baby food packages.” One mother said, My mother told me that she had given us all hilba and cerelac when we were 4 months and nothing happened to us (Jameela, 32, Dubai).
One mother stated that “Infants should be given sugared water because they are born with low sugar level” (Shaikha, 22, Al Ain). Another one said that her mother had advised her to give water to her infant, otherwise his eyes will squint from thirst. Moreover, it is worth noting that most families still practice “Tahneek” (which is an Islamic tradition of rubbing the infants’ mouth with chewed dates when he or she is born).
It seems that exclusive breastfeeding education campaigns and programs in the health care facilities were not sufficiently clear or detailed for the Emirati mothers who were convinced that water and some fluids are needed by the infants.
Mothers’ Perception of the Benefits of Breastfeeding
Leffler reported that the decision to breastfeed is greatly influenced by breastfeeding knowledge and awareness of the potential benefits of breastfeeding. 20
It was noted that while there was a general belief among the participants that breastfeeding is the best way to feed a baby, the general public was fairly uninformed when it came to the specific benefits of breastfeeding and exclusive breastfeeding. Breastfeeding campaigns in the BFHI prenatal clinics and maternal wards have been somewhat successful in improving mother’s knowledge and understanding of the general benefits of breastfeeding for both themselves and their babies. However, the respondents had limited factual knowledge and only stated 1 or 2 benefits of breastfeeding. Many mothers reported that breast milk is the best for its immunological and health benefits. There was a general recognition that breastfeeding offers the baby some protection from illness and disease “Breastfeeding gives immunity to my child.” Other mothers stated other benefits of breastfeeding; for example, one mother said that “breastfeeding is good for my baby’s brain and bones” (Amna, 27, Dubai). Some mothers mentioned that breastfeeding is beneficial for the mother by changing body shape and weight back to normal: “Breastfeeding is good for my body.”
When mothers were asked about the relationship between breastfeeding and decreased fertility, only a few recognized this relationship and the rest did not know why their regular menses had been delayed. The influence of breastfeeding on the mother’s fertility was barely mentioned in the breastfeeding education campaigns. I did not know that breastfeeding prevents pregnancy. Nobody told me about that
This is one of the important breastfeeding benefits, knowledge of which needs to be stressed during the breastfeeding education campaigns, since a second pregnancy was reported as one of the main reasons, reported in the survey research, why some mothers stopped breastfeeding.
Discussion
One important limitation of the study is recall bias due to the retrospective approach to data collection. This might lead to over-/underestimation of the actual practice. However, the answers are likely to be roughly right. There is no reason to doubt them where women from all 3 cities say the same thing, and the differences between cities should be reliable because all the interviews were conducted by the researcher and this should have ensured a consistent technique and interpretation of the answers.
One clear conclusion, across all 3 cities, is that the presence of grandmothers favors breastfeeding but not exclusive breastfeeding. All grandmothers appear to play an important role in supporting some of the desirable child-feeding and child care practices. In other traditional communities in Africa, Asia, Latin America, and the Pacific societies, older women, or grandmothers, traditionally have considerable influence on decisions related to MCH and on infant feeding practices at the household level. 21–24 It is culturally expected that mothers should learn from the experience of grandmothers. The mother may be consciously or unconsciously influencing her daughter’s breastfeeding decisions and her ways of communicating with the baby. 25 The daughter may simply repeat how her mother interacted with her in her early childhood. 26 However, grandmothers may not necessarily convey adequate knowledge of infant feeding, leading to conflict situations. 27 Some mothers in this study said their mother-in-law had given prelacteal feeds even without the consent of the mother.
Although most of the fathers in this study were supportive of breast-feeding for the healthy development of infants, their actual assistance to infant feeding was limited. It is a traditional norm that men should not involve themselves with infant feeding because it is a “women’s job.”
Some of our participants commented on conflicting advice between the grandmothers and the health professionals. Conflicting advice has an overwhelming negative effect, as it confuses rather than empowers women, hence confirming a woman’s lack of self-confidence. 28 Several authors 17,29,30 have shown a correlation between poor or conflicting advice and breast feeding duration.
In this study, mothers reported receiving the information from health care services, either directly from health personnel or indirectly via handouts or brochures. Posters promoting breastfeeding were displayed at every health care facility, and some leaflets, pamphlets, and manuals relevant to breastfeeding are usually available on displays in the clinics and MCH and PHC centers. However, distributing leaflets in these centers is an inadequate solution to the problem and the focus was almost entirely on benefits, with little reference to techniques. Moreover, health care facilities do not carefully assess social–cultural dynamics at the household level nor do they develop interventions to build on the roles and strategies of other key household and community actors. 31 It would be more helpful for the mothers to have first-hand information related to them by an experienced breastfeeding mother 32 –34 since mothers lacked more practical “how to” information (how to latch the baby, how to increase breast milk secretion, how to …). Peer counseling has been reported by many studies to be an effective support for breastfeeding mothers. 35 –37 Mothers often feel more comfortable talking to other mothers about breastfeeding than to a health professional. 38 Anderson and coworkers have reported that low confidence in government recommendations on food and health may undermine motivation to comply with current dietary guidelines. 2 In addition, low awareness of the evidence base for the current recommendation and possible inconsistencies in dietary advice from lay advisors compared to professional advisors may add to confusion over how important the timing of weaning really is in infant health and development.
All the mothers in the study had identified some of the advantages of breastfeeding—in particular, that breastfeeding offers protection to their infants from illness. However most of them did not identify the benefits related to the mother. The majority of those surveyed agreed that breastfed babies get all the required nutrients and that breastfeeding reduces the risk of infection. Daikin and Naido have suggested that health education campaigns were successful in informing mothers of the benefits of breastfeeding, however, they were not always successful in promoting healthy behavior. 39
Benzer et al suggest new approaches for health education promotions and activities of mothers by involving key family members such as grandmothers and acknowledging the power dynamics that exists in extended families. 40 As previous work has shown the infant’s behavior appeared to be the main stimulus for changing feeding practices. 29,41,42 The crying of a baby in this study was seen as a sign of hunger and an indication that the baby was not getting enough food from breast milk—that what the mother is providing is inadequate. Some mothers-in-law pressured the mothers in our study to give prelacteal feeds in order to satisfy the baby’s hunger or treat colic pains. Maternal insecurity in the face of the child’s crying presented as an event which triggered weaning. Mothers do not know how to stimulate the breasts for more milk.
The dilemma of developing a flexible approach to child care behavior and being advised to follow rigid guidelines on avoiding solid feed till 6 months clearly presents a problem in this study. Mothers in the study have expressed doubt about their breast milk sufficiency and this makes them susceptible to the influence of family members and especially grandmothers who suggest that the quantity or quality of the mother’s milk may be deficient in some way. A better understanding about such issues as the feeding behavior of normal children and breastfeeding physiology, and the concept of supply and demand, would help mothers-in-law become more supportive and helpful when mothers feel tired or insecure about the adequacy of their breast milk.
This is the first interview study in this area of research in UAE and should be viewed as starting point for the development of a theory about mother’s experience of breastfeeding. This research has identified key people who support breastfeeding mothers. Grandmothers and husbands who have ongoing contact can be more supportive if they had more practical information about the management of breastfeeding. So recommendations for improving this support involve providing information that is both practical and timely in relation to the promotion and management of breastfeeding.
The research has particular significance for health professionals designing and implementing services that are appropriate to breastfeeding Emirati mothers. Health professionals must recognize the influence of family members such as fathers and grandmothers and the cultural norms on the mother’s breastfeeding and weaning practices and should incorporate them in their breastfeeding education programs. Health professionals should advise family members that their negative or positive beliefs about breastfeeding can have an impact on the mother’s breastfeeding practices. Black et al had concluded that the intervention program will be successful only if specifically targeting cultural barriers that may interfere with the mothers’ acceptance of established guidelines for feeding. 43
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.