PSYCHOSOCIAL FACTORS ASSOCIATED WITH BREASTFEEDING PRACTICE
AMONG SAUDI ARABIAN MOTHERS
By
Salmah Awad Alghamdi

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
Nursing – Doctor of Philosophy
2017

ABSTRACT
PSYCHOSOCIAL FACTORS ASSOCIATED WITH BREASTFEEDING PRACTICE
AMONG SAUDI ARABIAN MOTHERS
By
Salmah Alghamdi
Background/Significance: Breastfeeding has been identified as the most complete form of
infant nutrition in the first six months of infant life. The World Health Organization (WHO)
recommends exclusive breastfeeding throughout the first six months. Adherence to the WHO
recommendation of breastfeeding is important to lay a healthy foundation for infant growth and
development. However, there has been a noticeable decline in the rate of exclusive breastfeeding
in the Kingdom of Saudi Arabia (KSA). There is a lack of literature that examines theory-based
factors associated with breastfeeding practice among Saudi Arabian mothers; thus, the causes
that underlie the low rate of breastfeeding have not yet been established.
Framework: The conceptual framework for this study was guided by the breastfeeding selfefficacy theory.
Aims: The aims of the study were to examine: 1) the associations between perceived stress and
the practice of breastfeeding among first-time Saudi Arabian mothers, 2) the association between
social support and the practice of breastfeeding among first-time Saudi Arabian mothers, and 3)
the association between breastfeeding self-efficacy and the practice of breastfeeding among firsttime Saudi Arabian mothers at six to twelve months after birth.
Methods: This study used a cross-sectional, correlational design. A non-random convenience
sample of 160 first-time mothers was recruited from four primary care centers in Jeddah, KSA.
Multinomial logistic regression model was employed to examine the three aims. The associations
between the demographic variables in this study and the three breastfeeding categories

(exclusive, partial and discontinued breastfeeding) were examined using One-way analysis-ofvariance (ANOVA), Pearson’s chi-square test, and Fisher's exact test.
Results: The mean age of participants was 27.21 years. The proportions of exclusive, partial, and
discontinued breastfeeding in the study sample were 27.5%, 30.00%, and 42.5%, respectively.
Mothers who had higher levels of perceived stress were significantly more likely to discontinue
breastfeeding before the recommended six months. Mothers with higher levels of social support
were significantly more likely to continue breastfeeding throughout the first six months after
birth. Likewise, mothers with higher levels of breastfeeding self-efficacy were more likely to
continue exclusive or partial breastfeeding throughout the first six months. There were
significant associations between breastfeeding practice, maternal employment status, household
income, and educational level.
Implications: This study indicated that mothers with lower levels of perceived stress, higher
levels of social support, and higher levels of breastfeeding self-efficacy were more likely to
continue breastfeeding until at least six months postpartum. Clinicians should empower mothers
with psychosocial resources to promote the practice of breastfeeding. Moreover, there is a need
for policy that mandates assessment of psychosocial factors during prenatal and postnatal care.
Findings from this study lay the foundation for future intervention research through identifying
the theory-based factors that are associated with breastfeeding.

This dissertation is dedicated to my husband Ibrahim Alghamdi, my daughter Dina, and my son
Naif. I could not have completed this dissertation without your constant encouragement and
support throughout my PhD journey.

iv

ACKNOWLEDGEMENTS

All praise is to Allah for his guidance and blessing in completing this dissertation. I am
deeply grateful to every individual who has contributed to my success throughout my PhD
journey. I would like to acknowledge my advisor and dissertation committee chairperson, Dr.
Mildred Horodynski, for her continual advice and support. I cannot thank her enough for her
encouragement and guidance since my first day at Michigan State University. I appreciate her
insight on my topic of interest. I thank her for taking the time to meet with me, address my
concerns, and ensure that I stayed on the right track throughout the past three years. She allowed
me to work on her funded project, from which I developed my research skills. Her
professionalism and support have led to the completion of this dissertation.
I am also extremely grateful to the rest of my dissertation committee members. I would
like to express my sincerest thanks to Dr. Manfred Stommel for his enormous support and
guidance during all the phases of this dissertation. He provided me with the foundations in
research methods and statistics that enabled me to build upon on my research. I am incredibly
grateful to him for teaching me how to use the statistical program and interpret the findings. I
appreciate his brilliant ideas, wisdom, and input, which had an immense impact on my
achievements. I am also extremely indebted to Dr. Jiying Ling for her encouragement, advice,
and inspirational thoughts. Her comments on my work were most helpful. Her encouragement,
support, and perspective will never be forgotten. I would in addition like to express my deepest
appreciation to Dr. Desiree Qin for taking the time from her busy schedule to serve on my
committee. I feel very fortunate to have had the opportunity to learn from her experience in
parenting. I appreciate her availability to meet whenever I needed her valuable opinion. I also

v

would like to thank Dr. Shadia Yousuf for her supervision during the time of data collection. I
appreciate her advice, support, and guidance that facilitated the process of data collection.
I would like to express my thanks to all of the mothers who participated in this study. I
am thankful for the time that they took to complete the surveys while they were holding their
babies in the well-child clinics. I am grateful for their willingness to participate and share their
experience regarding their breastfeeding practices. Their input was highly appreciated toward the
end of improving the practice of breastfeeding in the Kingdom of Saudi Arabia. Special thanks
go to the research assistants who dedicated their time to data collection.
This dissertation was supported by a number of funding sources. I am very grateful for
the scholarship received from the Ministry of Education, King AbdulAziz University, that
allowed me to reach my academic goals. I am thankful for the Graduate School at Michigan
State University that provided the Dissertation Completion Fellowship. This dissertation was
supported by a co-funded grant from the Midwest Nursing Research Society and the American
Nurses Foundation. This dissertation was also supported by the Blue Cross Blue Shield of
Michigan Foundation Student Award Program.
Finally, I could not have completed this dissertation without the support of my mother,
sisters, brothers, friends, and fellow doctoral students. I cannot thank enough my husband,
Ibrahim, for his unending support throughout my academic journey. Last but not least, thank you
to my children, Dina and Naif, for being so patient with my busy schedule. Their love and
support made the completion of this dissertation possible.

vi

TABLE OF CONTENTS

LIST OF TABLES ............................................................................................................. xi
LIST OF FIGURES .......................................................................................................... xii
Chapter 1: Background and Significance ............................................................................1
An Overview of Births and Health Centers in the KSA ..........................................3
Prevalence of Breastfeeding in the KSA .................................................................4
History of Breastfeeding in the KSA .......................................................................5
Factors Contributing to Early Discontinuation of Breastfeeding ............................7
Lack of self-efficacy ....................................................................................7
Perceived high levels of stress .....................................................................8
Lack of social support ..................................................................................8
Significance..............................................................................................................9
Significance of breastfeeding to society ......................................................9
Significance to healthcare ..........................................................................11
Significance to the discipline of nursing ....................................................13
Gaps in Knowledge ................................................................................................15
Study Purpose ........................................................................................................16
Definitions of Key Concepts ..................................................................................17
Breastfeeding initiation ..............................................................................17
Breastfeeding practice ................................................................................17
Duration of breastfeeding ..........................................................................18
Perceived stress ..........................................................................................18
Social support.............................................................................................18
Breastfeeding self-efficacy ........................................................................18
Overarching Research Question ............................................................................19
Aims and Hypotheses ............................................................................................19
Summary ................................................................................................................19
Chapter 2: Conceptual Framework ....................................................................................21
Theories Used to Explain the Practice of Breastfeeding .......................................21
Social Cognitive Theory (SCT) .................................................................21
Breastfeeding Self-efficacy Theory (BSE) ................................................22
Main Constructs in the BSE Theory ......................................................................23
Theoretical Framework of the Study .....................................................................26
Application of the BSE Theory..............................................................................28
Rationale for Choosing the BSE Theory ...............................................................29
Evaluation of the BSE Theory ...............................................................................30
Synthesis of Conceptual and Theoretical Knowledge ...........................................31
Gaps in Breastfeeding Self-efficacy Theory ..........................................................32
Summary ................................................................................................................33

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Chapter 3: Review of the Literature...................................................................................35
Breastfeeding Practice ...........................................................................................36
An overview of breastfeeding practice in the KSA ...................................36
Initiation of breastfeeding in the KSA .......................................................37
Exclusive breastfeeding in the KSA ..........................................................38
Partial breastfeeding in the KSA................................................................38
Breastfeeding cessation in the KSA...........................................................39
Duration of breastfeeding in the KSA .......................................................40
Demographic factors associated with breastfeeding ..............................................42
Maternal age...............................................................................................42
Education and work status .........................................................................42
Income status .............................................................................................43
Perceived Stress .....................................................................................................44
Social Support ........................................................................................................49
Breastfeeding Self-efficacy ....................................................................................52
Summary ................................................................................................................55
Chapter 4: Methods ............................................................................................................56
Study Design ..........................................................................................................56
Sample....................................................................................................................56
Power Analysis and Sample Size...........................................................................57
Inclusion and Exclusion Criteria............................................................................57
Setting ....................................................................................................................58
Procedures ..............................................................................................................58
Procedure for human subject protection ....................................................58
Training procedures ...................................................................................59
Recruitment and data collection procedures ..............................................59
Data management.......................................................................................60
Instrumentation ......................................................................................................61
Demographic factors ..................................................................................61
The Perceived Stress Scale (PSS) ..............................................................61
Social Provisions Scale (SPS)....................................................................63
Breastfeeding Self-Efficacy Scale (BSES) ................................................64
Breastfeeding Practice Questionnaire ........................................................65
Translation and Back Translation of Instruments ..................................................65
Content Validity Evaluation ..................................................................................66
Data Analysis .........................................................................................................67
Data analysis for the main research questions ...........................................69
Summary ................................................................................................................69
Chapter 5: Results .............................................................................................................71
Psychometric Properties of Psychosocial Scales ...................................................71
The Perceived Stress ..................................................................................71
Factor structure ..............................................................................72
Reliability.......................................................................................72
Social Support ............................................................................................72

viii

Factor structure ..............................................................................74
Reliability.......................................................................................74
Breastfeeding Self-Efficacy Scale .............................................................76
Factor structure ..............................................................................76
Reliability.......................................................................................76
Sample Characteristics ...........................................................................................78
Maternal age...............................................................................................78
Infant age and sex ......................................................................................78
Relationship status .....................................................................................78
Maternal employment status ......................................................................79
Household size ...........................................................................................79
Household income .....................................................................................80
Level of education......................................................................................81
Mode of delivery ........................................................................................81
Family history of breastfeeding .................................................................81
Inter-relationships among Selected Psychosocial Factors .....................................81
Description of the Breastfeeding Practice..............................................................82
Breastfeeding initiation ..............................................................................82
The provision of free formula ....................................................................82
Breastfeeding education during pregnancy................................................82
Breastfeeding education and support after delivery...................................82
Sources of breastfeeding support after childbirth ......................................82
Breastfeeding duration ...............................................................................83
Breastfeeding exclusivity ...........................................................................83
Reasons for breastfeeding cessation or supplementation...........................84
The associations between the reported “insufficient breast milk”
and other selected variables .......................................................................85
Formula and solid introduction ..................................................................86
Liquid supplementation .............................................................................86
Demographic Variables by Breastfeeding Category..............................................87
Results Organized by Research Aims ....................................................................91
Aim 1: To determine the association between perceived stress and the
practice of breastfeeding among first-time Saudi Arabian mothers ..........92
Aim 2: To determine the association between social support and the
practice of breastfeeding among first-time Saudi Arabian mothers ..........95
Aim 3: To determine the association between breastfeeding self-efficacy
and Breastfeeding Practice among first-time Saudi Arabian mothers .......97
Overall Theoretical Model .........................................................................99
Chapter 6: Discussion and Implication ...........................................................................101
Discussion of the Main Research Findings According to Study’s Aims .............101
Aim 1 .......................................................................................................101
Aim 2 .......................................................................................................104
Aim 3 .......................................................................................................107
Additional Findings .............................................................................................109
Association among maternal psychosocial variables ...............................109

ix

Discussion of the overall conceptual framework .....................................112
Demographic characteristics ....................................................................113
Breastfeeding practices ............................................................................113
Demographic characteristics associated with breastfeeding practices.....117
Study Strengths ....................................................................................................120
Study Limitations .................................................................................................122
Implications and Recommendations for Future Nursing Research .....................123
Implications and Recommendations for Nursing Practice...................................125
Implications and Recommendations for Policy ...................................................127
Conclusion ...........................................................................................................128
APPENDICES .................................................................................................................130
APPENDIX A: Permission to use the Figure of Self-efficacy Framework
from Published Article .........................................................................................131
APPENDIX B: Institutional Review Board (IRB) Approval from Michigan
State University...................................................................................................132
APPENDIX C: Institutional Review Board (IRB) Approval from the
Ministry of Health in Saudi Arabia ......................................................................133
APPENDIX D: Protocol and Screening Questionnaire for Recruitment and
Enrollment of Participants ...................................................................................134
APPENDIX E: English and Arabic Consent Form..............................................137
APPENDIX F: English and Arabic Version of Self-Administered Survey.........141
APPENDIX G: The Permission to use the Validated Arabic Version of The
Perceived Stress Scale-10 item ............................................................................161
APPENDIX H: The Permission to use the Social Provisions Scale ....................163
APPENDIX I: The Permission to use the Breastfeeding Self-Efficacy
Scale .....................................................................................................................165
APPENDIX J: Assessment of Content Validity Index ........................................167
REFERENCES ................................................................................................................171

x

LIST OF TABLES

Table 1 Means, Standard Deviations, Factor Loadings, and Reliability of Items for
the Perceived Stress Scale..................................................................................................73
Table 2 Means, Standard Deviations, Factor Loading and Reliability of Items for the
Social Provision Scale........................................................................................................75
Table 3 Descriptive Statistics for All Scale Variables .......................................................76
Table 4 Means, Standard Deviations, Factor Loadings, and Reliability of Items for
Breastfeeding Self-Efficacy Scale .....................................................................................77
Table 5 Infant Age and Sex (N = 160)...............................................................................78
Table 6 Frequencies and Percentages of Categorical Demographic Variables
(N = 160) ............................................................................................................................79
Table 7 Sources of Breastfeeding Support and Education.................................................83
Table 8 Breastfeeding Duration and Categories (N = 160) ...............................................84
Table 9 Reasons for Early Breastfeeding Cessation and/or Formula Supplementation
(N = 116) ...........................................................................................................................85
Table 10 Descriptive Statistics for Psychosocial Variables by the Perceived
Insufficient Breast Milk .....................................................................................................86
Table 11 Formula and Solid Food Introduction According to Infant Age (N = 116)........87
Table 12 Demographic Variables by Breastfeeding Category ..........................................89
Table 13 The Mean Scores of Perceived Stress, Social Support, and Self-Efficacy
for each Breastfeeding Category (N = 160).......................................................................92
Table 14 Summary of Multinomial Logistic Regression Analysis of Perceived Stress
Predicting Breastfeeding Practice (N = 160) .....................................................................94
Table 15 Multinomial Logistic Regression Analysis of Social Support Predicting
Breastfeeding Practice (N = 160) ......................................................................................96
Table 16 Multinomial Logistic Regression Analysis of Breastfeeding Self-efficacy
Predicting Breastfeeding Practice (N = 160) .....................................................................98

xi

LIST OF FIGURES

Figure 1. Self-efficacy framework .....................................................................................25
Figure 2. The conceptual framework of factors associated with breastfeeding practice ...27
Figure 3. Scree plot of eigenvalues for the Perceived Stress Scale after principal
component analysis ............................................................................................................74

xii

Chapter 1: Background and Significance
Infant feeding is critical in order to lay a healthy foundation for growth and development.
Breastfeeding has been identified as the most complete form of nutrition in the first six months
of infant life (James & Lessen, 2009; The World Health Organization [WHO], 2016). Research
has shown that exclusive breastfeeding in the first six months of an infant’s life has numerous
advantages to both the infant and the mother (Ip et al., 2007; The United Nations Children's Fund
[UNICEF], 2015; Victora et al., 2016). The WHO reviewed the scientific evidence regarding the
potential benefits of the optimal duration of exclusive breastfeeding. Accordingly, in 2001, the
WHO revised the global breastfeeding recommendations on the duration of breastfeeding to
recommend exclusive breastfeeding throughout the first six months versus the first four to six
months after birth (Kramer & Kakuma, 2002).
The current recommendations by the WHO are consistent with the American Academy of
Pediatrics (AAP) that infants should be exclusively breastfed for the first six months of infant
life, and breastfeeding should be continued until two years of age accompanied by ageappropriate food (Gartner et al., 2005; WHO, 2016). Adherence to the WHO and the AAP
recommendations of breastfeeding is important in order to achieve optimal health benefits for
both infants and mothers (Khan, Vesel, Bahl, & Martines, 2015; Victora et al., 2016).
Unfortunately, this recommendation is not always being followed; worldwide, fewer than 40% of
infants are exclusively breastfed during the first six months of their life (WHO, 2015). The low
rate of breastfeeding has been identified as a global health issue that needs to be addressed
(Bevan & Brown, 2014).
Exclusive breastfeeding rates within the first six months have improved gradually over
the last decade in different countries around the world (Cai, Wardlaw, & Brown, 2012). Despite

1

the fact that rates of exclusive breastfeeding have improved in the United States of America
(USA), Sub-Saharan Africa, and East/South Asia, there has been a noticeable decline in the rate
of exclusive breastfeeding in the Kingdom of Saudi Arabia (KSA; Ogbeide, Siddiqui, Al Khalifa,
& Karim, 2004; UNICEF, 2013). Studies in the KSA has highlighted the issue of decreased
breastfeeding rates and the need for more research that addresses barriers to breastfeeding (AlJassir, El-Bashir, Moizuddin, & Abu-Nayan, 2006; Al Juaid, Binns, & Giglia, 2014). Therefore,
this study focused on examining the breastfeeding practice in the KSA.
It has been consistently reported that the rates of exclusive breastfeeding in developed
and developing countries decline as infant age advances (Abusaad & El-Gilany, 2011;
Alemayehu, Haidar, & Habte, 2009). The most commonly reported reason for the early
termination of breastfeeding among Saudi Arabian mothers is the perception of insufficient
breast milk (Al-Hreashy et al., 2008; Al-Jassir et al., 2006; Al Juaid et al., 2014). According to
McCarter-Spaulding & Kearney (2001), the perception of “insufficient milk supply” is defined
as the mother’s belief that her breast milk is deficient in quantity or quality to meet her infant’s
nutritional needs. Perceived insufficient milk supply may relate to the lack of confidence in a
mother’s ability to successfully breastfeed (Dennis, 2002; Otsuka, Dennis, Tatsuoka, & Jimba,
2008), known as breastfeeding self-efficacy (Dennis & Faux, 1999).
Repetitive reporting of “insufficient breast milk” as a reason for early breastfeeding
discontinuation can also be explained by infrequent breastfeeding that results from formula
supplementation (Wasser et al., 2011), which eventually leads to diminished breast milk (Al
Juaid et al., 2014; Neville & Morton, 2001). Other important psychosocial factors, such as
perceived stress and social support, can also impact the ability of mothers to continue
breastfeeding (Bandura, 1977a, 1977b; Dennis, 1999).

2

Psychosocial factors are important determinants of breastfeeding that can influence a
mother’s decision and ability to breastfeed (Hauff, Leonard, & Rasmussen, 2014; Meedya,
2010). The influences of such factors are yet unknown in the KSA, a country that has a low
breastfeeding rate (Al Juaid et al., 2014). In order to improve the current rate of breastfeeding in
the KSA, psychosocial factors that can be modified with appropriate intervention strategies need
to be identified.
An Overview of Births and Health Centers in the KSA
Saudi Arabia, one of the largest developing countries in the Middle East, is located in the
southwest corner of Asia. Total population of the KSA as of 2016 census was approximately
31,7 million people, including about 20,1 million Saudi, and 11,7 million non-Saudi (Saudi
Arabian General Authority for statistics, 2016). The total number of Saudi females was
9,850,218 including 4,622,041 who were of childbearing age between 19-45 years (Saudi
Arabian General Authority for statistics, 2016). Jeddah city, the second largest city, is located in
the western region of the KSA. The city of Jeddah has five governmental hospitals and other 33
private hospitals (Ministry of Health in the KSA, 2016).
According to the Ministry of Health Statistics (2015), the total number of births in the
government hospitals was 262,792 births in 2015. Of the total births, there were 10,126
deliveries in Jeddah’s government hospitals including 8,825 vaginal deliveries, 1,301 cesarean
deliveries and others assisted deliveries (Ministry of Health in the KSA, 2016). There are 45
primary care centers (PCCs) in the city of Jeddah that provide preventative and regular health
services for community members. The PCCs are available for the public in every geographic
sector and serve under the rules and regulations of the Ministry of Health. There are well-baby

3

clinics in each primary care center. In Jeddah, the total well-baby visits per the recent yearly
statistics were 187,301 Saudi and 107,318 non Saudi (Ministry of Health in the KSA, 2016).
Prevalence of Breastfeeding in the KSA
The global exclusive breastfeeding rate of infants younger than six months has not
exceeded 39% over the past decade (UNICEF, 2015). There are no recent data on national
breastfeeding rates in the KSA since 2014, which may hinder the accurate monitoring of
progress and change over time of breastfeeding patterns (Al Juaid et al., 2014). Almost all Saudi
Arabian mothers initiate breastfeeding after the birth of their infants. The documented
breastfeeding initiation rates have been consistently over 90%, ranging from 91.6% to 95% (AlHreashy et al., 2008; Al-Jassir et al., 2006; El Mouzan , Al Omar, Al Salloum, Al Herbish, &
Qurachi, 2009). However, this high rate of breastfeeding drops following the first weeks after
birth. National surveys’ findings reported that fewer than 24% of infants were breastfed (either
exclusively or accompanied with formula) throughout the first six months of life (Al-Jassir et al.,
2006; El Mouzan et al., 2009).
A study in the KSA revealed a declining trend of exclusively breastfed infants, from
76.1% at birth to only 19.2%, and 12.2%, at four and six months of infant age, respectively
(Amin, Hablas, & Al Qader, 2011). Similarly, another regional survey in the KSA reported a
sharp decline of breastfeeding rates from 98.9% at the first week after birth to only 0.8% at six
months (Al-Jassir, El-Bashir, & Moizuddin, 2004; El-Gilany et al., 2011). This decline in
breastfeeding rates over the first six-months is consistent with the findings from other countries
where exclusive breastfeeding rates decline as infant age advances (Abusaad & El-Gilany, 2011;
Alemayehu, Haidar, & Habte, 2009; CDC 2012). There are numerous possible reasons for the

4

declining trends of breastfeeding over the first six months after birth including early introduction
of solids and formula (Wasser et al., 2011).
In Riyadh, the central largest city of the KSA, the percentage of exclusive breastfeeding
through the first six months is less than 2%, much lower than in many developed countries (AlHreashy et al., 2008; Al-Jassir et al., 2004). The causes that underlie the early discontinuation of
breastfeeding among Saudi Arabian mothers before the recommended six months are not yet
established. The current breastfeeding rates cannot be improved, unless the factors related to the
early discontinuation of breastfeeding are identified.
History of Breastfeeding in the KSA
The KSA is governed by Islamic rules and regulations based on the Quran and tradition
of Prophet Muhammad. The Holy Quran explicitly recommended breastfeeding more than 1000
years ago: “Mothers shall give suck to their offspring for two whole years for those who desire to
complete the term” (Quran, 2:233). These Islamic principles strongly shape the mother-infant
relationship and feeding decision in the KSA. Historically, breastfeeding among Saudi mothers
was a common practice until recently, when alternatives, such as formula feeding, became more
accessible and affordable for most Saudi mothers (Murshid, 2006). The recent significant
changes in the education and employment opportunities for females might account for declining
breastfeeding rates in the KSA (The World Breastfeeding Trends Initiative [WBTi], 2012).
Moreover, the country’s rapid socio-economic growth might also contribute to the current
pattern of infant feeding (Al-Madani, Vydelingum, & Lawrence, 2010; Twum-Danso & Ame,
2012).
Concurrent sub-optimal infant feeding practices that may result in negative health
outcomes are common among Saudi mothers within the first six month including the early

5

introduction of water, herbal tea (Al-Hreashy et al., 2008), and formula (Murshid, 2006).
Maternal dissatisfaction with breastfeeding might lead to the introductions of different type of
nutritional supplements. A recent study examined maternal concerns about breastfeeding among
Saudi Arabian and Egyptian mothers, and revealed that only 14% of Saudi mothers were
satisfied with their exclusive breastfeeding experience compared to 65% of Egyptian mothers
(Nafee Elsayed & Al-Dossary, 2016). Different reasons might explain breastfeeding
dissatisfaction among Saudi Arabian mothers including embarrassment from breastfeeding in
public places, and unsuitability of breastfeeding with working mothers (Nafee Elsayed & AlDossary, 2016). This high rate of breastfeeding dissatisfaction among Saudi mothers indicates
the critical needs for addressing concerns and barriers to breastfeeding.
Globally, the practice of breastfeeding has been accepted and acknowledged as the gold
standard for infant nutrition (WHO, 2015). Strategies that support breastfeeding, such as the
Baby-Friendly Hospital Initiative (BFHI) and lactation consultants, have been implemented in
different developed countries around the world to ensure the best possible health outcomes and
improve mothers’ confidence in breastfeeding (WHO & UNICEF, 2009). Breastfeeding
supporting strategies have shown to be effective in helping mothers to overcome potential
barriers that nursing mothers may encounter, and to improve breastfeeding outcomes (James &
Lessen, 2009; Patel & Patel, 2015). Yet, such supportive measures and policies are lacking in the
KSA, hindering the improvement of current breastfeeding rates. So far, no successful strategy
has been found that guarantees that mothers, who initiate breastfeeding, will continue to do so
throughout the recommended six months.
Despite the consistent agreement on the steps of BFHI among Saudi mothers, a recent
study revealed that the BFHI steps are not being followed by health professionals and policy

6

makers in the KSA (Salem & Al Madani, 2015). Among the strategies used to promote
breastfeeding was a social media campaign that was initiated in the KSA, which showed a
slightly positive effect on breastfeeding rates (Bahkali et al., 2015). Nevertheless, there is a lack
of intervention programs that support breastfeeding and address mothers’ concerns. Thus,
understanding individual psychosocial factors that might influence the practice of breastfeeding
in the KSA is important in order to effectively support breastfeeding mothers.
Factors Contributing to Early Discontinuation of Breastfeeding
Despite religious instructions and the well-documented evidence on the benefits of
breastfeeding, about half of breastfeeding mothers in the KSA discontinue breastfeeding before
the recommended period of six months (Al-Hreashy et al., 2008). In the KSA, several studies
have cited the perception of insufficient breast milk that could result from lack of breastfeeding
knowledge as the most frequent reason for early breastfeeding discontinuation (Al-Hreashy et al.,
2008; Al-Jassir et al., 2006; Al Juaid et al., 2014). Another study carried out in western Saudi
Arabia, city of Jeddah, revealed that 50% of a sample of 128 mothers identified insufficient
breast milk as the cause of inability to sustain breastfeeding, followed by return to work (Fida &
Al-Aama, 2003). McCarter-Spaulding and Kearney (2001) defined the expression of perceived
insufficient milk as the mother’s belief about her breast milk being insufficient in amount or
quality to meet the needs of her infant.
Lack of self-efficacy. After birth, it is unlikely for mothers to have inadequate breast
milk supply due to physiologic or primary reasons. Literature that supports the associations
between the perception of insufficient milk and the primary physical issues is lacking.
Nevertheless, research has found a negative association between the perception of insufficient
milk and breastfeeding confidence, known as breastfeeding self-efficacy (Dennis & Faux, 1999).

7

Two studies conducted in the USA and Japan revealed a significant correlation between
breastfeeding self-efficacy and the perception of insufficient milk (McCarter-Spaulding &
Kearney, 2001; Otsuka et al., 2008). Therefore, breastfeeding self-efficacy could be a very
important factor to address in order to understand its correlation with the practice of
breastfeeding among Saudi Arabian mothers.
Perceived high levels of stress. Some of the psychosocial influences affecting
breastfeeding exclusivity and duration among Saudi mothers are related to Saudi mothers’
unique sociocultural contexts (Al Juaid et al., 2014). The common practice of newly married
Saudi women moving from rural to urban areas (migration), often around the time of their first
baby, can cause stress and social isolation (Aldosari, Bello, & Alhidary, 2015; Salam, 2013).
Saudi Arabian mothers are expected to serve as the primary caregivers for their infants,
and coordinate household tasks with the lack of their husbands’ support (Aldosari & Pufpaff,
2014). Within this unique social-cultural context, Saudi Arabian mothers could experience high
levels of stress. Stress has been identified as a significant predictor of postpartum depression,
another factor strongly associated with the early cessation of breastfeeding (Brown, Rance, &
Bennett, 2016; Henderson, Evans, Straton, Priest, & Hagan, 2003; Miller, 2002). Thus,
addressing perceived stress among Saudi mothers is crucial in order to promote the healthy
outcomes of breastfeeding.
Lack of social support. The social barriers of breastfeeding cessation are evident in the
KSA, where there is a lack of established policy to support breastfeeding in the workplace or in
public (Al-Binali, 2012). While they are a minority, employed mothers are at high risk for the
early discontinuation of breastfeeding due to experiencing high levels of stress and a lack of
support (WBTi, 2012). For instance, in developed country, mothers who had breastfed for six

8

months or longer reported a drop in their earnings that resulted from reduced working hours and
a loss of promotions (Rippeyoung & Noonan, 2012).
Several social barriers have been documented in the KSA, including the common norm
that it is unacceptable to breastfeed in public places (WBTi, 2012), a lack of private nursing
rooms, and embarrassment regarding breastfeeding in public (Nafee Elsayed & Al-Dossary,
2016). In addition, employed Saudi mothers are granted a short maternity leave (about five
weeks), which may prevent them from continuing breastfeeding throughout the recommended
six months (WBTi, 2012). The possible loss of income associated with prolonged maternity
leave, sleep disturbances with newborn responsibilities, and a lack of support pose a high risk of
psychological stress among breastfeeding mothers, and can lead to the early cessation of
breastfeeding (Gardazi, Mobeen, & Syeda Ahsan Ali, 2016).
Significance
Significance of breastfeeding to society. Supporting appropriate feeding choices is
essential for optimizing infant health outcomes. Research has shown unquestionable long-term
benefits of exclusive breastfeeding for infants and mothers (Khan et al., 2015; Sankar et al.,
2015; Victora et al., 2016). For infants, breastfeeding is associated with improved brain
development and cognitive performance (Victora et al., 2016), increased protection and
immunity against several pathogens (Stuebe & Schwarz, 2010), a decreased risk of infant
mortality (Khan et al., 2015; Sankar et al., 2015; Victora et al., 2016), and a reduced risk of
obesity and asthma (Krenz-Niedbala et al., 2015; Victora et al., 2016). In addition, the odds of
sudden infant death syndrome (SIDS) are approximately three times lower in breastfeeding
infants than in formula-fed infants (Hauck, Thompson, Tanabe, Moon, & Vennemann, 2011).
The potential protective effects of breastfeeding against SIDS can be explained by the survival

9

mechanism in reducing the arousal thresholds during infant sleep (Horne, Parslow, Ferens,
Watts, & Adamson, 2004).
Breastfeeding not only benefits infant health outcomes, but also benefits their mothers.
Mothers, who breastfed their infants, had a significantly decreased maternal risk of breast and
ovarian cancers compared to those who never breastfed (Victora et al., 2016). Moreover,
breastfeeding releases the oxytocin hormone, which reduces the risk of postpartum bleeding
(Chen & Rogan, 2004). In addition, regular breastfeeding can help in natural birth spacing
(Victora et al., 2016).
The previous advantages become more evident with exclusive breastfeeding.
Nevertheless, a recent study has revealed that even partial breastfeeding can provide some
protective effects for infants against certain diseases compared to exclusive formula feeding
(Sankar et al., 2015). It is important to note that the previously cited health benefits of
breastfeeding were based on correlational and observational studies; thus, careful interpretation
of the results is advised. In addition, causal inferences cannot be assumed due to the lack of
evidence about ruling out all potential confounding factors that could account for the correlations
between the health benefits and the practice of breastfeeding.
Establishing an emotional bond through breastfeeding is vital for a healthy mother-infant
relationship. Breastfeeding is a natural way to continue the mother-infant attachment that usually
begins during pregnancy (Yu, 2011). Breastfeeding not only strengthens the quality of motherinfant relationship, but it also releases hormones that encourage mothering behaviors (Yu, 2011).
For example, the hormone oxytocin, which is released when mothers breastfeed, has been linked
to changes in maternal brain activity in response to infants’ cues (Peltola et al., 2014).
Furthermore, mother-infant bonding via breastfeeding can reduce the risk of child maltreatment

10

and enhance the long-term mother-infant relationship (Strathearn, Mamun, Najman, &
O'Callaghan, 2009).
Breastfeeding is also environmentally-friendly because it does not require the disposal of
formula or cans (Gartner et al., 2005). It saves the use of natural resources and raw materials that
can take decades to break down after disposal, such as plastic bottles. Moreover, breastfeeding
saves time and money because it eliminates the cost of artificial milk, bottles, heating, and
storage.
Despite the health benefits and environmental advantages of breastfeeding, there are
other psychological, physiological, economical, and social factors that influence the ability of
mothers to breastfeed. Thus, these factors need to be specified to further promote breastfeeding
by taking into account variations in sociocultural norms and backgrounds (Al Juaid et al., 2014).
Significance to healthcare. The risks of the early cessation of breastfeeding include
increasing infants’ susceptibility for contracting infectious diseases, such as diarrhea and
pneumonia, which are most often associated with infant mortality (Black, Morris, & Bryce,
2003). Infants, who were never breastfed, face elevated risks of diabetes, SIDS, and leukemia (Ip
et al., 2007). Other infectious diseases, such as otitis media, gastroenteritis, and atopic dermatitis,
are also more common among non-breastfed infants due to their underdeveloped immune
systems (Black et al., 2003; Stuebe & Schwarz, 2010).
Breastfeeding significantly impacts healthcare and its associated costs. Breastfeeding is
not only associated with decreased mortality and morbidity (Stuebe & Schwarz, 2010), but it also
has the potential for decreased annual healthcare costs (Bartick & Reinhold, 2010; Weimer,
2001). It has been estimated that a minimum of $10 billion could be saved yearly in the USA if
the prevalence of exclusive breastfeeding was improved to 80% at six months (Bartick &

11

Reinhold, 2010; Weimer, 2001). The cost savings associated with exclusive breastfeeding can be
direct, via the reduction of formula costs, infant’s sick clinic visits, and diagnostic procedure fees
that may be requested for a sick infant, and indirect, such as through the reduction of parental
absenteeism that occurs when parents must accompany a sick infant (Rippeyoung & Noonan,
2012; Weimer, 2001).
Mothers’ feeding behavior plays a major role in regulating the ongoing process of weight
gain during infancy (Koupil & Toivanen, 2008). In the USA, approximately 17% of the children
are obese (Ogden et al., 2016). In the KSA, there is very limited information on the prevalence of
early childhood obesity. However, research has found that obesity is evident in all age groups
and affects all regions of the KSA (Al-Othaimeen, 2007). Studies conducted in the Middle East
have found that children and adolescents are likely to experience a great weight gain as they age
and grow (Al-Hourani, Henry, & Lightowler, 2003; Al-Isa, 2004). The current epidemic of
childhood obesity cannot be attributed to the alterations in genes that are linked to adult obesity
alone (Gittner, Ludington-Hoe, & Haller, 2014); however, it might, in part, be the result of
mothers’ suboptimal feeding behaviors. Childhood obesity can lead to comorbidities and lifelong
weight struggles (Gittner et al., 2014). The risk of early childhood obesity can be reduced, in
part, through exclusive breastfeeding (Krenz-Niedbala et al., 2015; Victora et al., 2016).
Obesity and its associated diseases place a huge financial cost on individuals and
healthcare systems. Treating childhood obesity and its associated medical conditions is expected
to cost $48 to $60 billion in the USA, per year by 2030 (Finkelstein, Fiebelkorn, & Wang, 2003;
Wang, McPherson, Marsh, Gortmaker, & Brown, 2011). Exclusive and longer-duration
breastfeeding can protect against the development of childhood obesity (Reynolds, Hennessy, &

12

Polek, 2014). Therefore, efforts need to be taken by healthcare systems to encourage mothers to
follow the current recommendations for breastfeeding.
Breastfeeding support has become a global health goal to ensure maximum health
benefits with reduced costs. The WHO and UNICEF introduced the BFHI in 1991, which
included the Ten Steps to Successful Breastfeeding. The Ten Steps to Successful Breastfeeding
were developed by global experts for healthcare providers to adopt in order to increase the
initiation, duration, and exclusivity of breastfeeding. There are vast differences between the
breastfeeding promotion strategies implemented by healthcare facilities in developed versus
developing countries.
Additionally, the assessment of maternal psychosocial factors that may influence the
practice of breastfeeding is often not included in prenatal and postnatal care in the KSA (Habib,
Hanafi, & El-Sagheer, 2011). Thus, it is important to address maternal psychosocial factors, and,
by doing so, breastfeeding recommendations could be incorporated into the healthcare system
(Gartner et al., 2005; Glassman, McKearney, Saslaw, & Sirota, 2014).
Significance to the discipline of nursing. Addressing breastfeeding and its associated
factors is imperative for the discipline of nursing to achieve adherence to the current
breastfeeding recommendations, particularly in developing countries where the rates of
breastfeeding are relatively low (Murshid, 2006). It has not been established that a physical or
hormonal factor alone causes insufficient milk production (Neifert, 2001), which was the most
cited reason for early breastfeeding discontinuation (Al-Hreashy et al., 2008; Al-Jassir et al.,
2006; Al Juaid et al., 2014). Thus, there must be other factors that also influence early
breastfeeding discontinuation, such as psychosocial factors including self-efficacy (McCarterSpaulding & Kearney, 2001; Otsuka et al., 2008), perceived stress (Doulouger, Panagopoulou, &

13

Montgomery, 2013), and social support (Dashti, Scott, Edwards, & Al-Sughayer, 2010; Nassar et
al., 2014). Such psychosocial factors need to be addressed to equip nurses with the knowledge
and skills needed to effectively encourage breastfeeding throughout the first six months of
infant’s life.
Understanding psychosocial factors enables nurses to integrate the assessment of such
factors into their daily practice. Given the fact that the majority of Saudi Arabian mothers initiate
breastfeeding (Al-Hreashy et al., 2008; Al-Jassir et al., 2006), efforts are needed to identify the
main factors that contribute to the discontinuation of breastfeeding. Factors influencing
breastfeeding initiation are different than factors that influence the exclusivity of breastfeeding at
six months postpartum (Jones, Kogan, Singh, Dee, & Grummer-Strawn, 2011). Thus, exploring
psychosocial factors at six months postpartum is needed to identify the possible determinants of
breastfeeding exclusivity and enhance evidence-based practice. Maternal psychosocial factors
are important components of the basic nursing metaparadigm: health, person, environment, and
nursing (Fawcett & Desanto-Madeya, 2013). Clarifying the psychosocial determinants of
breastfeeding assists nurses in educating and assisting mothers who may be at risk of early
termination of breastfeeding.
Integrating conceptual knowledge into nursing practice is essential to provide holistic
care that could improve the health outcomes of mothers and infants via breastfeeding.
Furthermore, nurses need to be well-informed about the psychosocial factors associated with the
exclusivity and duration of breastfeeding so they can identify at risk mothers for early
breastfeeding discontinuation and develop individualized plans to assist all breastfeeding
mothers. It is imperative to integrate the assessment of psychosocial factors into practice through
supportive breastfeeding policy in healthcare systems.

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Gaps in Knowledge
Numerous antecedents of the early breastfeeding cessation are psychosocial factors
(Balogun, Dagvadorj, Anigo, Ota, & Sasaki, 2015; McCarter-Spaulding & Kearney, 2001;
Meedya, 2010; Otsuka et al., 2008). Research that examines the relationships between
psychosocial factors and breastfeeding practice is lacking in the KSA; hence, the associations
between such factors are not well-known. Existing literature from different countries has
revealed inconsistent findings related to the association between psychosocial factors and the
practice of breastfeeding (Aubuchon-Endsley, Kennedy, Gilchrist, Thomas, & Grant, 2015;
McQueen, Dennis, Stremler, & Norman, 2011; Souza & Fernandes, 2014), suggesting the need
for more research in this area.
While some studies have reported a positive association between stress levels and the
practice of breastfeeding (Dimitraki et al., 2016; Doulouger et al., 2013; Dozier, Nelson, &
Brownell, 2012), other studies did not support this positive relationship (Groer, 2005; Groer,
Davis, & Hemphill, 2002). Research has also not established whether breastfeeding self-efficacy
is a cause or a consequence of breastfeeding behavior. The lack of knowledge related to the
psychosocial factors of breastfeeding could impede the ability of researchers and professionals to
improve breastfeeding practice.
Several studies in the KSA that examined the maternal characteristics associated with
breastfeeding focused on the first weeks of postpartum period (Al-Jassir et al., 2006; Al-Yousif,
Sabra, Sebiany, & Hafez, 2011; Shawky & Abalkhail, 2003); thus, the reasons behind the
discontinuation of breastfeeding before the recommended six months period are still not well
understood. Studies conducted in the KSA have identified factors associated with breastfeeding
exclusivity and duration, including increased maternal age, low income, rural residence, and low

15

educational levels (Al-Jassir et al., 2006; Al-Madani et al., 2010; Amin et al., 2011; Shawky &
Abalkhail, 2003). However, these demographic factors are not amenable to change in the short
term, though they are important to consider for intervening.
Furthermore, research has not examined how the three modifiable factors of stress, social
support, and breastfeeding self-efficacy can affect the breastfeeding practices of mothers in the
KSA, which makes it difficult to develop health promotion programs and monitor progress of
breastfeeding parameters. Thus, these factors need to be addressed within a Saudi population,
who has different cultural norms and social backgrounds than populations in developed countries
(Al-Binali, 2012; Al Juaid et al., 2014; Habib et al., 2011).
This study was innovative in the following ways: 1) It involved the assessment of the
associations that have not been empirically well-established between modifiable psychosocial
factors of perceived stress, social support, and breastfeeding self-efficacy as primary exposures,
while other studies focused on breastfeeding self-efficacy as an ultimate outcome (Dozier et al.,
2012); 2) It involved examining the maternal psychosocial factors associated with a longer
duration of exclusive breastfeeding at six months of infant age, while several other studies have
focused on breastfeeding primarily during the early postpartum period; and 3) It targeted firsttime Saudi Arabian mothers who have low rates of exclusive breastfeeding (Murshid, 2006).
Study Purpose
The purpose of the study was to examine associations between three modifiable maternal
psychosocial factors (perceived stress, social support, and breastfeeding self-efficacy) and
breastfeeding practices in a sample of primiparous mothers who initiated breastfeeding in the
KSA. As part of the overall pursuit of knowledge that can be used to promote healthy
breastfeeding practices worldwide, this study has provided an original contribution to nursing

16

science by exploring the associations between modifiable psychosocial factors and breastfeeding
practice within a population of Saudi Arabian women.
Definitions of Key Concepts
Breastfeeding initiation. Breastfeeding initiation, one of the main indicators of
breastfeeding outcomes, is related to the time of the first breastfeeding session after the birth of
an infant (Jana, 2006). Breastfeeding initiation can be determined based on the provision of
breast milk for the newborn within the first 24 hours after birth (Dennis, Gagnon, Van Hulst,
Dougherty, & Wahoush, 2013). The WHO defined “early breastfeeding initiation” as providing
mothers’ breast milk to infants within the first hour of their birth (WHO, 2016). In this study,
early breastfeeding initiation was subjectively determined according to the provision of breast
milk for the newborn within the first 24 hours after birth.
Breastfeeding practice. Breastfeeding practice can be described by three categories:
exclusive, partial, and discontinued. Breastfeeding exclusivity is an important parameter of
global breastfeeding outcomes. The specifications and definitions of breastfeeding categories are
widely varied across the studies. The following definitions are the most consistent with the
current WHO classifications. Exclusive breastfeeding was defined as an infant who is fed only
breast milk for the first six months of life with no additional supplementation of any kind of food
or drink, not even water, except syrups, vitamins, and minerals (WHO, 2016). Partial
breastfeeding was defined as infants who were fed some combination of breast milk and any
other food or liquid, including supplemental formula and water for the first six months (WHO,
2016). Discontinued breastfeeding was defined as infants who were breastfed (either exclusively
or partially) for a period of time but breastfeeding was completely stopped before the

17

recommended first six months, and the infants were fed any food or liquid other than breast milk,
including non-human milk.
Duration of breastfeeding. Duration of breastfeeding was defined as the period of any
breastfeeding in days or months from the time of breastfeeding initiation to the time of
breastfeeding cessation.
Perceived stress. Perceived stress was defined as a mother’s perception of a situation as
overwhelming and exceeding her available resources (Goodnite, 2014; Lazarus, 2006). It has
been identified as a potential risk factor for the early cessation of breastfeeding (Doulouger et al.,
2013).
Social support. Social support was defined as any form of social resources or helping
relationships that are provided or perceived as available (Cohen, Brittney, Gottlieb, & Fetzer,
2000). Social support has been associated with high breastfeeding self-efficacy and longerduration breastfeeding (Dashti et al., 2010; Nassar et al., 2014; Zhu, Tian, Chen, & Christensson,
2014).
Breastfeeding self-efficacy. The concept of breastfeeding self-efficacy emerged in 1999
as an important correlate of breastfeeding practice (Dennis, 1999). It refers to a mother’s
confidence in her ability to successfully breastfeed (Dennis, 2002; Otsuka et al., 2008). In
developed countries, breastfeeding self-efficacy has been reported as a significant variable for
predicting exclusive and longer-duration breastfeeding (de Jager, Skouteris, Broadbent, Amir, &
Mellor, 2013; Dennis, 2006; Meedya, 2010).

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Overarching Research Question
How do perceived stress, social support, and breastfeeding self-efficacy influence the
practice of breastfeeding among Saudi Arabian mothers?
Aims and Hypotheses
Aim 1: To determine to what extent perceived stress is associated with the practice of
breastfeeding at six to twelve months after birth among first-time Saudi Arabian mothers.
H1: Mothers who have lower levels of stress will tend to exclusively breastfeed through the first
six months after birth compared to mothers who have higher levels of stress.
Aim 2: To determine to what extent social support is associated with the practice of breastfeeding
at six to twelve months after birth among first-time Saudi Arabian mothers.
H2: Mothers who have higher levels of social support will continue to exclusively breastfeed
their infants through the first six months after birth compared to mothers with lower levels of
social support.
Aim 3: To determine to what extent breastfeeding self-efficacy is associated with the practice of
breastfeeding at six to twelve months after birth among first-time Saudi Arabian mothers.
H3: Mothers who have higher levels of breastfeeding self-efficacy will continue to exclusively
breastfeed their infants through the first six months compared to mothers who have lower levels
of breastfeeding self-efficacy.
Summary
This study addressed the associations among the selected modifiable psychosocial
variables (perceived stress, social support, and breastfeeding self-efficacy) and breastfeeding
exclusivity and duration. Understanding the associations between perceived stress, social
support, breastfeeding self-efficacy, and the practice of breastfeeding is important to effectively

19

improve breastfeeding practice. Findings from this study can be incorporated into clinical
practice to improve mother and infant health outcomes in the KSA. The following is discussed in
sequence: Chapter Two- conceptual framework for the study, Chapter Three- literature review on
the study variables, Chapter Four- study design, methods of data collection and analysis, Chapter
Five- results of the study, and Chapter Six- discussion of the findings and conclusions.

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Chapter 2: Conceptual Framework
Human behavior reflects a complex interaction of physical, mental, emotional, and social
actions. Different personal, psychosocial, and cultural factors influence individual behavior
(Bandura, 1986). Breastfeeding is one of the natural maternal behaviors that support infant
healthy growth and development (Victora et al., 2016). Breastfeeding behavior can be facilitated
or impeded through personal and social contexts. A conceptual framework is important to clarify
the complex interactions among an array of different factors that influence breastfeeding.
This chapter provides an overview of the conceptual framework that was used to guide
the proposed study. The chapter starts with a brief description of the social cognitive theory from
which the breastfeeding self-efficacy theory was derived. A detailed description of the most
commonly used theory, breastfeeding self-efficacy, is provided, followed by an explanation of
the concepts and propositions within that theory that relate to the study’s concepts of perceived
stress, social support, and breastfeeding self-efficacy and their associations with breastfeeding
exclusivity and duration. The analysis of the breastfeeding self-efficacy theory elucidates the
strengths, weaknesses, and gaps in the related literature. This chapter aims to clarify the
conceptual associations between breastfeeding practice and the selected theory-based
psychosocial factors of perceived stress, social support, and breastfeeding self-efficacy.
Theories Used to Explain the Practice of Breastfeeding
Social Cognitive Theory (SCT). The SCT was developed by Bandura in 1977 to
explain how people perform and maintain behaviors (Bandura, 1977a, 1977b). The SCT suggests
that human behavior can be described through the triadic reciprocal causation in which
behavioral, personal, and social factors mutually influence each other (Bandura, 1986). Bandura
re-named social learning theory to social cognitive theory, to reflect the role of cognitive process

21

involved in the performance of behavior. The SCT is a fundamental theory that explains human
behavior as the product of dynamic interplay between personal, behavioral, and environmental
influences (Glanz, Rimer, & Viswanath, 2008). The SCT provides a framework for breastfeeding
behavior by enhancing breastfeeding knowledge (personal factors), equipping mothers with
skills to overcome breastfeeding barriers (behavioral factors), and providing breastfeeding
support (environmental factors). In the SCT framework, behavioral, personal and environmental
factors cannot function independently; rather they interact, regulate, and determine each other
(Bandura, 1977b).
The SCT framework has been applied widely in nursing research. A study aimed to
identify factors that may influence mothers’ comfort level with breastfeeding in public, using
SCT, concluded that past breastfeeding experience and knowledge were significant personal
factors (Patenaude, Knol, & Turner, 2015). Significant environmental factors related to higher
comfort with breastfeeding in public were supportive grandmother(s) and not working outside
the home, while father’s support and media campaigns were not significant in influencing
mothers’ public breastfeeding comfort (Patenaude et al., 2015). Another study guided by the
SCT identified self-efficacy as an important predictor of breastfeeding initiation and duration
among African-American mother (Eastin & Sharma, 2015). Thus, the foundation was laid for the
breastfeeding self-efficacy theory.
Breastfeeding Self-Efficacy Theory (BSE). The BSE theory was derived from
Bandura’s social cognitive theory (Bandura, 1977a, 1977b; Dennis, 1999). The basic tenets of
BSE theory were based on Bandura’s theory of self-efficacy (Bandura, 1977a). Self-efficacy is a
thought process about an individual’s confidence in his/her perceived ability of performing a
specific behavior (Bandura, 1986). Within this context, the BSE theory proposed that

22

breastfeeding self-efficacy is crucial in determining the exclusivity and duration of breastfeeding
(Dennis & Faux, 1999). In different countries around the world, such as Canada, Australia,
China, Brazil, and England, the concept of self-efficacy has been identified as an important
determinant of breastfeeding behavior, as with other health behaviors (Babakazo, Donnen,
Akilimali, Ali, & Okitolonda, 2015; McCarter-Spaulding & Gore, 2009; McQueen, Sieswerda,
Montelpare, & Dennis, 2015; Wu, Hu, McCoy, & Efird, 2014). Studies from developed countries
supported a strong positive association between breastfeeding self-efficacy and exclusive
breastfeeding duration (de Jager et al., 2013; Dennis, 2006; Meedya, 2010).
Main Constructs in the BSE Theory
The BSE theory presents a systematic view for elucidating the behavior of breastfeeding.
(Dennis, 1999). Self-efficacy is a central concept in the theoretical framework that reflects an
individual’s perceived ability about performing a behavior (Dennis & Faux, 1999). In the nursing
literature, the concepts “self-efficacy” and “confidence” are used interchangeably. In the last
decade, the concept of breastfeeding self-efficacy has been widely used in the literature
reflecting the underlying theory of breastfeeding self-efficacy (Dennis, 1999). Breastfeeding selfefficacy (confidence) is one of the psychological factors that can be improved and modified
through education and support (Dennis, 2003; Nichols, Schutte, Brown, Dennis, & Price, 2009;
Wu et al., 2014). According to Dennis (1999), breastfeeding self-efficacy is affected by four
sources of information based on Bandura’s self-efficacy theory, known as antecedents, including
performance accomplishments (e.g., previous breastfeeding experiences), vicarious experiences
(e.g., watching other mothers practice breastfeeding), physiological states (e.g., stress, fatigue),
and verbal persuasion (e.g., encouragement, social support).

23

The following four main sources of information that influence breastfeeding self-efficacy
differ from person to person; thus, self-efficacy levels can be situation-specific (Dennis, 1999).
First, performance accomplishments relate to previous personal experience in performing certain
behavior. Research has supported this assumption by finding higher breastfeeding self-efficacy
scores among mothers with previous breastfeeding experiences than in primiparous women
(Blyth et al., 2002; Nichols et al., 2009). Moreover, it has been found in various longitudinal
studies that the pattern of mothers’ breastfeeding self-efficacy scores increased with the
progression of time, when repeatedly measured on different occasions in a single study
(McCarter-Spaulding & Gore, 2009; McQueen et al., 2011; Otsuka et al., 2014). Second,
vicarious experiences involve observational learning about skills needed through live, recorded,
or printed demonstrations (Dennis, 1999). An example of vicarious experience is watching other
mothers while they breastfeed their infants, which can be influential. Third, verbal persuasion
involves any form of social support, appraisals, or encouragement, which in turns influences the
level of self-efficacy. Fourth, physiological states may involve positive interpretation of behavior
(e.g., satisfaction) or negative interpretations (e.g., stress, fatigue, and pain). Health professionals
can enhance mothers’ BSE by modifying these sources of information (Dennis, 2006).
Self-efficacy directly influences individual response to behavior, which is known as
consequences of self-efficacy. According to Dennis (1999), breastfeeding self-efficacy
influences thoughts and actions via different ways: the choice of behavior (breastfeeding vs
bottle feeding), the amount of effort and perseverance, thoughts patterns about the expectations
of successful breastfeeding, and emotional reactions accompanied the success and failure of the
breastfeeding behavior. The BSE theory predicts the following: initiation, performance as it
relates to the ability to overcome obstacles, and the duration of breastfeeding (Dennis, 1999).

24

Self-efficacy is an important factor that can predict certain behaviors via beliefs and
thought processes; however, it does not necessarily reflect the ability or skills needed to perform
the actual behavior (Bandura, 1977b). Perceived stress, social support, past experience, and
observing others performing the behavior can have a direct relationship with the practice of
breastfeeding or an indirect relationship via the influence of BSE (Bandura, 1977a, 1977b;
Dennis, 1999). The original BSE framework is displayed in Figure 1.

Figure 1. Self-efficacy framework.
Source: Dennis, C. (1999). Theoretical underpinnings of breastfeeding confidence: A self-efficacy
framework. Journal of Human Lactation, 15(3), 195-201. Used with permission (Appendix A).

25

Theoretical Framework of the Study
Self-efficacy is a constantly evolving process that enhances over time with practice
(Bandura, 1977b). Mothers’ breastfeeding self-efficacy scores were found to increase over time,
when they were evaluated multiple times throughout a single study (McQueen et al., 2011;
Otsuka et al., 2014). Furthermore, the ability of breastfeeding self-efficacy to significantly
predict breastfeeding duration varied from one week to six months postpartum (Blyth et al.,
2004; de Jager et al., 2015; Henshaw, Fried, Siskind, Newhouse, & Cooper, 2015). For example,
findings from a recent study showed that breastfeeding self-efficacy was a significant predictor
for breastfeeding practices at six months postpartum, but not at six weeks postpartum (Henshaw
et al., 2015). To control for the influence of past breastfeeding experience on breastfeeding selfefficacy, the sample of this study included only first-time mothers with their infants aged from
six to 12 months.
The application of the core concepts of breastfeeding self-efficacy theory in research has
been lacking. For example, breastfeeding self-efficacy has been commonly examined as an
ultimate outcome of the four identified sources of information (predictors) including
performance accomplishments, vicarious experiences, physiological states, and verbal
persuasion. A major issue with the application of the BSE theory is its lack of consideration of
the breastfeeding outcome in terms of exclusivity and duration (Resnick, 2013). Thus, the
theoretical framework for the study conceptualized the associations between the selected
maternal psychosocial factors of perceived stress, social support, and breastfeeding self-efficacy
as primary exposures, and the practice of breastfeeding as the outcome (see Figure 2).

26

Figure 2. The conceptual framework of factors associated with breastfeeding practice.
The conceptual framework in Figure 2 has been developed based on the breastfeeding
self-efficacy theory (Dennis, 1999). The conceptual framework of this study proposes that
perceived stress that may occur with transition to the motherhood role among primiparous
mothers can have a direct influence on the exclusivity and duration of breastfeeding (Bandura,
1977a, 1977b). Perceived stress can also indirectly impact the breastfeeding practice in terms of
exclusivity and duration through the influence of breastfeeding self-efficacy (Dennis, 1999).

27

Breastfeeding self-efficacy can also be affected by the influence of perceived stress and
social support, as both conceptualized in the BSE model as antecedents of breastfeeding selfefficacy (Bandura, 1977a, 1977b; Dennis, 1999). Social support was conceptualized in the
framework of this study based on the concept of “verbal persuasion” in the original BSE model
(Figure 1). Social support can indirectly influence the breastfeeding practice through influencing
breastfeeding self-efficacy, and/or it can have direct influence on breastfeeding exclusivity and
duration (Bandura, 1977a, 1977b; Dennis, 1999).
Modifiable variables conceptualized in the model differ from person to person and from
context to context. Mothers’ sociodemographic factors are important characteristics that may
influence the practice of breastfeeding (Al Juaid et al., 2014; Amin et al., 2011). Maternal
sociodemographic factors included in the study conceptual framework were the ages of mothers
and their infants, education, work status, and income status.
Application of the BSE Theory
Dennis (2006) conducted the first study to test the assumptions in the BSE theory and
assess the associations between breastfeeding self-efficacy and the outcomes of breastfeeding in
the early postpartum period among Canadian breastfeeding mothers (N = 522). Dennis concluded
that mothers who were exclusively breastfeeding had significantly higher levels of breastfeeding
self-efficacy than mothers who were partially breastfeeding (2006). Dennis suggested through
extensive research on breastfeeding that the BSE theory can be used to identify mothers at risk
for early breastfeeding termination based on modifiable factors, including stress, social support,
and breastfeeding self-efficacy (Dennis et al., 2013; Dennis, 2006; Dennis, 1999; Dennis,
Heaman, & Mossman, 2011).

28

During the postpartum period, breastfeeding self-efficacy was a significant predictor of
breastfeeding initiation and exclusivity in studies that were guided by the BSE (Blyth et al.,
2002; McQueen et al., 2011; Wu et al., 2014). The postpartum period starts from the first hour
after the delivery of a newborn to six weeks later (WHO, 2010). The postpartum period includes
the immediate postpartum period (first 24 hours), early postpartum period (first week), and late
postpartum period that extends up to 42 days (WHO, 2010).
Recently, the BSE framework was used to guide several observational and interventional
studies that aimed to improve the practice of breastfeeding. For example, “self-efficacy
enhancing sessions” was an intervention strategy that was developed for first-time mothers based
on the BSE theory (McQueen et al., 2011; Wu et al., 2014). These “enhancing sessions”
included: 1) initial assessment of breastfeeding self-efficacy, the breastfeeding goals, perception,
physiologic state, and psychologic state; 2) individualized strategies to increase breastfeeding
self-efficacy based on the previously listed four antecedents of breastfeeding self-efficacy; and 3)
re-evaluation of the breastfeeding self-efficacy (McQueen et al., 2011; Wu et al., 2014). Another
intervention was also based on the BSE theory’s “self-efficacy workbooks,” and it was
developed to be given to pregnant women in their third trimester (Nichols et al., 2009). A
majority of these theory-based interventions have been effective in improving breastfeeding selfefficacy, exclusivity, and duration.
Rationale for Choosing the BSE Theory
The rationale for using the BSE theory was that the BSE’s constructs were specific to
breastfeeding practice. For example, the outcomes of breastfeeding initiation, performance, and
maintenance were explicitly conceptualized in the BSE theory as an outcome behavior for
breastfeeding self-efficacy (Babakazo et al., 2015; Blyth et al., 2002). The BSE theory addressed

29

the basic propositions of self-efficacy theory in relation to breastfeeding practice, such as past
breastfeeding experience and physiologic status.
The BSE theory allows constructs associated with breastfeeding to be operationalized and
measured; thus, the model can be tested in different contexts with various populations. For
example, the BSE theory has been used to design intervention studies that aim to promote
breastfeeding among pregnant women (Blyth et al., 2004; Nichols et al., 2009) and first-time
mothers (McQueen et al., 2011; Wu et al., 2014). The BSE theory has the potential to enhance
breastfeeding self-efficacy and practice through the modification of the main sources of
information “antecedents” identified in Figure 1. Overall, the BSE theory provides a holistic
approach to variables that are amenable to change in order to enhance and promote breastfeeding
exclusivity and duration.
Addressing the theory-based psychosocial factors of maternal perceived stress, social
support, and breastfeeding self-efficacy has the potential to lay the foundation for innovative
intervention designs and research in the KSA. Furthermore, hypotheses for future research that
aim to promote exclusive and longer-duration breastfeeding cannot be generated without
knowledge gained from examining psychosocial factors associated with breastfeeding at six
months of infant age.
Evaluation of the BSE Theory
The description of the main concepts and constructs in the BSE theory are clearly
defined. Moreover, the relationships between the concepts are explained in sequential process
starting from the antecedents of the self-efficacy, and ending with the behavior of breastfeeding.
The relationships between the concepts in the conceptual model of BSE remain consistent
throughout the explanation and application of the theory. The theory addressed the four core

30

concepts of the nursing profession: nurse, health, person, and environment (Peterson & Bredow,
2017). Thus, the BSE is useful to predict human behavior in both practice and research. It can
also be used to test or generate hypotheses to advance nursing science.
An important limitation of the BSE theory was that high self-efficacy may not be
sufficient to execute the behavior, particularly in situations where support and resources are
lacking (Bandura, 1977b). Moreover, low self-efficacy may lead to unpredictable and
undesirable consequences that have not been explained in the model, such as depression
(Bandura, 1977a, 1977b). Other than these limitations, the theory presents a dynamic and
comprehensive view of breastfeeding behavior that can guide future studies that aim to improve
the practice of breastfeeding.
Synthesis of Conceptual and Theoretical Knowledge
The BSE theory identified confidence in the ability to perform breastfeeding, known as
breastfeeding self-efficacy, as a basic component of determining breastfeeding behavior
(Bandura, 1977a; Dennis, 1999). Likewise, Ajzen (1991) added perceived control over
performance in situations where one may not have control over the behavior as an additional
construct to the theory of reasoned action. The concept of perceived behavioral control resembles
the concept of self-efficacy in the BSE theory, as both concepts can be measured with the same
items that determine one’s belief in his/her ability to perform a certain behavior under different
circumstances (Montano & Kasprzyk, 2008). In addition, the BSE assumes that human behavior
is determined by intrinsic factors, which include individual’s beliefs, and extrinsic factors, which
include environmental influences.
Breastfeeding self-efficacy was identified as an important correlate with breastfeeding
practice (Blyth et al., 2002; McQueen et al., 2011; Wu et al., 2014). High breastfeeding self-

31

efficacy scores have been correlated with high social support scores and low maternal perceived
stress (Dennis, 2006). The BSE theory can be applied to guide future research that aims to
identify mothers at high risk of early breastfeeding cessation in the first six months after birth
and to develop effective interventions.
Gaps in Breastfeeding Self-efficacy Theory
The BSE theory provides insight into the nature of breastfeeding behavior. The BSE
theory precisely addresses maternal psychosocial factors that predict breastfeeding self-efficacy
and breastfeeding behavior. However, the majority of studies have focused on breastfeeding selfefficacy as an ultimate outcome (Dennis, 2006; Dozier et al., 2012). To close this gap, the focus
of this study was on the assessment of the modifiable psychosocial factors of perceived stress,
social support, and breastfeeding self-efficacy as primary exposures.
Antecedents of the breastfeeding practice in the BSE conceptual framework (e.g., verbal
persuasion, vicarious experience) have limited research implications due to unclear operational
definitions. Furthermore, the linear relationships between the antecedents and the breastfeeding
outcomes in the BSE theoretical model require a complex longitudinal prospective design in
order for the relationships to be established. Additionally, the causal relationships between
psychosocial factors (e.g., stress) and breastfeeding practices have not been established in the
literature. For instance, studies have found that breastfeeding women had lower stress than
women who were not breastfeeding, while other studies reported no differences between the
stress levels of women who were breastfeeding versus those who were formula feeding (Dozier
et al., 2012; Groer, 2005; Groer et al., 2002).
It has been well-documented that the rates of breastfeeding decline as infants advance in
age. However, BSE does not address the time frame between constructs, considering the changes

32

in the practices of breastfeeding over time. Numerous studies have focused on breastfeeding
during the early postpartum period in the application of the BSE theoretical framework
(Glassman et al., 2014; McQueen et al., 2015; Souza & Fernandes, 2014). Therefore, this study
aimed to close this gap by examining the maternal psychosocial factors associated with exclusive
and longer-duration breastfeeding at six months of infant age. Moreover, the proposed
conceptual framework in this study is the first to examine the associations between the selected
psychosocial factors and breastfeeding practice among first-time Saudi Arabian mothers who
initiated breastfeeding.
Summary
Theoretical frameworks are important in understanding human behavior. The
breastfeeding self-efficacy theory has been used widely in nursing research. However, gaps in
the theoretical knowledge exist with unclear propositions about the influence of self-efficacy as
the primary exposure on the practice of breastfeeding at six months of infant age. Thus, the
conceptual framework of this study was adapted based on the breastfeeding self-efficacy theory
to examine to what extent the psychosocial factors of perceived stress, social support, and
breastfeeding self-efficacy were associated with breastfeeding exclusivity and duration at six
months of infant age.
Several conceptual frameworks in the literature have focused on breastfeeding primarily
during the early postpartum period. However, this conceptual framework further tested the
assumptions with longer duration of exclusive breastfeeding, specifically at six months of infant
age. The findings from this study can be incorporated into practice to identify women at risk for
early breastfeeding cessation. Moreover, findings can be used to develop and test interventions

33

that aim to improve Saudi Arabian mothers’ ability to overcome barriers and continue
breastfeeding through the recommended period.

34

Chapter 3: Review of the Literature
Breastfeeding is a complex process affected by psychological, physiological, and social
dynamics (Thulier & Mercer, 2009). The purpose of this study was to examine the associations
between the breastfeeding practice and three maternal psychosocial factors of perceived stress,
social support, and breastfeeding self-efficacy in a sample of primparous mothers in the KSA.
This chapter provides a review and critique of the empirical literature concerning selected study
variables based on the study’s theoretical framework discussed in Chapter 2. A comprehensive
literature search of electronic databases was conducted to find studies that addressed the
relationships between maternal psychosocial factors and breastfeeding practice, particularly
exclusivity and duration. Databases included the Cumulative Index of Nursing and Allied Health
Literature (CINAHL), PubMed, and PsychInfo. Additional relevant articles were included in the
review through a manual search in the databases and Google Scholar.
The main global indicators of breastfeeding outcomes include: the percentage of mothers
who ever breastfed; the percentage of mother who breastfed at 6 months, and the percentage of
mothers who exclusively breastfed at 3 and 6 months (Healthy People, 2016). The main outcome
of this study was the breastfeeding practice (exclusivity and duration) at six months of infant’s
age. There were three categories of breastfeeding practice in this study: exclusive breastfeeding
which refers to mothers, who exclusively breastfed through the first six months with no
additional supplement; partially breastfeeding, which refers to mothers who breastfed and
supplemented with formula through the first six months postpartum; and discontinued
breastfeeding, which refers to mothers who initiated breastfeeding but completely stopped prior
to six months postpartum.

35

The review of the literature begins with the discussion of breastfeeding practices in the
KSA concerning initiation, exclusivity, and duration. A review of independent maternal factors
related to breastfeeding includes selected demographics, perceived stress, social support, and
breastfeeding self-efficacy is also addressed. In addition, the current state of the science about
the study variables, their relationships with the breastfeeding practice, and gaps in the literature
are discussed. At the end of this chapter, an overall summary on the literature review is provided.
Breastfeeding Practice
An overview of breastfeeding practice in the KSA. Breastfeeding was a common
practice among Saudi Arabian mothers based on their culture and Islamic instructions. The
current rates of exclusive breastfeeding at six months of infant’s age in the KSA are less than
24% (Al-Jassir et al., 2004; El-Gilany, Shady, & Helal, 2011). There have been significant
changes in the education levels of Saudi Arabian women; subsequently, more employment
opportunities are available for Saudi Arabian females (WBTi, 2012). Based on the latest labor
force statistics, approximately 10% of Saudi Arabian females are engaged in the labor force
(General Authority for Statistics, 2016). Given the lack of supportive breastfeeding policy in the
workplace, employment could be one possible factor for the decline in the breastfeeding rates in
the KSA.
The roles of Saudi Arabian mothers have evolved from being housewives in the late
nineteenth century to mothers working outside the home. Additionally, the country’s rapid socioeconomic growth could also contribute to the lower rates of breastfeeding (Al-Madani et al.,
2010; Twum-Danso & Ame, 2012). Marketing of formula feeding has been successful in
displacing breastfeeding with artificial formula through unchecked advertisement and samples
(Batterjee, 2010). Recently, breastfeeding alternatives (e.g., formula feeding) have become more
accessible and affordable for most Saudi Arabian mothers (Murshid, 2006). According to the
36

changes in socio-economic status and the role of Saudi Arabian mothers in society, breastfeeding
is no longer a norm among Saudi Arabian mothers (WBTi, 2012).
Despite the compelling evidence on the advantages of breastfeeding (Ip, 2007; UNICEF,
2015; Victora et al., 2016) and Islamic encouragement in the Holy Qur’an, it has been
consistently stated that the breastfeeding practice in the KSA falls far short of the WHO
recommendation of exclusive breastfeeding (providing breastmilk only with no additional
supplement) for the first six months of infant life (Alwelaie et al., 2010; Amin et al., 2011; El
Mouzan et al., 2009). The exact rates of exclusive breastfeeding in the KSA are not able to be
determined due to the lack of recent national surveys and standard breastfeeding definitions (Al
Juaid et al., 2014).
Initiation of breastfeeding in the KSA. Breastfeeding initiation is related to mothers
who initiate breastfeeding their infants within the first hour after birth (WHO, 2016), or within
the first 24 hours after birth (Debes, Kohli, Walker, Edmond, & Mullany, 2013). According to
two national surveys, the rate of breastfeeding initiation in the KSA is 92% (Al-Jassir et al.,
2006; El Mouzan et al., 2009). The initiation of breastfeeding after birth is the common practice
in the KSA; however, the sharp decline afterwards in the breastfeeding rates as an infant
advances in age is a prominent issue (El Mouzan et al., 2009).
High initiation rates of over 90% have also been consistently reported in almost all other
geographic regions across the KSA including Riyadh (Al-Hreashy et al., 2008; Al-Jassir et al.,
2004), Jeddah (Fida & Al-Aama, 2003; Shawky & Abalkhail, 2003), Al-Hassa (Amin et al.,
2011). The high rates of breastfeeding initiation among Saudi Arabian mothers indicate their
readiness to breastfeed their infants after birth. Yet, no successful strategy has been found that

37

induces mothers, who initiate breastfeeding, to continue with breastfeeding throughout the
recommended six months.
Exclusive breastfeeding in the KSA. Exclusive breastfeeding is defined as an infant
who is fed only breast milk for the first six months of life with no additional supplementation of
any kind of food or drink, not even water, except syrups, vitamins, and minerals (WHO, 2016).
Exclusive breastfeeding is recommended by the WHO as the most complete nutrition for six
months after birth (WHO, 2016).
In the studies that classified “exclusive breastfeeding” according to the WHO definitions,
the rates of exclusive breastfeeding at six months of infant’s age in the KSA ranged from 0.8% to
24% (Al-Jassir et al., 2004; El-Gilany et al., 2011). Other regional studies revealed low rates of
exclusive breastfeeding at six months after birth with 1.7 % in Riyadh (Al-Hreashy et al., 2008),
and 12% in Al-Hassa (Amin et al., 2011).
The variations in the rates of the exclusive breastfeeding in the KSA could be attributed
to the inconsistent definitions and classifications of describing the term of exclusive
breastfeeding. The practice of exclusive breastfeeding has been described as predominant
breastfeeding that includes liquid supplements (Al-Jassir et al., 2006; Shawky & Abalkhail,
2003), while other researchers referred to the practice of exclusive breastfeeding as giving baby
only breast milk without any other supplements (Amin et al., 2011; Eldeek, Tayeb, &
Habiballah, 2012).
Partial breastfeeding in the KSA. Partial breastfeeding is defined as infants who are fed
some combination of breast milk and any other food or liquid, including supplemental formula
(WHO, 2016). Partial breastfeeding has been very common in the KSA (Al-Jassir, Moizuddin, &
Al-Bashir, 2003; Al-Jassir et al., 2006). According to national surveys, the rates of partial

38

breastfeeding at six months ranged from 42% to 76% in the KSA (Al-Jassir et al., 2006;
Murshid, 2006). Another regional study that was conducted in the eastern region of the KSA
revealed that 52% of mothers were partially breastfeeding their infants at four months
postpartum (Al-Madani et al., 2010).
Early introduction of formula is likely a result of a decreased milk supply with infrequent
breastfeeding (El Mouzan et al., 2009). Partial breastfeeding practice poses risks to infant health
by increasing the likelihood of diarrhea, electrolyte imbalance, malnutrition, and other infectious
disease (UNICEF, 2015; WHO, 2016). The majority of Saudi Arabian mothers who engage in
the “partial feeding” practice tend to introduce water to their infant during the first six months
due to the hot climate in the KSA (Al-Hreashy et al., 2008). Introducing water for infants prior to
six months can result in breastfeeding refusal due to fullness of the infant’s stomach.
Consequently, breast milk supply will be reduced due to infrequent breastfeeding, and it can
eventually lead to breastfeeding cessation. It is important to mention that providing water to
infants prior to six months of age is not recommended by the WHO and the AAP even in a hot
climate (Eidelman & Schanler, 2012; WHO, 2016). Indeed, breast milk contains 80% of water
(WHO, 2016); thus, it is a complete source of nutrition and hydration for optimal infant growth
and development.
Breastfeeding cessation in the KSA. Discontinued breastfeeding is defined as initiation
of breastfeeding followed by a complete stopping of breastfeeding after a period of time and
prior to six months postpartum, when the infant is fed only foods or liquids other than breast
milk, including non-human milk. A survey conducted in Riyadh with 548 mothers showed that
half of the mothers who initiated breastfeeding completely stopped at six months after birth (AlHreashy et al., 2008). There is a lack of recent national data on the proportion of breastfeeding

39

discontinuation in the KSA. However, reasons for early breastfeeding cessation have been
partially identified in the literature (Al-Hreashy et al., 2008; Al-Jassir et al., 2006; Al Juaid et al.,
2014; El Mouzan et al., 2009; Fida & Al-Aama, 2003).
There are several psychological, social, and biological explanations given for
breastfeeding cessation. The most commonly reported explanation for the early termination of
breastfeeding among Saudi Arabian mothers is the perception of insufficient breast milk (AlHreashy et al., 2008; Al-Jassir et al., 2006; Al Juaid et al., 2014; El Mouzan et al., 2009; Fida &
Al-Aama, 2003), followed by sickness of infant or mother (Al-Jassir et al., 2006; El Mouzan et
al., 2009; Fida & Al-Aama, 2003), becoming pregnant (Al-Jassir et al., 2006; Fida & Al-Aama,
2003), returning to work (Al-Hreashy et al., 2008; Al-Madani et al., 2010), and the usage of oral
contraceptives (Shawky & Abalkhail, 2003). According to Neifert (2001), only 5% of mothers
who reported insufficient breastmilk have true primary lactation problems that prevent milk
production. Thus, it is unlikely that a physical or hormonal factor causes insufficient milk
production (Neifert, 2001). However, a significant negative relationship between the perception
of insufficient milk and breastfeeding confidence, known as breastfeeding self-efficacy, has been
identified (McCarter-Spaulding & Kearney, 2001; McCarter‐Spaulding & Kearney, 2001;
Otsuka et al., 2008).
Duration of breastfeeding in the KSA. According to the WHO (2016), exclusive
breastfeeding should last until six months after birth. Following the first six months,
breastfeeding should be continued with solid food until two years of age (WHO, 2016).
Unfortunately, this recommendation is not being followed in the KSA. While high rates of
breastfeeding initiation are consistently reported, the rates of breastfeeding duration have sharply
declined over the past 25 years in the KSA (Al Juaid et al., 2014). A national survey in 1987

40

showed a high breastfeeding duration mean of 13.4 months (al-Mazrou, Aziz, & Khalil, 1994). A
more recent national survey revealed a drop in the mean duration of any breastfeeding from 13.4
months in 1987 to 6.57 months in 2009 (El Mouzan et al., 2009). Available data on
breastfeeding rates in the KSA vary widely due to variations in study design, sample sizes,
length of the recall, and locations (Al Juaid et al., 2014). There are no recent national data on the
breastfeeding rates and duration, which makes it difficult to monitor progress over time.
There are several maternal characteristics that influence the breastfeeding practice
including demographic characteristics and psychosocial factors. Studies conducted in the KSA
have identified demographic factors associated with breastfeeding exclusivity and duration, such
as increased maternal age, low income, and rural residence (Al-Jassir et al., 2006; Al-Madani et
al., 2010; Amin et al., 2011; Shawky & Abalkhail, 2003). However, such factors are not
amenable to be improved or altered over a short period of time to improve the breastfeeding
practice.
To date, there is no current information available regarding the association of modifiable
factors of perceived stress, social support, and breastfeeding self-efficacy with exclusive
breastfeeding among Saudi Arabian mothers. Thus, it is difficult to work effectively towards
improving the current suboptimal breastfeeding practices in the KSA without addressing the
possible modifiable factors. In the following section, selected demographic and psychosocial
factors related to breastfeeding are discussed including maternal age, education, work status,
income status, perceived stress, social support, and breastfeeding self-efficacy. The
interdisciplinary nature of the literature review offers theoretical and empirical evidence on the
selected psychosocial factors in relation to breastfeeding.

41

Demographic factors associated with breastfeeding
Maternal age. Several studies have examined the relationships between maternal age and
breastfeeding practice among Saudi Arabian mothers. There is a consistent pattern of the
association between maternal age and the breastfeeding practice. The vast majority of the studies
in the KSA revealed that older maternal age was significantly associated with longer duration of
breastfeeding (Al-Jassir et al., 2006; Al-Madani et al., 2010; al-Mazrou et al., 1994; Amin et al.,
2011). Likewise, a systematic review that included studies from different countries around the
world revealed that older maternal age was a consistent predictor of longer breastfeeding
duration (Thulier & Mercer, 2009).
Education and work status. Higher levels of education among Saudi Arabian mothers
were not common until the late nineteenth century (Alsuwaida, 2016). Historically, a large
number of Saudi mothers included in breastfeeding studies were illiterate and non-employed (alNasser, Bamgboye, & Alburno, 1991). Recently, the levels of education have increased among
Saudi Arabian mothers with advancement in social and economic circumstances. According to
the General Authority for Statistics in the KSA (2016), approximately 749,375 females
compared to 778,394 males were enrolled in higher education at college level or above.
Consequently, more work opportunities have become available for educated women in the KSA.
Currently, the proportion of women engaged in the labor force in the KSA is 16.8% of the total
population including 10.1% Saudi and 6.7% non-Saudi (General Authority for Statistics, 2016).
The majority of females who are engaged in the labor force are working in the city of Jeddah,
where various work opportunities are available.
While western studies revealed positive associations between the level of education and
breastfeeding practice (Dennis, 2006; McQueen et al., 2015), the majority of studies conducted

42

in the KSA revealed negative associations between such factors (Al-Jassir et al., 2004; Amin et
al., 2011; El-Gilany et al., 2011). A national survey in the KSA included a random sample of
mothers with children aged less than two years (N = 912) revealed that a higher levels of
maternal education was among the most significant factors negativelly influencing breastfeeing
exclusivity and duration in the KSA (Murshid, 2006). In the eastern-province of the KSA, a
longitudinal study with a sample of pregnant Saudi Arabian women (N =160) revealed
significant associations between educational levels and breastfeeding intention (Al-Madani et al.,
2010). All illiterate women included in the study (7%) along with 84% of women who had a high
educational level intended to breastfeed their infants (Al-Madani et al., 2010).
On the other hand, other studies in the KSA revealed that employed mothers tended to
breastfeed less frequently and for shorter duration than non-employed mothers (Al-Hreashy et
al., 2008; Amin et al., 2011; El-Gilany et al., 2011; Murshid, 2006). In summary, it is
consistently noted in the literature that employment status and education level are negatively and
significantly associated with breastfeeding exclusivity and duration.
Income status. Household income is an important factor that may influence the practice
of breastfeeding. In the USA, the rate of breastfeeding is low among low-income, particularly
among those who enrolled in The Special Supplemental Nutrition Program for Women, Infants,
and Children (Silk et al., 2010). In the KSA, formula feeding has become accessible and
affordable for most Saudi mothers (Murshid, 2006). Studies that have examined the association
between income status and breastfeeding in the KSA revealed inconsistent findings. While it has
been shown that exclusive breastfeeding was more prevalent among low-income Saudi Arabian
mothers (al-Ayed & Qureshi, 1998; Amin et al., 2011), another study with 128 mothers in the
KSA found that the association between income and breastfeeding were not statistically

43

significant (Fida & Al-Aama, 2003). However, the sample size in the later study, that found no
significant association, might not be adequate to detect significant associations. In addition, 70%
of the participants in the later study had a low household income of less than $1,300 (Fida & AlAama, 2003).
Perceived Stress
Stress has been identified as an important concept in health research which links to
different diseases and health outcomes. Among a sample from Greece, maternal stress has been
inversely associated with early breastfeeding initiation and duration (Doulouger et al., 2013).
Research has examined stress through evaluating one’s ability to respond or cope with
overwhelming situations that occur in the environment, known as perceived stress (Goodnite,
2014; Lazarus, 2006). An individual’s stress level can have an impact on the individual’s
physiological and psychological status including the risk of illness, the ability to execute certain
behavior, and the belief of self-efficacy (Cohen, Janicki-Deverts, & Miller, 2007; Dennis, 1999).
Stressors often emerge from task demands and workload that exceed one’s capabilities (Bandura,
Cioffi, Taylor, & Brouillard, 1988). The transition to motherhood can be very stressful for many
women, particularly, first-time mothers.
The role of first-time mothers in caring and fulfilling their infants’ needs is challenging
and stressful as it requires time, knowledge, and skills (Liu, Chen, Yeh, & Hsieh, 2012). A poor
transition to motherhood can result in a high level of stress, which in turn can negatively impact
the mother-infant interaction (Coyl, Roggman, & Newland, 2002). Furthermore, persistent
maternal stress could result in long-term physiologic and psychological disorders and health
issues, such as the suppression of immune system (Cohen et al., 2007; Segerstrom & Miller,
2004), and postpartum depression (Doulouger et al., 2013; Hammen, 2005; Miller, 2002).

44

There are several sources of maternal stress in the first year after birth, such as traumatic
(physical) stress, financial stress, emotional stress, and partner-associated stress (Dozier et al.,
2012). Other causes for maternal stress after childbirth are sleep disturbances (Gardazi et al.,
2016), and physical changes to the mother’s body (Rallis, Skouteris, McCabe, & Milgrom,
2014). An additional source of stress among Saudi mothers relates to their individual
sociocultural context (Al Juaid et al., 2014). This refers to the common rural-urban migration of
Saudi women after getting married and around the time of the first baby; this can result in stress
and social isolation (Aldosari et al., 2015; Salam, 2013). After migration, mothers may have
difficulties forming social relationships in the new community with no one to discuss
breastfeeding concerns that may arise.
Employed mothers are at high risk for the early discontinuation of breastfeeding due to
experiencing high levels of stress (Hibel, Mercado, & Trumbell, 2012). Employed Saudi mothers
are granted a short maternity leave (about five weeks), which may influence breastfeeding, and
prevent exclusive breastfeeding throughout the recommended six months period (WBTi, 2012).
In addition, mothers who have breastfed for six months or longer reported a drop in their
earnings that resulted from reduced working hours and a loss of promotions (Rippeyoung &
Noonan, 2012). The possible loss of income, sleep disturbances with newborn responsibilities,
and a lack of support pose a high risk of psychological stress among breastfeeding mothers that
can lead to the early cessation of breastfeeding. Therefore, managing stress in the first year after
birth is important to improve maternal and infant health outcomes.
Stress in the first months after birth can lead to anxiety and depression (Cutrona &
Troutman, 1986; Venkatesh, Phipps, Triche, & Zlotnick, 2014). The literature identified a
correlation between postpartum depression and the practice of breastfeeding (Hamdan & Tamim,

45

2012; Henderson et al., 2003). Furthermore, several studies identified stress as a risk factor for
postpartum depression (Doulouger et al., 2013; Hammen, 2005; Miller, 2002). Hence, mothers
with high levels of stress need to be identified and managed early during the postpartum period
to promote milk production and a healthy mother-child relationship. Unfortunately, the vast
majority of the literature is focused on the relationship between breastfeeding and postpartum
depression, the outcome of maternal stress (Rallis et al., 2014). However, little is known about
the relationships between maternal stress as a primary exposure and breastfeeding exclusivity
and duration. This was the first study that examined the associations between perceived stress
and the practice of breastfeeding among first-time Saudi Arabian mothers who initiated
breastfeeding.
Maternal psychological stress can lead to impaired milk production by reducing the
release of breastfeeding hormones, such as oxytocin (Dewey, 2001). Maternal stress not only
impacts the process of milk production, but could also lead to behavioral and cognitive issues
among infants, such as attention deficit (Weinstock, 2005). Maternal responses and reactivity to
postpartum stressors differ in lactating mothers from a mother who is not breastfeeding (Groer et
al., 2002). Breastfeeding mothers tend to have more positive mood and perceive less stress than
non-breastfeeding mothers (Groer, 2005). Maternal stress levels measured objectively (e.g.,
plasma cortisol levels) and subjectively (e.g., self-reported questionnaires) were also
significantly associated with lower milk volume and less frequent breastfeeding (Doulouger et
al., 2013). However, the literature has not presented any causal sequence between maternal
perceived stress and the practice of breastfeeding.
A recent empirical study was conducted in Greece to examine the relationship between
stress level and lactogenesis in a sample of 100 pregnant women, of which 61 were multiparous

46

and 34 nulliparous (Dimitraki et al., 2016). Stress levels were assessed using the positive and
negative affectivity scale, posttraumatic stress disorders scale, and were also measured from
mother’s serum and cord blood after normal delivery. Breast milk volume was assessed through
24 hours breast milk collection, breastfeeding frequency, and mother’s feeling of fullness in the
breasts. The results revealed that mothers who experienced stressful events during labor had
delayed onset of lactation and decreased milk volume (Dimitraki et al., 2016). However, the
generalizability of the findings may be limited due to small sample size, and the uncontrolled
differences between multiparous and nulliparous women.
Two other quantitative studies with a sample of 95 mothers from Greece and 499 mothers
from the USA mothers have examined the association between maternal stress and breastfeeding
practice using self-administered surveys and plasma cortisol levels (Doulouger et al., 2013;
Dozier et al., 2012). The findings from these two studies showed that maternal stress was
associated with delayed initiation of breastfeeding, lower milk volume, less frequent feeding, and
shorter duration of breastfeeding (Doulouger et al., 2013; Dozier et al., 2012). However, the
generalizability of these findings may be limited due to the following reasons: suitability to recall
bias, and inability to rule out the influence of other confounding factors that can greatly impact
breastfeeding, such as social support.
The relationship between breastfeeding and maternal stress has emerged in qualitative
studies as well. A qualitative study of 127 postpartum American mothers aged from 18 to 45
years was conducted using written responses to the open-ended question about describing the
stressful event or feeling (Jevitt, Groer, Crist, Gonzalez, & Wagner, 2012). The content analysis
of responses was performed as a secondary analysis of a large study funded by the National
Institutes of Health. The majority of women in this qualitative analysis were white, married, and

47

from low-income households. The results of the content analysis identified breastfeeding
problems as one of the stressful events arising within the maternal–newborn dyad (Jevitt et al.,
2012). The large number of participants and the rigor of the independent investigators strengthen
this qualitative study. However, the generalizability of this content analysis results are limited by
a lack of diversity given that the sample was predominantly white and low-income.
Another qualitative study was conducted in Switzerland to identify events perceived as
stressful among primiparous mothers (N = 60) via semi-structured interview (Razurel, BruchonSchweitzer, Dupanloup, Irion, & Epiney, 2011). The participants in this qualitative study
described breastfeeding as a major stressful event during early postpartum period due to
associated difficulties and unbearable pain (Razurel et al., 2011). Despite an adequate number of
participants (n = 60) in this qualitative study, the generalization of the findings is limited because
the sample was limited to urban European women. To alleviate stress during the postpartum
period, it was found that support from family members, friends, health professionals, and society
was identified as a coping strategy and as one means to promote breastfeeding exclusivity and
duration.
In summary, the previously mentioned studies revealed that mothers who had low levels
of perceived stress were more likely to breastfeed. However, there have been a very limited
number of studies examining the association between maternal perceived stress and
breastfeeding practice at six months postpartum. Maternal perceived stress was measured
differently across the studies using objective and subjective measures. Thus, the causal inference
and the direction of the association between perceived maternal stress and breastfeeding practice
have not been established among Saudi Arabian mothers. More research is warranted to
understand how maternal stress influences the breastfeeding practice.

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Social Support
Several studies have addressed the importance of social support for breastfeeding
exclusivity and duration (Dashti et al., 2010; Nassar et al., 2014). Two major types of support
have been identified in the literature: perceived support and received support (Cutrona &
Troutman, 1986). Perceived support refers to one’s belief or judgment on the support as effective
and helpful, while received support refers to one’s judgment about support provided as not
helpful (Gottlieb & Bergen, 2010). In this study, the variable of interest was the perceived social
support. The most commonly identified sources of breastfeeding support included family
members (Dashti et al., 2010; Nassar et al., 2014), health professionals (Britton, McCormick,
Renfrew, Wade, & King, 2007), and peers (Dennis, 2006; Dennis, 2002).
With a lack of social support, the practice of breastfeeding can be a frustrating experience
for first-time mothers. Moreover, breastfeeding can be stressful and challenging for the mother if
her breastfeeding concerns have not been addressed (O'Brien, Buikstra, Fallon, & Hegney, 2009;
Razurel et al., 2011). Social support can buffer against depression and stress by improving a
mother’s ability to cope with postpartum stress (Schwarzer & Knoll, 2007).
Social influences affecting breastfeeding exclusivity and duration among Saudi mothers
are related to Saudi mothers’ unique sociocultural contexts (Al Juaid et al., 2014). Social barriers
that have been documented in the KSA include the norm that it is unacceptable to breastfeed in
public places (WBTi, 2012), a lack of private nursing rooms, and embarrassment regarding
breastfeeding in public places (Nafee Elsayed & Al-Dossary, 2016).
Additionally, Saudi mothers are expected to serve as the primary caregivers for their
infants, and coordinate household tasks, often without their husbands’ support (Aldosari &
Pufpaff, 2014). All of these circumstances could cause Saudi mothers to experience stress and a

49

lack of social support, which have been identified as significant predictors of postpartum
depression, another factor strongly associated with the early cessation of breastfeeding
(Henderson et al., 2003; Miller, 2002). Thus, addressing perceived stress and social support
among Saudi mothers is crucial in order to promote the positive health outcomes of
breastfeeding.
Social support, including support from the husband or other family members, has been
associated with early breastfeeding initiation and duration among mothers in Kuwait (Dashti et
al., 2010; Nassar et al., 2014). A study in the KSA with a sample of 704 mothers aged on average
30 years, who had at least one child, revealed that advice and encouragement regarding
breastfeeding were significantly and positively associated with the practice of exclusive
breastfeeding (Ogbeide et al., 2004). However, in the study by Ogbeide and colleagues (2004),
social support was measured subjectively with only one “Yes” or “No” closed-ended question.
Further research with psychometrically robust scales is needed to confirm the association
between social support and breastfeeding exclusivity among Arabian mothers.
The Cochrane systematic review and meta-analysis conducted by Britton and colleagues
(2007) included 34 trials with a total number of 29,385 mother-infant pairs from different
countries to assess the effectiveness of support services on breastfeeding duration and
exclusivity. The results of the review revealed that professional support had a positive impact on
breastfeeding. Furthermore, all other forms of support, such as professional and lay support had a
larger impact on the duration of exclusive breastfeeding than on any other categories of
breastfeeding; whereas using telephone contact as a supportive intervention showed no
significant impact on breastfeeding continuation (Britton et al., 2007). Using Social Provisions
Scale (24-item) and Perceived Social Support Scale (12-item), additional two studies from

50

different countries indicated that maternal perceived social support was positively correlated
with breastfeeding self-efficacy and longer-duration breastfeeding (Dennis, 2006; Zhu, Chan,
Zhou, Ye, & He, 2014).
Nabulsi (2011) conducted a qualitative study through three focus group discussions and
series of in-depth interviews to identify barriers and facilitators of breastfeeding among Lebanese
postpartum mothers (N = 36) of at least one healthy newborn. Lebanese women who continued
breastfeeding for longer than six months reported that they were relying mostly on family
support for encouragement and assistance during breastfeeding practice (Nabulsi, 2011).
However, findings from this study may not be generalized to other populations, giving the fact
that mothers in this study were recruited from high-income urban settings only.
The existing literature has revealed insufficient evidence to conclusively support the
association between social support and breastfeeding practice. The association between social
support and the practice of breastfeeding is not well established for several reasons. First, the
types of support as well as the sources of support have been inconsistently described across
studies. Second, the instruments that have been used to measure social supports are varied and
rely on different operationalization of the social support concept. Third, the description of the
breastfeeding as an outcome varied widely leading to inconclusive findings. Fourth, there is a
lack of a valid and reliable instrument that measured social support. In summary, there is a need
to rigorously examine possible associations between social support and breastfeeding exclusivity
and duration at six months among the Saudi Arabian mothers using a valid and reliable
multidimensional instrument.

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Breastfeeding Self-efficacy
The association between breastfeeding self-efficacy and breastfeeding practice has been
examined by a variety of quantitative and qualitative studies. A comprehensive literature search
of electronic databases was conducted to find studies that addressed the association between
breastfeeding self-efficacy and breastfeeding practice, particularly exclusivity and duration. A
total of 17 studies (15 quantitative and two qualitative) were identified and included in the
literature review. All the included studies were from different countries around the world since
no studies were found from the KSA. The mean ages were not consistently reported across the
studies and varied from 24–30 years. The majority of the participants in the studies (n = 10) were
postpartum, primiparous mothers, who had given birth to a single, healthy, full-term infant, and
who were planning on breastfeeding (Babakazo et al., 2015; Henshaw et al., 2015; Kronborg &
Væth, 2004; Loke & Chan, 2013; McQueen et al., 2015; McQueen et al., 2011; Semenic,
Loiselle, & Gottlieb, 2008; Souza & Fernandes, 2014; Wu et al., 2014). The sample sizes ranged
from 57 (Bailey, Clark, & Shepherd, 2008) to 781 (Otsuka et al., 2014), with a total sample size
of 3,257. The most consistently used scale to assess breastfeeding self-efficacy across all the
included studies is the breastfeeding self-efficacy scale (Dennis, 2003).
Findings regarding the association between breastfeeding self-efficacy and the practice of
breastfeeding are consistent across the vast majority of the studies. Of the 15 quantitative studies,
13 studies consistently found breastfeeding self-efficacy to be significantly and positively
associated with exclusive breastfeeding duration (Babakazo et al., 2015; Bailey et al., 2008;
Blyth et al., 2002; Blyth et al., 2004; de Jager et al., 2015; Henshaw et al., 2015; Kronborg &
Væth, 2004; Loke & Chan, 2013; McQueen et al., 2015; Nichols et al., 2009; Otsuka et al., 2014;
Semenic et al., 2008; Wu et al., 2014).

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Across the studies, the association between breastfeeding self-efficacy and breastfeeding
duration was examined at different time frames during the postpartum period. Breastfeeding selfefficacy was found to be a significant predictor for breastfeeding duration at one week
postpartum (Blyth et al., 2002; Blyth et al., 2004), four weeks postpartum (Nichols et al., 2009;
Wu et al., 2014), six weeks postpartum (Loke & Chan, 2013), two months postpartum (de Jager
et al., 2015), four months postpartum (Blyth et al., 2002; Blyth et al., 2004; Kronborg & Væth,
2004), and six months postpartum (de Jager et al., 2015; Henshaw et al., 2015).
Among the 15 included quantitative studies, only two studies showed no statistically
significant difference in the comparison of mean duration of exclusive and non-exclusive
breastfeeding with the scores of breastfeeding self-efficacy (McQueen et al., 2011; Souza &
Fernandes, 2014). However, both studies had small sample sizes which ranged from 100-150
mothers, which may have resulted in inadequate statistical power to detect significant differences
(McQueen et al., 2011). Second, Souza and Fernandes (2014) used the translated Brazilian
version of the breastfeeding self-efficacy scale with un-reported psychometric properties (Souza
& Fernandes, 2014). Further research with adequate sample sizes is warranted to better
understand the association between breastfeeding self-efficacy and breastfeeding practice among
Saudi Arabian mothers.
Qualitative studies also support the association between breastfeeding self-efficacy and
the practice of breastfeeding (Avery, Zimmermann, Underwood, & Magnus, 2009; O'Brien et al.,
2009). A thematic analysis of interviews with three groups of Australian mothers (n = 17), who
planned to breastfeed for at least 6 months, and clinicians (n = 14) identified mother’s confidence
in breastfeeding as an essential psychological factor for breastfeeding duration (O'Brien et al.,
2009). Another qualitative study was conducted to identify the process that contributed to

53

successful breastfeeding, using the grounded theory approach (Avery et al., 2009). The sample of
this qualitative study included 24 focus groups of Caucasian and African American women who
were either pregnant, formula feeding, or breastfeeding. The findings revealed that mothers who
had confidence in their ability to breastfeed were committed to breastfeeding, and their
confidence led to successful sustainment of breastfeeding (Avery et al., 2009).
The literature review revealed a major limitation across the study findings. The outcomes
of the breastfeeding practices of exclusivity and duration have been defined and measured
inconsistently across the studies. The practice of breastfeeding was classified inconsistently; for
example, the term “breastfeeding” can be interpreted as exclusive (only breast milk),
predominant breastfeeding (breast milk with other liquid supplements), or mixed feeding
(Haroon, Das, Salam, Imdad, & Bhutta, 2013). Hence, the practice of breastfeeding needs to be
based on the WHO definition of breastfeeding categories to eliminate the ambiguity and ensure
usefulness of findings.
In reviewing the literature on the association between breastfeeding self-efficacy and
breastfeeding practice, the following gaps have been identified. The samples included in some
studies were small and ranged from 90-143 mothers (Henshaw et al., 2015; Nichols et al., 2009).
Furthermore, contamination between the treatment “self-efficacy intervention” group and control
groups of mothers recruited from the same private service can jeopardize the internal validity
(Otsuka et al., 2014).
Another gap in the research approaches is the inconsistency in the follow-up periods
across the studies, which varied from two days to six months. This variation may influence the
findings because the practice of breastfeeding is susceptible to change over time. It was unclear
whether the follow-up durations were adequate or not; thus, follow-up periods need to be

54

justified in future longitudinal studies. Another limitation in the state of knowledge on
breastfeeding self-efficacy is that the existing findings were based on studies conducted in
developed countries. Thus, findings from these studies cannot be generalized to Saudi mothers
with different cultural norms and social backgrounds.
Summary
The review of the literature indicates that numerous demographic and psychosocial
factors are important for breastfeeding exclusivity and duration, including perceived stress,
social support, and breastfeeding self-efficacy. The literature provides support for the aims of
this study. It is crucial to assess such factors in the first few months after women have given birth
to identify women at high risk for early breastfeeding cessation. However, there is a dearth of the
literature that examines the direct associations between the selected psychosocial factors and the
practice of breastfeeding at six months after birth, particularly, among Arabic mothers. Further
research is needed to better understand the associations between psychosocial factors and the
practice of breastfeeding. This study aimed to close the existing gaps in the state of knowledge
through examining the associations between maternal psychosocial factors and the practice of
breastfeeding at six months of infant age. The following chapter describes the study methods
including detailed information on design, sample, recruitment procedure, data collection,
instruments, and data analysis.

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Chapter 4: Methods
The purpose of this study was to examine the associations between three modifiable
maternal psychosocial factors of perceived stress, social support, and breastfeeding self-efficacy
and breastfeeding practice among primiparous mothers who initiated breastfeeding and had
infants aged six to 12 months in Jeddah, KSA. This chapter discusses the methods of this inquiry
with details on design, settings, sample, instruments, data collection procedure, and data analysis.
Ethical protection for study participants is also addressed.
Study Design
A cross-sectional correlational design was used to examine the associations among the
study variables. The cross-sectional correlational design is well-suited for the aims of this study,
which focused on establishing associations between the theory-based psychosocial factors of
perceived stress, social support, and breastfeeding self-efficacy, and breastfeeding practice
among Saudi Arabian mothers of infants.
Sample
The population of interest in this study was first-time Saudi Arabian mothers who
initiated breastfeeding and had infants 6 to 12 months of age. A non-random convenience sample
of 160 mothers was recruited for the purpose of this study. Mothers were recruited from
immunization clinics, well-child clinics, and physicians’ offices at four public primary care
centers (PCCs) in Jeddah, KSA.
Recruited mothers were stratified into three groups according to their breastfeeding
practices determined at six months after childbirth: exclusive breastfeeding for six months,
partial breastfeeding for six months, and discontinued breastfeeding that occurred at any point
prior to six months. The exclusive breastfeeding stratum included mothers who provided only
breast milk for the first six months of life with no additional supplementation of any kind of food
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or drink, except syrups, vitamins, and minerals. The partial breastfeeding stratum included
mothers who offered some combination of breast milk and any other food or liquid, including
supplemental formula and water throughout the first six months. The discontinued breastfeeding
stratum included mothers who breastfed for a period of time but stopped completely before the
infant became six months old, at which time the infant was fed any food or liquid other than
breast milk. Each stratum included approximately 53 mothers. To ensure about equal cases in
each stratum, the principle investigator (PI) tracked the number of enrolled mothers in each
group on a regular basis during the data collection period.
Power Analysis and Sample Size
A power analysis was performed using G*Power 3.1 for the Analysis of Variance
(ANOVA) to determine the required sample size (Faul, Erdfelder, Buchner, & Lang, 2009). A
priori analysis was performed to compute the sample size for ANOVA. The number of groups
entered was three to account for the three groups of breastfeeding: exclusive, partial, and
discontinued. Based on an alpha of 0.05, a power of 0.80, and a medium effect size of 0.25, the
recommended sample size was 160.
Inclusion and Exclusion Criteria
The study’s inclusion criteria were: 1) first-time Saudi mothers, 2) over 18 years of age,
3) initiated breastfeeding at birth, and 4) having a healthy infant between 6 and 12 months of
age. Given the high initiation rates of breastfeeding in the KSA, mothers who had never
breastfed were not included in this study. However, the indicators of breastfeeding exclusivity
and duration were the major criterion outcome variables. Limiting the sample to mothers with six
to12-month-old infants allowed the categories of breastfeeding to be determined based on the
WHO recommendation of exclusive breastfeeding. Exclusion criteria for participation in this

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study were mothers who have had a previous live birth, multiple births, low-birth weight infants
(≤2500 grams), mothers who did not initiate breastfeeding, as well as mothers or infants with any
health issues or medical diagnoses that interfered with breastfeeding.
Setting
Four PCCs in Jeddah, a major city in western KSA were selected for recruitment and data
collection. These PCCs provide preventative and regular health services for community members
including routine check-ups and childhood vaccinations. There are approximately 45 PCCs
affiliated with the Ministry of Health in the city of Jeddah and distributed in five different
geographical regions in Jeddah (Ministry of Health, 2016). All 45 PCCs received the approval
letter from the Ministry of Health along with another facilitating letter that requested the Director
of each PCC to cooperate and provide the researcher access to participants.
Four convenient public PCCs were selected from different geographical regions of
Jeddah: Al-Sulimaniyah, Al-Hamadaniyah, Al-Balad, and Al-Marwah. The selected four
convenient PCCs are located in the urban area (the city of Jeddah), and available to all people in
the community. Women with low to medium household income are more likely to visit the
PCCs. Each of these PCCs had vaccination and well-baby clinics that provide equal health care
services. None of the PCCs offered patients free formula or formula samples. The four
designated PCCs provide equal access and care for all community members (Habib et al., 2011).
Procedures
Procedure for human subject protection. The PI obtained the Institutional Review
Board (IRB) approvals from Michigan State University (MSU) and the Ministry of Health in the
KSA (Appendices B and C). Potential participants were approached during their visit in the
selected PCCs by the PI or a research assistant (RA) through a recruitment script. Participation in

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this study was completely voluntary. Participants were assured that refusal or withdrawal
involved no penalty or loss of any health benefits to which they were entitled. There were no
anticipated potential risks of participating in this study. The participants were not placed in any
physical or financial risk by their participation. Participant confidentiality was maintained
throughout the procedures of data collection and management. Participants were identified
through identification numbers instead of names on all related forms. Surveys were coded with
an identification number, and no names were used on them.
Training procedures. The PI obtained the internal permission from the Director of the
selected PCCs prior to approaching the mothers. A Saudi full time staff nurse from each of the
four selected PCC was hired by the PI as a RA to assist with recruitment, enrollment, and data
collection. Each RA successfully completed the IRB training.
The PI provided extensive individual training to the RAs according to the protocol for
recruitment and enrollment of participants into the study. This protocol included a screening
questionnaire that determined mothers’ eligibility before enrolling into the study (Appendix D).
The PI demonstrated the recruitment procedures for the RA in each site. The PI ensured that the
research assistants understood the process of the study, and that they were able to follow the
recruitment and enrollment protocol. The data were collected by the PI and four trained RAs.
Recruitment and data collection procedures. Participants were recruited during
immunization and well-baby visits. The PI or the research assistants approached mothers in the
waiting room, explained the study and invited mothers to participate. The eligibility of the
mothers who agreed to participate was assessed through the screening questionnaire (Appendix
D). Mothers who met the eligibility criteria were given a written informed consent to read, sign
and receive a copy of the consent form to keep (Appendix E). Participants were assured that their

59

participation in the study was completely voluntary and that they had the right to withdraw from
the study at any time without consequences to their care at the center. Participants completed the
survey in a private area to maintain confidentiality.
Participants used Qualtrics, a web-based survey software tool, to complete the survey
using the provided iPad. Four iPads were available in each PCC. Participants were asked to
complete the survey using an iPad or paper and pencil survey, depending on the participant’s
comfort level. Participants were asked by the PI or RA to submit the completed web-based
survey on-site using the provided iPad. A paper-based survey was available, if a participant felt
uncomfortable with completing the survey on line, or requested to fill-out a paper survey instead
of an electronic survey. The PI and/or the RAs were present at each site to answer any questions
the participants may have had.
Those who chose to fill out the electronic survey were given access to the survey through
the installed Qualtrics “offline surveys” on the available iPad. Those who chose to fill out the
paper survey were given a packet containing the questionnaire, pencil, and unsealed envelope.
Once the survey was completed by the participant, it was placed in a sealed questionnaire packet
and, then placed in a labeled locked box, which was located at the nurses’ station. All data in the
paper surveys (N = 9) were manually entered into Qualtrics by the RA and verified by the PI,
using double data entry. The participants spent approximately an average of 15 - 17 minutes to
complete the paper or electronic survey, and received a cash incentive (40 SAR) upon the
completion of survey.
Data management. The consent forms were separated from other documents and stored
in a secure locked box, which was available in each selected PCC. Participants could choose not
to answer some questions or stop participation at any time. All information provided by

60

participants was kept confidential, and only the PI had access to the completed surveys. The
completed surveys and data were not shared with other individuals except the PI and her
dissertation committee members. Electronic data were stored on a password-protected personal
computer. After the end of the data collection period, the PI physically transferred the paperbased surveys, consent forms, and the personal computer from the KSA to MSU in a secure
locked bag that was kept with the PI inside the airplane. After the completion of the study, all
collected data were stored on a password-protected computer and a locked cabinet in MSU for a
minimum of three years.
Instrumentation
Demographic factors. Maternal demographic characteristics including age, education,
family income, marital status, type of birth, and work status were measured by a selfadministered questionnaire (Appendix F). Maternal age was measured in years while infant age
was measured in months. Family income was assessed based on monthly household income.
Participants were asked to circle their selected response or fill in the blank for other responses.
The Perceived Stress Scale (PSS). The PSS was used to measure perceived stress in this
study. The PSS was developed by Cohen and colleagues in 1983 to measure the degree to which
situations are identified as stressful (Cohen, Kamarck, & Mermelstein, 1983). It is the most
commonly used tool to measure the level of perceived stress that can lead to the early cessation
of breastfeeding and impaired milk production via reducing the release of oxytocin (Dewey,
2001; Doulouger et al., 2013).
Researchers recommend the use of 10-item PSS over the original 14-item scale for future
research due to its improved psychometric characteristics (Cohen & Williamson, 1988). The
PSS-10 is a 10-item, five-point Likert-type scale ranging from zero (never) to four (very often),

61

producing total scores that range from 0 to 40 (Cohen et al., 1983). There are four positively
stated items (4, 5, 7, and 8). The total score was obtained by summing all the ten scale items with
reverse scoring responses: 1, 2, 3, 4-Reverse, 5-Reverse, 6, 7-Reverse, 8-Reverse, 9, and 10.
Higher scores indicated higher levels of perceived stress.
The internal reliability of the PSS-10 in a national probability sample was acceptable
with an alpha coefficient of 0.78 (Cohen & Williamson, 1988). The PSS-10 demonstrated a high
reliability of 0.90 with postpartum Canadian mothers (Dennis, 2006). It showed acceptable testretest reliability between two days and four weeks (Cohen et al., 1983). The scale is strongly
correlated with negative life events and depressive symptoms representing convergent validity
(Cohen et al., 1983). The factorial validity and unidimensionality of the scale have not been
established with the 10 items of the PSS (Lee, 2012).
The PSS has been translated into Arabic and the psychometric proprieties were evaluated
in postpartum Arabic women. The Arabic version demonstrated acceptable internal consistency,
with a Cronbach’s alpha of 0.74 among Arabic postpartum women (Chaaya, Osman, Naassan, &
Mahfoud, 2010), and a Cronbach’s alpha of 0.85 among a large sample (N = 1099) of Moroccan
Arabic population (Ben Loubir, Serhier, Battas, Agoub, & Bennani Othmani, 2014). The Arabic
version of the PSS-10 in this study demonstrated an excellent reliability with a Cronbach’s alpha
of .90, which was consistent with the reliability of the PSS-10 with postpartum Canadian
mothers (Dennis, 2006).
Convergent validity of the Arabic version was also demonstrated by a significant
correlation with the Edinburgh Postpartum Depression Scale (Chaaya et al., 2010). Test-retest
reliability was not satisfactory over six weeks, which may indicate reliability problems
(inconsistency over time), or the need for frequent re-assessment of mother’s perceived stress

62

levels that may have changed over a period of six weeks (Lee, 2012). However, the test-retest
reliability of the Arabic version was acceptable with a correlation coefficient of 0.74 over varied
intervals, which ranged from one to three weeks (Chaaya et al., 2010). The English version of the
PSS-10 is publicly available on the internet for free use. Permission to use the validated Arabic
version of PSS-10 scale was obtained from the first author, Dr. Chaaya (Appendix G).
Social Provisions Scale (SPS). Social support was measured using the 10-item short
version of the SPS (Cutrona & Russell, 1987). The SPS is recommended to use for the
comprehensive assessment of perceived support regardless of the sources (Gottlieb & Bergen,
2010). Items are rated on the SPS using a four-point Likert-type scale, ranging from one
(strongly disagree) to four (strongly agree). There are five negatively worded statements (2, 3, 5,
6, and 9). The scores are obtained by calculating the total sum of all item responses after reverse
coding the negatively worded items; higher scores indicate higher perceived support (Cutrona &
Russell, 1987).
The SPS has been used with postpartum women with reporting of high reliability of 0.86
(Dennis, 2006). The SPS-10 scale has demonstrated acceptable reliability with a Cronbach's
alpha of 0.83 among community adults (Gottlieb & Bergen, 2010). The SPS-10 has also been
psychometrically examined with a large sample of over 600 African American adults, and
showed a high reliability of 0.81 and test-retest reliability of 0.48 over two years (Gottlieb &
Bergen, 2010). In the current study, the Arabic version of SPS-10 had an excellent reliability
with a Cronbach’s alpha of .90. Convergent validity was demonstrated by the significant
correlation between the SPS and relationship quality and stability (Gottlieb & Bergen, 2010).
Permission for use and translation of the SPS was obtained from the author (Appendix H).

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Breastfeeding Self-Efficacy Scale (BSES). It is a 33-item, self-report instrument
developed by Dennis and Faux in 1999 based on the BSE theory. In 2003, Dennis developed the
BSES-short form (SF), which contains 14 items with five-point Likert-type response scales. All
items are positively worded. Higher summed scores indicate higher levels of breastfeeding selfefficacy; there are no cut-off scores. The BSES-SF has been a commonly used tool for the
following research purposes: measuring breastfeeding self-efficacy, predicting the practice of
breastfeeding, identifying at-risk mothers for early breastfeeding termination, developing
individualized plans, and evaluating the effectiveness of a breastfeeding intervention (de Jager et
al., 2013; Dennis, 2003; McCarter-Spaulding & Gore, 2009).
Dennis (2003) examined the psychometric characteristics of the BSES-SF and found
good inter-item correlations ranging from 0.41 to 0.73, and high single factor loading of over
0.66 of all the 14 items. The scale also has excellent reliability, with a Cronbach’s alpha of 0.97
(Dennis, 2003). Moreover, it has demonstrated excellent consistent test-retest reliability of (r=
0.99) over eight weeks postpartum (Dennis, 2003). The most commonly used tool for assessing
breastfeeding self-efficacy across studies was the BSES-SF (Dennis, 2003). In the current study,
the Arabic version of the BFSE -14 demonstrated a similar high internal consistency coefficient
of 0.95.
Content validity of the scale was constructed based on the literature, mothers’ interviews,
and experts’ judgments (Dennis, 2003). Construct validity was assessed with factor analysis
showing adequate positive correlations (r>0.30) among all variables, and all items loaded highly
on one factor, demonstrating that the BSES-SF items are appropriate measures of breastfeeding
self-efficacy (Dennis, 2003). The BSES-SF correlated positively with the Rosenberg Self-Esteem
Scale, which represents convergent validity, and it negatively correlated with the Edinburgh

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Postnatal Depression Scale, which supports divergent validity (Dennis, 2003). Predictive validity
was supported by the significant association between high BFSE-SF scores and breastfeeding at
four and eight weeks postpartum (Dennis, 2003). The BFSE-SF has been used to predict the
discontinuation of breastfeeding before six months (Babakazo et al., 2015). Studies have found
that high levels of maternal self-efficacy predict exclusive and longer-duration breastfeeding
(Dennis, 2006; McCarter-Spaulding et al., 2009; Wu et al., 2014). For the previously mentioned
adequate psychometric properties, the BFSE-SF scale was selected to examine the association
between breastfeeding self-efficacy and the practice of breastfeeding at six months of infant age.
Permission for use and translation of the scale was obtained from the original author (Appendix
I).
Breastfeeding Practice Questionnaire. The author developed the Breastfeeding Practice
Questionnaire as a self-administered questionnaire to elicit information about the following: the
categories of breastfeeding (e.g., exclusive, partial, discontinued), the duration of breastfeeding,
breastfeeding support, sources of breastfeeding support, type of supplements if introduced prior
to six months of infant age, and reasons for breastfeeding cessation. Participants were asked to
fill in the blank or circle their selected response. Duration of breastfeeding was measured using
the periods of breastfeeding in months from the time of breastfeeding initiation to the time of
breastfeeding cessation
Translation and Back Translation of Instruments
All surveys were translated from English to Arabic by a bilingual translator through
Certified Translation Center in the KSA. All translated Arabic surveys were translated back to
English through another Certified Translation Center in the KSA. Prior to data collection, the
translated versions of the questionnaire were pilot-tested with five Saudi mothers to assess the

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clarity of the items and applicability to Saudi mothers. Five Arabic-speaking mothers were asked
to fill out the questionnaire and provide comments on the clarity of items. These five mothers
were not included in the analysis. The five mothers provided a few minor comments on the
wording of some items. Accordingly, a few items were revised according to the mothers’
suggestions to enhance the clarity of items. There were no suggestions to delete or add any
additional survey items.
For the demographic questionnaire, it was suggested to reorder the infant’s date of birth
blanks starting with day, month, and year. For the marital status it was suggested to remove one
option “separated” as it is considered very similar to “divorced”. For work status, it was
suggested to delete the option of “student” as it can be confused with other options of “working”
and “not working”. For the social provisions scale, one of the mothers suggested to revise item 4
for more clarity. There were no other suggestions on the rest of the surveys. The revised Arabic
versions of the scales were judged by other five Arabic-speaking experts in breastfeeding and
maternal health to evaluate their content validity. There were consistent comments on the BSES
item number five suggesting re-wording of the statement with deleting extra words to enhance
clarity.
Content Validity Evaluation
To assess content validity of the translated versions of SPS and BSES, a 10-point ordinal
rating relevance scale ranging from 1 (not relevant) to 10 (very relevant) was developed
(Appendix J). Five Arabic-speaker experts in the field of maternity and neonatal care, including
three professors and two master-prepared nurses, evaluated the relevance of the items to the
construct. Two of the experts consistently rated several items in the SPS as (not relevant). Three
experts added suggestions and comments to improve clarity of the items. The scales were revised

66

according to the suggestions. The PI discussed the scales’ rating with the experts and asked them
if there were any suggestions for improvement of the low rating items. The two experts who
rated the SPS scale as (not relevant) had misunderstood the negatively worded statements; thus,
they rated them as non-relevant in the validity scoring sheets (Appendix J). The PI clarified with
the experts that the SPS contained some negatively worded statements, and asked them to re-rate
the SPS’s items.
The content validity index (CVI) is defined as the extent to which a scale has appropriate
sample of items for a given construct (Polit & Beck, 2006). Both BSES and SPS demonstrated
excellent item content validity index (I-CVI) of 0.97 and 1, respectively. The interrater
agreement refers to the proportion of agreement among raters for the same scale construct (Polit
& Beck, 2006). Interrater agreement for BSES and SPS were 93% and 100%, respectively,
which is acceptable. Another indicator for scale content validity is the average congruency
percentage (ACP), which refers to the average of the I-CVIs for all items on the scale (Polit &
Beck, 2006). The ACP for BSES and SPS is acceptable of 97% and 100%, respectively.
Data Analysis
The data were analyzed using Stata statistical software, version 14.0 (StataCorp, 2015).
The data were exported from Qualtrics software to Stata14 statistical software. Prior to the data
analysis, all data were reviewed twice against the original surveys by the PI to ensure the
accuracy of data entry. The entire data file was checked for errors, and outliers, and missing
responses. All Arabic responses on open-ended items including Arabic numbers and letters were
translated into English. The data were coded, and the codebook for the entire data set was
generated.

67

The likelihood of missing data for the scale variables in this study was eliminated using
two strategies. First, the settings in Qualtrics enabled “force response” option for all scale items,
which required the completeness of responses before progressing to the next page of the survey.
If any item of the scale was left blank, the participant would see an instant reminder message.
Second, the RAs reviewed the submitted paper surveys and ensured the completeness of the
responses.
Summary tables and graphic diagrams were used to examine the data and identify any
out of range values. Descriptive statistics, including means (standard deviations) and frequencies
(percentages), were employed for preliminary analysis to describe continuous and categorical
variables, respectively. Descriptive statistics were computed for each study variable and
demographic variables. After describing the study variables, inferential analyses were performed
for each of the research aims.
All scale items were evaluated for reliability using item total correlations. Principal
component analysis was performed for each scale to confirm the dimensionality of the scale. The
criteria used to determine the number of factors were eigenvalues >1 and the scree plot. Internal
consistency of each instrument in the study was also calculated using Cronbach’s alpha.
Pearson’s product moment correlation was used to examine the interrelationships among the
three psychosocial variables of perceived stress, social support, and breastfeeding self-efficacy.
Summary statistics were applied to examine scale means across the categories of breastfeeding
practice.
The associations between the demographic variables in this study and the three
breastfeeding categories (exclusive, partial and discontinued breastfeeding) were examined using
one-way analysis-of-variance (ANOVA), Pearson’s chi-square test, and Fisher's exact test.

68

Kruskal-Wallis H tests were performed to examine the associations between psychosocial
variables and the selected demographic variables of household income, maternal employment
status, and maternal educational levels. The associations between the reported “insufficient
breast milk” and demographic and psychosocial variables were examined using Fisher's exact
tests and t-tests, respectively. Responses obtained from open-ended questions were analyzed as
well.
Data analysis for the main research aims. The aims of this study were to examine the
associations between breastfeeding practice and three modifiable maternal psychosocial factors
of perceived stress, social support, and breastfeeding self-efficacy. Multinomial logistic
regression models were employed to examine the relative risks of engaging in different
breastfeeding practices (exclusive, partial, or discontinued breastfeeding) after adjusting for
demographic covariates. For each aim, two multinomial logistic regression models were
performed using different breastfeeding categories as a reference group. A p-value of 0.05 or less
was considered to be statistically significant.
Additional multiple multinomial logistic regression models were utilized to examine the
relative risks of engaging in different breastfeeding practices based on the scores of all three
psychosocial variables, using the same demographic control variables including maternal age,
employment status, household income, and educational level. The likelihood-ratio test was used
to compare the model fit among different models with the three psychosocial variables.
Summary
This study aimed to examine the associations between selected maternal psychosocial
factors and the practice of breastfeeding, using a cross-sectional, correlational design. A detailed
description of the sample, setting, and data collection procedure was presented, followed by

69

description of human subject protection and analysis plan. An overview of the selected three
measures of PSS, SPS, and BSES was provided along with detailed description of the
psychometric properties. The results of the data analysis will be presented in the following
Chapter.

70

Chapter 5: Results
This study examined the associations between breastfeeding practices and selected
psychosocial factors of perceived stress, social support, and breastfeeding self-efficacy among
Saudi Arabian mothers. This study included a sample of first-time Saudi Arabian mothers who
had an infant aged from six to 12-months old. The data collection was completed over the period
of December 2016 to February 2017. A total of 160 Saudi mothers were recruited from AlSulimaniyah (n = 38, 23.8%), Al-Hamadaniyah (n = 41, 25.6%), Al-Balad (n = 41, 25.6%), and
Al-Marwah (n = 40, 25.0%). All the included 160 mothers had completed the surveys.
This chapter presents the results of the study in a sequence. First, information pertaining
to the factor structures and reliabilities of the Perceived Stress Scale-10, Social Provisions Scale10, and Breastfeeding Self-Efficacy Scale-14 are provided. Then, the demographic background
characteristics of the study participants are described, including their associations with the
pattern of breastfeeding practices. Finally, multinomial logistic regression models are presented
that shed light on the associations between the psychosocial factors and the breastfeeding
practice in accordance with the study aims and hypotheses.
Psychometric Properties of Psychosocial Scales
Perceived stress. Perceived stress was measured using the translated Arabic version of
the Perceived Stress Scale (PSS; Chaaya et al., 2010; Cohen et al., 1983). The PSS was a 10item, five-point Likert-type scale ranging from zero (never) to four (very often), producing total
scores that ranged from 0 to 40. The average score was obtained by summing all the ten scale
items with reverse scoring of the four positively worded items (4, 5, 7, and 8). Higher total
scores indicated higher levels of perceived stress.

71

Factor structure. The exploratory factor analysis of the Arabic PSS-10 in this study was
performed using principal component analysis and oblique rotation. The criteria used to
determine the number of factors were eigenvalues >1 and the scree plot. The eigenvalues and
scree plot indicated that scale items loaded on two factor structures (see Table 1, and Figure 3).
The first factor, “perceived stress” had an eigenvalue of 5.29 explaining 52.9% of the variance.
The second factor “coping” had an eigenvalue of 1.12 accounting for 11.8%. The same factor
structures were identified in studies conducted with the Arabic translated version of PSS-10 (Ben
Loubir et al., 2014; Chaaya et al., 2010). However, the two subscales are measuring one
construct, perceived stress, by using two related concepts of negative reaction and positive
coping with stressful events (Hewitt, Flett, & Mosher, 1992). In addition, when the scale items
were forced to load on one factor structure, the correlation coefficients were over 0.62 among all
the scale items. Thus, the total overall score of 10-item was used to measure “perceived stress” in
this study.
Reliability. The reliability analysis revealed a high Cronbach’s alpha of .90, indicating a
strong internal consistency of the scale items. The item-rest correlations ranged from 0.56 to 0.76
with corresponding Cronbach’s alpha coefficients suggesting no deletion of any item. The mean
scores for each item are presented in Table 1.
Social support. Social support was measured using the Arabic version of the Social
Provisions Scale (SPS)-10 item (Cutrona & Russell, 1987). Items were rated on the SPS using a
four-point scale, ranging from one (strongly disagree) to four (strongly agree). There were five
negatively worded statements (2, 3, 5, 6, and 9). The scores were obtained by calculating the
total sum of all item responses after reverse coding the negatively worded items (2, 3, 5, 6, and
9); higher scores indicated higher perceived support (Cutrona & Russell, 1987).

72

Table 1
Means, Standard Deviations, Factor Loadings, and Reliability of Items for the Perceived Stress
Scale
M

SD

Item-rest
Correlation

Factor 1
Loading

Factor 2
Loading

0.69

Cronbach’s
alpha if item
deleted
0.89

1. How often have/had you been upset
because of something that happened
unexpectedly?

1.98

1.08

0.91

-0.09

2. How often have/had you felt that you
were unable to control the important things
in your life?

1.91

1.05

0.72

0.89

0.90

-0.05

3. How often have/had you felt nervous
and “stressed”?

2.19

0.97

0.66

0.89

0.89

-0.10

4. When you are/were breastfeeding, how
often have you felt confident about your
ability to handle your personal problems?

1.75

1.04

0.60

0.89

-0.03

0.86

5. How often have/had you felt that things
were going your way?

1.73

1.01

0.54

0.90

-0.08

0.83

6. How often have/had you found that you
could not cope with all the things that you
had to do?

2.06

1.08

0.60

0.89

0.58

0.17

7. How often have/had you been able to
control irritations in your life?

1.65

0.99

0.56

0.90

0.13

0.63

8. How often have /had you felt that you
were on top of things?

1.86

1.01

0.63

0.89

0.12

0.72

9. How often have/had you been angered
because of things that were outside of your
control?

2.14

1.04

0.76

0.88

0.66

0.26

10. How often have/had you felt
difficulties were piling up so high that you
could not overcome them?

2.13

1.13

0.73

0.89

0.61

0.28

Items

Note. Extraction method: principal component analysis. Rotation method: Oblique with Kaiser
normalization. The one factor solution explained 52.9% of the overall variance. Cronbach’s
alpha = .90 for all 10 items.

73

5
4
Eigenvalues
2
3
1
0
0

2

4

Number

6

8

10

Figure3. Scree plot of eigenvalues for the Perceived Stress Scale after principal component
analysis.
Factor structure. The exploratory factor analysis of the translated SPS-10 in this study
was performed to inspect factor structure. The principal component analysis indicated that all
scale items were highly loaded on a single factor structure. The criteria used to determine the
number of factors retained were eigenvalues >1 and the scree plot. The results of factor analysis
suggested a one-factor structure with an eigenvalue of 5.38 and accounted for 53.8% of overall
variance. The second factor was associated with an eigenvalue of 0.93 and accounted for 9% of
overall variance.
Reliability. The 10-item scale had a Cronbach’s alpha of .90 with item-rest correlation
coefficient of .51-.76. As shown in Table 2, all 10 items were retained since deleting any item
did not result in increasing the overall internal consistency coefficient.

74

Table 2
Means, Standard Deviations, Factor Loadings and Reliability of Items for the Social Provision
Scale
M

SD

Item-rest
Correlation

Cronbach’s
alpha if item
deleted

Factor
Loading

1. There are/were people I can depend on to help me
if I really need it.

2.74

0.84

0.76

0.89

0.82

2. I feel/felt that I do not have close personal
relationships with other people.

2.73

0.85

0.66

0.89

0.74

3. There is/was no one I can turn to for guidance in
times of stress.

2.67

0.86

0.64

0.89

0.71

4. There are/were people who enjoy the same social
activities that I do.

2.62

0.84

0.52

0.90

0.60

5. I do/did not think other people respect my skills
and abilities.

2.75

0.87

0.62

0.89

0.69

6. If something went wrong, no one would come to
my assistance.

2.76

0.86

0.61

0.89

0.68

7. I have/had close relationships that provide me
with a sense of emotional security and well-being.

2.93

0.75

0.69

0.89

0.77

8. I have/had relationships where my competence
and skills are recognized.

2.92

0.80

0.68

0.89

0.76

9. There is/was no one who shares my interests and
concerns.

2.67

0.86

0.71

0.89

0.77

10. There is/was a trustworthy person I could turn to
for advice if I were having problems.

2.97

0.91

0.68

0.89

0.76

Items

Note. Extraction method: principal component analysis. Rotation method: unrotated. The one
factor solution explained 53.8% of the overall variance in the items. Cronbach’s alpha = .90 for
all 10 items.

75

Breastfeeding Self-Efficacy. Breastfeeding self-efficacy was measured using the short
form of the Breastfeeding Self-Efficacy Scale (BSES), which contains 14 items (Dennis, 2003).
Items were rated using a five-point Likert-type, ranging from one (Not at all confident) to five
(Very confident). All items were positively worded. Higher summed scores indicated higher
levels of breastfeeding self-efficacy; there were no cut-off scores. As shown in Table 3, the mean
scores of participant indicated moderate to high breastfeeding self-efficacy (M= 44.95, SD =
13.62).
Table 3
Descriptive Statistics for All Scale Variables

M

SD

Ranges
Min-Max

Cronbach’s
alpha

Perceived Stress scale

19.41

7.56

0-37

0.90

Social Support scale

27.76

6.19

10-40

0.90

Breastfeeding Self-Efficacy scale

44.59

13.62

14-70

0.95

Scales

Factor structure. The exploratory factor analysis of the translated BFSE-14 was
performed to inspect factor structure. The criteria used to determine the number of factors were
eigenvalues >1, and the scree plot. The principal component analysis indicated that all scale
items were highly loaded on a single factor structure. The unidimensionality in factor analysis
was suggested through scree plot and eigenvalue of 8.72 that explained 62% of variance in the
items, followed by an eigenvalue of 0.70 that explained 5% of variance.
Reliability. The BFSE -14 had an excellent internal consistency coefficient of 0.95. The
item-rest correlation ranged from 0.72 to 0.82. Accordingly, no item has been deleted and all 14
items were retained (see Table 4).
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Table 4
Means, Standard Deviations, Factor Loadings, and Reliability of Items for Breastfeeding Self-Efficacy

Scale
M

SD

Item-rest
Correlation

1. I can/could always determine that my baby
is/was getting enough milk

3.13

1.16

0.77

Cronbach’s
alpha if item
deleted
0.95

2. I can/could always successfully cope with
breastfeeding like I have with other
challenging tasks
3. I can/could always breastfeed my baby
without using formula as a supplement

3.18

1.10

0.81

0.95

0.84

2.88

1.34

0.63

0.95

0.67

4. I can/could always ensure that my baby is
properly latched on for the entire feeding

3.3

1.17

0.78

0.95

0.81

5. I can/could always manage the
breastfeeding situation to my satisfaction

3.03

1.21

0.75

0.95

0.79

6. I can/could always manage to breastfeed
even if my baby is crying

2.95

1.33

0.72

0.95

0.78

7. I can/could always keep wanting to
breastfeed

3.47

1.24

0.74

0.95

0.76

8. I can/could always comfortably breastfeed
with my family members present

3.09

1.30

0.75

0.95

0.78

9. I can/could always be satisfied with my
breastfeeding experience

3.23

1.24

0.72

0.95

0.79

10. I can/could always deal with the fact that
breastfeeding can be time consuming
11. I can/could always finish feeding my baby
on one breast before switching to the other
breast
12. I can/could always continue to breastfeed
my baby for every feeding

3.41

1.19

0.76

0.95

0.77

3.26

1.20

0.76

0.95

0.79

3.22

1.31

0.73

0.95

0.80

13. I can/could always manage to keep up with
my baby’s breastfeeding demands

3.2

1.24

0.82

0.95

0.85

14. I can/could always tell when my baby is
finished breastfeeding

3.25

1.27

0.75

0.95

0.79

Items

Note. Extraction method: principal component analysis. Rotation method: unrotated.

77

Factor
Loading
0.81

Sample Characteristics
Maternal age. The ages of the women who participated in this study varied from 20 to
38 years. The mean maternal age was 27.21 years (SD = 4.02). The largest percentage of mothers
were between 25 and 26 years of age (n = 30, 18.8%). There were no missing responses on
maternal age.
Infant age and sex. Infant age was calculated in months from birth to the time of data
collection through a fixed choice question. The ages of infants ranged from six to 12-months.
The mean infant age was 8.90 months (SD = 2.04). The frequencies and percentages for each
month of infant age are displayed in Table 5.
Table 5
Infant Age and Sex (N = 160)
Frequency
n

Percentage
%

Six months

25

15.6

Seven months

19

11.9

Eight months

30

18.8

Nine months

31

19.4

Ten months

14

8.8

Eleven months

10

6.2

Twelve months

31

19.4

Males

79

49.4

Females

81

50.6

Demographic variable
Infant age (Months)

Infant sex

Relationship status. The majority of mothers in this study were married (n = 154, 96.
3%). Only 6 mothers (3.8%) were divorced.

78

Maternal employment status. Three-fourths of the mothers were not working (n = 120,
75.0%) at the time of data collection. As displayed in Table 6, one fourth were working either
part time (n = 17, 10.6%), or full time (n = 23, 14.4%).
Household size. The mothers were asked about the number of people who lived in their
household including themselves. On average, the participants in this study lived in households
with 3 members (M = 3, SD = 0.98). Table 6 shows the frequency distribution for household
members. It is important to note that mothers included in this sample were all first time mothers.
Thus, household sizes may not be accurate given that some married women (n = 22) reported
total household members ≤ 2. This inaccuracy of reporting household sizes could be related to
misinterpretation of the survey question.
Table 6
Frequencies and Percentages of Categorical Demographic Variables (N = 160)
Frequency n

Percent %

Mother’s marital status
Married
Divorce

154
6

96.3
3.8

Mother’s employment status
Full Time (at least 35 hours/week)
Part-time
Not Working

23
17
120

14.4
10.6
75.0

Living with extended family members
Yes
No

34
126

21.3
78.8

11
13

6.9
8.2

Demographic variable

Household members a
1
2

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Table 6 (Cont’d)
Frequency n

Percent %

115
14
1
3
1
1

72.3
8.8
0.6
1.9
0.6
0.6

Household monthly income (SAR) b
3000 or Less
4000- 6000
7000- 12000
13000 or more
Don’t know
Choose not to answer

8
67
55
20
8
2

5.0
41.9
34.4
12.5
5.0
1.3

Maternal education level
Less than high school
High school
Bachelor’s degree
Master or higher degree

9
81
59
11

5.6
50.6
36.9
6.9

Mode of delivery
Vaginal Delivery
Caesarean section

133
27

83.1
16.9

Demographic variable
3
4
5
6
7
9

Note. a Household sizes may not be accurate given that all mothers included in this sample
were first time mothers. This inaccuracy of reporting household could be related to
misunderstanding of the question. b household income is represented in Saudi Arabia Riyal
(SAR) which approximately equal to 3.75 United States dollars.
Household income. Household income was measured based on monthly household
incomes through fixed responses in Saudi Riyals (SAR). The choices ranged from less or equal
to 3000 (approximately 800 USD) to 13000 SAR (approximately 3,467 USD) or more. The
largest proportion of participants (n = 67, 41.9%) reported a low to medium household income of

80

4000-6000 SAR (approximately 1066 -1600 USD). Using Fisher's exact test analyses, household
income was positively associated with the maternal employment status (p < .05), and maternal
educational levels (p < .01).
Level of education. Maternal education level ranged from less than high school to
masters or higher degrees. As shown in Table 6, the highest level of education for about half of
the mothers was high school education (n = 81, 50.6%). Using Fisher's exact test analyses, there
was a significant positive association between maternal level of education and employment
status (p < .01).
Mode of delivery. As shown in Table 6, the majority of the births were vaginal delivery
(n = 133, 83.1%).
Family history of breastfeeding. The majority of the participants (n = 112, 70%)
reported that their mothers practiced breastfeeding. Of those, more than half (n = 66, 58.9%)
reported that their mothers practiced exclusive breastfeeding.
Inter-relationships among Selected Psychosocial Factors
The results of interrelationships among the three psychosocial variables of perceived
stress, social support, and breastfeeding self-efficacy were examined using a Pearson’s product
moment correlation. The results revealed that perceived stress was negatively associated with
breastfeeding self-efficacy (r = -.70, p < .001). Conversely, social support had a strong positive
association with breastfeeding self-efficacy (r = .63, p < .001). In addition, social support and
perceived stress had a strong negative association (r = -.76, p < .001).

81

Description of Breastfeeding Practice
Breastfeeding initiation. According to the inclusion criteria for this study, all
participants had initiated breastfeeding after childbirth. The majority of the mothers included in
the study (n = 112, 70%) initiated breastfeeding within the first 24 hours after delivery.
The provision of free formula. Two-thirds of the sample (n = 106, 66.3%) received free
infant formula from a hospital, clinic, or other agency. Of those who received free infant
formula, only 31 (29.3%) did not use any of the received free formula.
Breastfeeding education during pregnancy. Less than half of the participants (n = 63,
39.4%) reported receiving education on breastfeeding during pregnancy.
Breastfeeding education and support after delivery. More than half of the participants
(n = 94, 58.8%) had received help, education or support for breastfeeding and ensuring good
latching after childbirth from different sources identified below.
Sources of breastfeeding support after childbirth. Of those who lived with extended
families, about three-fifths of mothers (n = 21, 61.8%) reported that an extended family member
did support or encourage breastfeeding. As shown in Table 7, the largest percentage of
participants who received breastfeeding support and education after childbirth identified their
mothers as the primary source of breastfeeding support, followed by the nurses, and
physicians/doctors.
On average, each participant had 1.4 persons who supported them and 1.2 persons
providing education to them. There were significant positive correlations between social support
and breastfeeding support (r = .33, p < .001), as well as between social support and education
received on breastfeeding (r = .39, p < .001).

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Table 7
Sources of Breastfeeding Support and Education
Sources

Support for breastfeeding
(n = 94)
n (%)

Education on breastfeeding
(n = 82)
n (%)

Nurse

47 (50.0)

33 (40.2)

Doctor

32 (34.0)

32 (39.0)

Lactation consultant

19 (20.2)

12 (14.6)

Mothers

64 (68.1)

58 (70.1)

Grandmother

13 (13.4)

11 (13.4)

Sister

17 (18.1)

14 (17.1)

Husband

13 (13.8)

10 (12.2)

Friend

10 (10.6)

10 (12.2)

4 (4.3)

4 (4.9)

Other (internet, relatives)

Breastfeeding duration. Slightly more than one-third of the mothers breastfed their
infants for more than six months (n = 59, 36.9%). Table 8 shows the frequencies of breastfeeding
duration by months.
Breastfeeding exclusivity. Of those who breastfed for six months or more (n = 92),
almost half (n = 44, 47.8%) breastfed their infants for the first six months of infant age. Table 8
displays the categories of breastfeeding.

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Table 8
Breastfeeding Duration and Categories (N = 160)

Variable

n

%

9

5.6

1 month

17

10.6

2 months

16

10.0

3 months

13

8.1

4 months

8

5.0

5 months

5

3.1

6 months

33

20.6

More than 6 months

59

36.9

Exclusive breastfeeding at 6 months

44

27.5

Partial breastfeeding at 6 months

48

30.0

Discontinued breastfeeding before 6 months

68

42.5

Duration of breastfeeding
Less than a month.

Breastfeeding categories

Reasons for breastfeeding cessation or supplementation. As shown in Table 9, a little
more than three-fifths of the participants (n = 76, 65.5%) reported insufficient milk as the
primary reason for early cessation of breastfeeding, followed by one fourth (n = 30, 25.9%)
reported returning to work, and about one fifth (n = 26, 22.4%) reported sickness of baby or
mother as the reasons for early breastfeeding cessation. When mothers were asked about the

84

most important reasons, the top three reasons identified for early breastfeeding cessation were
insufficient milk (47.4%), returning to work (15.5%), and introduction of formula in the first day
of baby’s life (13.8%).
Table 9
Reasons for Early Breastfeeding Cessation and/or Formula Supplementation (N = 116)

Reasons for breastfeeding cessation

All reasons
n (%)
76 (65.5)

Insufficient milk
Return to work

30 (25.9)

New pregnancy

1

(0.9)

Most important reason
n (%)
55 (47.4)
18 (15.5)
0 (0)

Sickness of baby or mother

21 (18.1)

10 (8.6)

Introduction of the formula in the first day of life

26 (22.4)

16 (13.8)

Not applicable/ did not stop breastfeeding

3

(2.6)

Other

26 (22.4)

2 (1.7)
15 (12.9)

Refusal of infant

2

4

Use of contraceptive pills

6

4

Unspecific pain

3

2

The associations between the reported “insufficient breast milk” and other selected
variables. The associations between the reported “insufficient breast milk” and the three
psychosocial variables of perceived stress, social support, and breastfeeding self-efficacy were
examined using t-tests. As shown in Table 10, the associations between the reported “insufficient
breast milk” and the three psychosocial variables of perceived stress, social support, and
breastfeeding self-efficacy were non-significant (P > 0.05).

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Table 10
Descriptive Statistics for Psychosocial Variables by the Perceived Insufficient Breast Milk
Perceived insufficient breast milk

Yes (n = 55)

No (n = 105)

M

SD

M

SD

t

p

Perceived stress

19.9

5.7

19.2

8.4

0.55

0.58

Social support

27.8

4.9

27.8

6.8

0.01

0.99

Breastfeeding self-efficacy

42.7

11.3

45.6

14.7

-1.26

0.21

The associations between the reported “insufficient breast milk” and the selected
demographic variables were examined using Fisher's exact tests. The results of the analysis
showed no significant associations between the reported “insufficient breast milk” and the any of
the selected demographic variables of household income (p = 0.29), maternal employment status
(p = 0.52), and maternal educational levels (p = 0.90).
Formula and solid introduction. Close to one-third of breastfeeding mothers (n = 35,
30%) introduced formula when their infants were younger than one month, and introduced solids
at six months of infant age. Table 11 shows the ages of infants when formula and solids were
first introduced.
Liquid supplementation. Prior to six months, water was the most commonly introduced
liquid supplement (n = 75, 64.7%), followed by herbal liquids (n = 34, 29.3%), and juices (n =
14, 12.1%).

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Table 11
Formula and Solid Food Introduction According to Infant Age (N = 116)

Infant Age

Formula Introduction

Solid Food Introduction

n (%)

n (%)

Younger than a month

35 (30.2)

2 (1.7)

1 month

19 (16.4)

0 (0)

2 months

27 (23.3)

2 (1.7)

3 months

15 (12.9)

0 (0)

4 months

13 (11.2)

15 (12.9)

5 months

2 (1.7)

25 (21.6)

6 months

3 (2.6)

35 (30.2)

Older than 6 months
Not yet started

-

12 (10.3)

2 (1.7)

25 (21.6)

Demographic Variables by Breastfeeding Category
One-way analysis-of-variance (ANOVA), Pearson’s chi-square test, and Fisher's exact
test analyses were conducted to examine the associations between the demographic variables in
this study and the three breastfeeding categories: exclusive, partial, and discontinued
breastfeeding before six months.
One-way ANOVA was performed to test the differences in the mean ages of mothers and
infants across the breastfeeding categories. The results revealed that there were no significant
differences in the mean ages of mothers and infants across the breastfeeding categories (see
Table 12). Using Pearson’s chi-square test, there were no significant associations between the

87

breastfeeding categories and infant’s gender (p > 0.05). Moreover, using Fisher's exact test, the
results indicated that there were no significant associations of the breastfeeding categories with
mothers’ marital status, childbirth type, and family history of breastfeeding (p > 0.05).
However, there was a significant association between mothers’ employment status and
the category of breastfeeding chosen by the mothers (p = .01). Among participants who worked
full time, there was a greater percentage of participants who discontinued breastfeeding (n = 16,
69.6%), compared to those who breastfed partially (n = 5, 21.7%) and exclusively (n = 2, 8.7%).
Among participants who worked part time, there was a greater percentage of them who engaged
in partial breastfeeding (n = 8, 47.1%), compared to those who discontinued breastfeeding (n = 7,
41.2%) and those who exclusively breastfed (n = 2, 11.8%). Lastly, the greater percentage of the
participants who were not working outside the home continued breastfeeding throughout the first
six months after birth (n = 75, 62.5%), compared to participants who discontinued breastfeeding
(n = 45, 37.5%).
In addition, there was a significant association between household income and
breastfeeding exclusivity (p < .01). Among those participants who were in the 3000 SAR or less
income category, over half of them breastfed exclusively (n = 5, 62.5%), compared to those who
partially breastfed (n = 2, 25.0%) and those who discontinued breastfeeding (n = 1, 12.5%). Of
those participants who were in the 4000 to 6000 SAR range, there was a greater percentage who
breastfed exclusively (n = 25, 37.31%), closely followed by the partial strata (n = 23, 34.3%),
with a smaller proportion of women who discontinued breastfeeding (n = 19, 28.4%). Of the
participants in the 7000 to 12000 SAR range, a little over half were in the discontinued category
(n = 29, 52.7%), compared to the partial (n = 15, 27.3%) and exclusive (n = 11, 20.0%)
breastfeeding categories. Of the 13000 SAR or more income category, a greater percentage of

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women discontinued breastfeeding (n = 15, 75.0%), compared to women in the partial (n = 3,
15.0%) and exclusive (n = 2, 10.0%) breastfeeding categories.
Table 12
Demographic Variables by Breastfeeding Category

Variable

Exclusive BF

Partial BF

n

n

%

Discontinued BF
%

n

%

Mother's age
20 to 23 years

9

26.5

15

44.1

10

29.4

24 to 27 years

14

26.4

12

22.6

27

50.9

28 to 31 years

13

29.6

11

25.0

20

45.5

32 to 38 years

8

27.6

10

34.5

11

37.9

Infant's age
6 months

5

20.0

7

28.0

13

52.0

7 months

4

21.1

8

42.1

7

36.8

8 months

9

30.0

11

36.7

10

33.3

9 months

7

22.6

9

29.0

15

48.4

10 months

7

50.0

3

21.4

4

28.6

11 months

2

20.0

2

20.0

6

60.0

12 months

10

32.3

8

25.8

13

41.9

Infant's gender
Male

20

25.3

20

25.37

39

49.4

Female

24

29.6

28

34.6

29

35.8

Relationship status

p

0.12

.89

F

p

0.86

.42

χ2

p

3.14

.20

Fisher’s
exact *

p
.33

Married

44

28.6

46

29.9

64

41.6

Divorced

0

0

2

33.3

4

66.7

Employment status

.01

Working full-time

2

8.7

5

21.7

16

69.6

Working part-time

2

11.8

8

47.1

7

41.2

40

33.3

35

29.2

45

37.5

Not working

F

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Table 12 (Cont’d)
Variable

Exclusive BF
n

%

Partial BF

Discontinued BF

%

n

n

%
Fisher’s
exact *

Household monthly
income SAR

.00

3000 or less

5

62.5

2

25.0

1

12.5

4000-6000

25

37.3

23

34.3

19

28.4

7000-12000

11

20.0

15

27.3

29

52.7

2

10.0

3

15.0

15

75.0

13000 or more
Educational level
Less than high
school

p

.01
2

22.2

4

44.4

3

33.3

High school

28

34.6

30

37.0

23

28.4

Bachelor's degree
Master's degree or
higher

12

20.3

13

22.0

34

57.6

2

18.2

1

9.1

8

72.7

Birth Type

.20

Vaginal delivery

40

30.1

37

27.8

56

42.1

Caesarean section

4

14.8

11

40.7

12

44.4

Did your mother ever
breastfeed?

.22

Yes

35

31.3

32

28.6

45

40.2

No

3

33.3

1

11.1

5

55.6

Note. F denotes the F test statistic based on one-way ANOVA. χ2 denotes the Pearson’s Chisquare of association statistic. p is the p-value. BF denotes breastfeeding. * Fisher’s exact test
has no statistics other than the p values.
Lastly, there was a significant relationship between educational level and breastfeeding
categories (p = .01). Of the participants with less than a high school education, there was a
greater proportion in the partial breastfeeding category (n = 4, 44.4%) compared to the exclusive
(n = 2, 22.2%) and discontinued categories (n = 3, 33.3%). Of those participants with a high
school education, a greater percentage were in the partial breastfeeding category (n = 30, 37.0%),
90

followed closely by the exclusive breastfeeding category (n = 28, 34.6%), and the discontinued
category (n = 23, 28.4%). Of the participants with bachelor’s degrees, the largest percentage was
in the discontinued category (n = 34, 57.6%), compared to the partial (n = 13, 22.0%) and the
exclusive breastfeeding categories (n = 12, 20.3%). Of those participants who had a master’s
degree or higher, the greatest proportion were in the discontinued breastfeeding category (n = 8,
72.7%) compared to the exclusive breastfeeding (n = 2, 18.2%) and partial breastfeeding (n = 1,
9.1%) categories. It is important to note the small numbers of participants in some of the
categories of the demographic variables by breastfeeding practice.
Results Organized by Research Aims
The main aim of this study was to examine the associations between breastfeeding
practice and three maternal psychosocial factors of perceived stress, social support, and
breastfeeding self-efficacy. The main outcome variable of breastfeeding practice has three
categories: discontinued breastfeeding, which included mothers who breastfed less than six
months (n = 68, 4%); partial breastfeeding, which included mothers who breastfed through the
first six months or more and supplemented with formula within the first six months (n = 48,
30%); and exclusive breastfeeding, which included mothers who exclusively breastfed through
the first six months or more (n = 44, 27.5%). The categories of breastfeeding practice were
created from two different variables, duration and exclusivity. The mean scores of the perceived
stress, social support, and self-efficacy for each breastfeeding categories are displays in Table 13.
Additional analysis Kruskal-Wallis H tests were performed to examine the associations
between psychosocial variables and the selected demographic variables. Psychosocial factor of
perceived stress, social support, and breastfeeding self-efficacy were not significantly associated
with household income and maternal educational levels. However, there was a statistically

91

significant difference between perceived stress and maternal employment status (p = 0.01).
Participants who were not working had significantly lower perceived stress (M = 18, SD = 7.49)
than those who were working full-time (M = 22.7, SD = 6.59) or part-time (M = 23.5, SD =
6.87). However, the levels of perceived stress among mothers who were working full-time did
not differ significantly from mothers who were working part-time.
Table 13
The Mean Scores of Perceived Stress, Social Support, and Self-Efficacy for each Breastfeeding
Category (N = 160)
Variable

Exclusive
M (SD)

Partial
M (SD)

Discontinued
M (SD)

Perceived stress

16.1 (8.85)

18.2 (6.72)

22.4 (6.01)

Social support

29.7 (7.14)

28.8 (5.26)

25.8 (5.61)

Breastfeeding self-efficacy

53.6 (12.40)

45.8 (11.13)

37.9 (12.47)

Participants who were not working had also significantly (p = 0.01) higher levels of
breastfeeding self-efficacy (M = 46.3, SD = 13.43) than those who were working part-time (M =
36.3, SD = 12.83). However, the levels of breastfeeding self-efficacy among mothers who were
working full-time (M = 41.9, SD = 12.97) did not differ significantly from mothers who were
working part-time or not working. In the following sections, multinomial logistic regression
models were employed to test the associations between each maternal psychosocial factor and
breastfeeding practice controlling for demographic factors. The results of these analyses are
organized by the study’s aims.
Aim 1: To determine the association between perceived stress and the practice of
breastfeeding among first-time Saudi Arabian mothers.
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The first multinomial logistic regression was employed to compare the risks of engaging
in discontinuing breastfeeding and partially breastfeeding relative to exclusive breastfeeding.
The multinomial logistic regression model was statistically significant, χ2(16) = 58.00, p < 0.001,
Pseudo R2 = 0.17. Perceived stress was positively related to breastfeeding discontinuation prior to
six months (RRR = 1.13, p = .001). As perceived stress increased by one unit, the relative risk of
being in the discontinued breastfeeding category relative to exclusive breastfeeding category
increased by 13% (p = .001) given that selected demographic variables including maternal age,
employment status, household income, and educational level were held constant (see Table 14).
The relative risk of being in the partial breastfeeding group compared to the exclusive group was
not significantly related to the perceived stress (RRR=1.02, p = .49).
An additional multinomial logistic regression model was performed to examine the
relative risks between partial and discontinued breastfeeding groups, using discontinued
breastfeeding category as a reference group. The model was statistically significant, χ2(16) =58.00,
p < 0.001, Pseudo R2 = 0.17. For a one-unit increase in the perceived stress, the probability of
being in the partial breastfeeding category relative to discontinued breastfeeding category
decreased by 10% (RRR=0.90, p= .002), given other demographic variables were held constant
including maternal age, employment status, household income, and educational level (Table 14).
In summary, mothers’ perceived stress level was significantly related to their breastfeeding
duration, but not the breastfeeding exclusivity.
As shown in Table 14, the employment status, household income, and education level
were statistically correlated with some breastfeeding practice. For working mothers, the risk of
partially breastfeeding relative to exclusive breastfeeding was 4.54 times greater than among
non-working (p =.024).

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Table 14
Summary of Multinomial Logistic Regression Analysis of Perceived Stress Predicting
Breastfeeding Practice (N = 160)
Discontinued breastfeeding vs.
Exclusive breastfeeding e

Partial breastfeeding vs.
Exclusive breastfeeding e

Partial breastfeeding vs.
Discontinued breastfeeding
f

95% CI
Predictor

Perceived Stress

RRR

LL

95% CI
UL

RRR

LL

95% CI

UL

RRR

LL

.84

UL

1.13**

1.05

1.21

1.02

.96

1.08

.90**

.96

24 to 27 years

.87

.25

3.09

.52

.16

1.72

.59

.18

1.93

28 to 31 years

.66

.18

2.43

.43

.13

1.48

.66

.19

2.23

32 to 38 years

.74

.17

3.30

.76

.20

2.87

1.02

.27

3.90

2.14

.59

7.70

4.54*

1.22

16.97

2.12

.76

5.94

4.52**

1.76

11.61

1.80

.70

4.63

.40

.16

.99

5.53

.52

58.48

6.03

.64

57.17

1.09

.22

5.34

2.39

.92

6.18

.58

.21

1.63

.24**

.09

.64

Mother's age a

Employment status b
Working

Household monthly
income SAR c
7000 or more
No answer

Educational level d
Bachelor's
degree or higher

Note. *p < .05, **p < .01
a
Compared to Reference group the 20 to 23 year age category. bCompared to not working
category cCompared to 6000 SAR or less category. dCompared to high school or less category. e
Base outcome: exclusive breastfeeding. f Base outcome: discontinued breastfeeding. Model
summary: Log likelihood = -143.78, χ2(16) =58.00, p < 0.001, Pseudo R2 = 0.17

94

For participants who identified as having a household income of 7000 or more, the risk of
discontinuing breastfeeding was 4.52 times greater than among mothers with family incomes of
6000 SAR or less. The last significant predictor was maternal educational level. The likelihood
of engaging in partially breastfeeding versus discontinued breastfeeding decreased among
mothers with a bachelor’s educational level or higher as compared to mothers with a high
school education or less (RRR= .24, p = .004).
Aim 2: To determine the association between social support and the practice of
breastfeeding among first-time Saudi Arabian mothers.
The multinomial logistic regression model for social support predicting the practice of
breastfeeding was statistically significant, χ2(16) = 55.71, p < 0.001, Pseudo R2 = 0.16. For a oneunit increase in the social support, the risk of discontinuing breastfeeding relative to exclusive
breastfeeding decreased by 13% (RRR = 0 .87, p = .001). There were no significant differences
in the probabilities of engaging in partial versus exclusive breastfeeding based on changes in the
social support.
An additional multinomial logistic regression model was performed to examine the
relative risk between partial and discontinued breastfeeding groups, using discontinued
breastfeeding category as a reference group. The model was statistically significant, χ2(16) =
55.71, p < 0.001, Pseudo R2 = 0.16. For a one unit increase in the social support, the probability
of being in the partial breastfeeding category relative to discontinued breastfeeding category
increased by 12% (RRR = 1.12, p =.004), given selected demographic variables of maternal age,
employment status, household income, and educational level were held constant (Table 15).

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Table 15
Multinomial Logistic Regression Analysis of Social Support Predicting Breastfeeding Practice
(N = 160)
Discontinued breastfeeding vs.
Exclusive breastfeeding e

Partial breastfeeding vs.
Exclusive breastfeeding e

95% CI
Predictor
Social support

RRR

LL

UL

Partial breastfeeding vs.
Discontinued
breastfeeding f

95% CI
RRR

LL

UL

95% CI
RRR

LL

UL

0.87**

.80

.94

.98

.91

1.05

1.12*

1.02

1.20

24 to 27 years

1.03

.30

3.60

.52

.16

1.73

.50

.14

1.63

28 to 31 years

.61

.17

2.23

.45

.13

1.53

.74

.22

2.52

32 to 38 years

.68

.16

2.88

.72

.19

2.70

1.07

.29

3.95

Employment
status b
Working

2.32

.64

8.36

4.57*

1.25

16.73

1.97

.70

5.56

Household
monthly income
SAR c
7000 or more

5.78**

2.22

15.03

1.86

.73

4.76

.32*

.13

.81

11.27

1.07

119.19

6.95

.73

66.32

.62

.13

3.01

2.27

.88

5.88

.59

.21

1.65

.26*

.10

.69

Mother's age a

No Answer
Educational level d
Bachelor's
degree or
higher

Note. *p < .05, **p < .01
a
Compared to Reference group the 20 to 23 year age category. bCompared to not working
category cCompared to 6000 SAR or less category. dCompared to high school or less category. e
Base outcome: exclusive breastfeeding. f Base outcome: discontinued breastfeeding. Model
summary: Log likelihood = -144.92, χ2(16) =55.71, p < 0.001, Pseudo R2 = 0.16

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As shown in Table 15, the maternal employment status, household income, and maternal
education level were statistically correlated with some breastfeeding categories. For working
mothers, the risk of partially breastfeeding relative to exclusive breastfeeding was 4.57 times
greater than among non-working mothers (p =.022). Additionally, for participants who identified
as having a household income of 7000 or more, the risk of discontinuing breastfeeding was 5.78
times greater than among mothers with family incomes of 6000 SAR or less. Furthermore,
mothers with household income of 7000 or more were less likely to engage in the partial
breastfeeding relative to discontinued breastfeeding (RRR= .32, p = .017). The last significant
association in the multinomial logistic regression models was maternal educational level. The
likelihood of engaging in partially breastfeeding versus discontinued breastfeeding decreased
among mothers with a bachelor’s educational level or higher relative to mothers with a high
school education or less (RRR= .26, p =.006).
Aim 3: To determine the association between breastfeeding self-efficacy and
Breastfeeding Practice among first-time Saudi Arabian mothers.
The multinomial logistic regression model predicting breastfeeding patterns based on
self-efficacy was statistically significant overall, χ2(16) = 79.05, p < 0.001, Pseudo R2 = 0.23. For
a one unit increase in the breastfeeding self-efficacy, the risks of discontinuing breastfeeding
(RRR = .88, p < .001) or switching to partial breastfeeding (RRR= .94, p = .006) declined
significantly relative to exclusive breastfeeding (Table 16).
An additional multinomial logistic regression model was performed to examine the
relative risk between partial and discontinued breastfeeding groups relative to breastfeeding selfefficacy, using discontinued breastfeeding category as a reference group. The model was
statistically significant, χ2(16) =79.05, p < 0.001, Pseudo R2 = 0.23.

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Table 16
Multinomial Logistic Regression Analysis of Breastfeeding Self-efficacy Predicting
Breastfeeding Practice (N = 160)
Discontinued
breastfeeding vs.
Exclusive breastfeeding e

Partial
breastfeeding vs.
Exclusive breastfeeding e

95% CI
Predictor

95% CI

95% CI

RRR

LL

0.88**

.84

.93

.94*

.90

24 to 27 years

1.02

.26

4.05

.61

28 to 31 years

.70

.16

2.84

32 to 38 years

1.75

.35

2.23

Breastfeeding Selfefficacy

Partial breastfeeding vs.
Discontinued
breastfeeding f

UL

RRR

LL

UL

RRR

LL

UL

.98

1.06*

1.02

1.11

.17

2.13

.60

.14

1.92

.49

.14

1.73

.70

.23

3.62

8.64

1.28

.31

5.24

.73

.16

3.60

.58

8.64

4.11*

1.06

15.81

1.84

.49

18.20

5.81**

2.04

16.58

1.99

.75

5.30

.34*

.03

7.56

6.51

.47

90.14

7.06

.66

75.85

1.08

.01

3.10

1.86

.65

5.33

.47

.16

1.40

.26*

.09

.67

Mother's age a

Employment status b
Working
Household monthly
income (SAR) c
7000 or more
No Answer
Educational level d
Bachelor's degree or
higher

Note. *p < .05, **p < .01
a
Compared to reference group the 20 to 23 year age category. bCompared to not working
category cCompared to 6000 SAR or less category. dCompared to high school or less category.
e
Base outcome: exclusive breastfeeding. f Base outcome: discontinued breastfeeding. Model
summary: Log likelihood = -133.25, χ2(16) =79.05, p < 0.001, Pseudo R2 = 0.23

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For a one unit increase in the breastfeeding self-efficacy, the probability of being in the
partial breastfeeding category relative to discontinued breastfeeding category increased by 6%
(RRR=1.06, p = .001), given that demographics were held constant (Table 16). Different from
perceived stress and social support, mothers’ breastfeeding self-efficacy was significantly
correlated with both breastfeeding duration and exclusivity.
As shown in Table 16, the employment status, household income, and education level
were statistically significantly correlated with some breastfeeding categories. For working
mothers, the risk of partially breastfeeding relative to exclusive breastfeeding was 4.11 times
greater than among non-working mothers (p = .040). For participants, who identified as having a
household income of 7000 or more, the risk of discontinuing breastfeeding relative to exclusive
breastfeeding was 5.81 times greater than among mothers with family incomes of 6000 SAR or
less (p = .001). Furthermore, mothers with household income of 7000 or more were less likely to
engage in the partial breastfeeding relative to discontinued breastfeeding (RRR= .34, p < .05). As
shown in Table 16, the last significant correlate was maternal educational level. The likelihood
of engaging in partially breastfeeding versus discontinued breastfeeding significantly decreased
among mothers with bachelor’s educational level or higher relative to mothers with high school
education or less (RRR= .26, p = .006).
Overall Theoretical Model
Three multinomial logistic regression models were utilized to examine the relative risks
of engaging in different breastfeeding practices based on the scores of all three psychosocial
variables together, using the same demographic control variables of maternal age, employment
status, household income, and educational level.

99

The first multinomial logistic regression model included perceived stress and social
support as the independent variables. The model was statistically significant, with χ2(18) = 59.30,
p < .001, Pseudo R2 = .17. However, perceived stress and social support were not significantly
correlated with breastfeeding practice. The second multinomial logistic regression model
included perceived stress and breastfeeding self-efficacy. The model was statistically significant,
with χ2(18) = 81.87, p < .001, Pseudo R2 = .24. Only breastfeeding self-efficacy was significantly
related to breastfeeding practice (p < .01). The third overall multinomial logistic regression
model included perceived stress, social support, and breastfeeding self-efficacy. The overall
model was statistically significant, with χ2(20) = 82.81, p < .001, Pseudo R2 = .24. Only
breastfeeding self-efficacy remained as a significant predictor of breastfeeding practice (p < .01).
The likelihood-ratio test was significant between the first model, that encompassed
perceived stress and social support, and the overall model that included perceived stress, social
support, and breastfeeding self-efficacy (χ2(2) = 23.51, p < .001). In other words, adding
“breastfeeding self-efficacy” led to a statistically significant enhancement in the overall model
fit. In contrast, the likelihood-ratio test was non-significant between the second model (perceived
stress and breastfeeding self-efficacy) and the overall model that included perceived stress, selfefficacy, and social support (χ2(2) = 0.94, p = .63). In other words, adding social support did not
result in a statistically significant improvement in the overall model fit. Likewise, adding
perceived stress to a model that included social support and breastfeeding self-efficacy did not
result in a statistically significant improvement in the overall model fit (χ2(2) = 0.65, p = .72). In
summary, “breastfeeding self-efficacy” was the most important factor influencing breastfeeding
practice.

100

Chapter 6: Discussion and Implications
This cross-sectional, correlational study examined the associations between the practice
of breastfeeding, and selected theory-based psychosocial factors: perceived stress, social support,
and breastfeeding self-efficacy, among a sample of first-time Saudi Arabian mothers who
initiated breastfeeding. To address the research purpose, a sample of 160 first-time mothers who
initiated breastfeeding recruited from four primary care centers in Jeddah, KSA, were surveyed
regarding the study variables. The major findings indicated that mothers with lower levels of
stress, higher levels of social support, and higher levels of breastfeeding self-efficacy were more
likely to continue breastfeeding throughout the first six months after childbirth than mothers with
higher levels of stress, lower levels of social support and lower levels of breastfeeding selfefficacy. Moreover, mothers with higher levels of breastfeeding self-efficacy were more likely to
exclusively breastfeed than those with lower levels of self-efficacy.
A discussion of the results described in Chapter 5 is presented in this final chapter. This
discussion focuses on the interpretation of the findings based on the study’s aims and
hypotheses, and validation from the current literature. A discussion of study strengths,
limitations, and implications for future research, practice, and policy will be provided in this
chapter, followed by conclusions.
Discussion of the Main Research Findings According to Study’s Aims
Aim 1. The first aim was to determine to what extent perceived stress was associated
with the practice of breastfeeding at six to twelve months after birth among first-time Saudi
Arabian mothers who initiated breastfeeding. It was hypothesized that mothers who had lower
levels of stress would be more likely to exclusively breastfeed throughout the first six months
after birth than mothers with higher levels of stress. The main outcome variable was the
breastfeeding practice which had three categories: exclusive breastfeeding throughout the first
101

six months after childbirth, partial breastfeeding throughout the first six months after childbirth,
and discontinued breastfeeding prior to six months. To examine the relative risks between the
three groups of breastfeeding practice, two multinomial logistic regression models were
performed using different breastfeeding categories as a reference group.
The current study found a significant risk of discontinuing breastfeeding prior to the
recommended first six months relative to perceived stress; nonetheless, no significant differences
arose in the relative risks of exclusive versus partial breastfeeding relative to perceived stress. In
other words, the findings indicate that perceived stress was significantly associated with
breastfeeding duration; however, perceived stress was not significantly related to breastfeeding
exclusivity. The results suggest that hypothesis one is partially supported; that is, first-time
mothers who had higher levels of perceived stress were somewhat more likely to discontinue
breastfeeding during the first six months after birth than mothers who had lower levels of
perceived stress.
The significant negative association between perceived stress and breastfeeding duration
is consistent with previous findings from other countries (Dozier et al., 2012; Li, Kendall,
Henderson, & Downie, 2008; Zhu, Hao, Jiang, Huang, & Tao, 2013). Yet, the comparisons
between such findings are inconclusive due to the use of different tools and different prospective
designs to examine the associations between maternal stress and breastfeeding duration. The
finding from this study confirmed that first-time mothers who perceived less stress during the
first six months of postpartum period were more likely to continue breastfeeding throughout the
recommended breastfeeding period. This finding emphasizes the importance of addressing
maternal perceived stress early after childbirth to improve mothers’ ability to breastfeed.

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The inverse association between perceived stress and breastfeeding duration may be
explained, in part, by the following mechanisms that have been revealed in studies from different
countries. First, high levels of maternal stress can lead to decreased breast milk volume and
production (Dimitraki et al., 2016; Doulouger et al., 2013; Zhu et al., 2013), through reducing the
production of the oxytocin hormone (Dewey, 2001). Perceived stress not only decreases breast
milk volume, but also results in decreasing the immune components of breast milk (Thibeau et
al., 2016).
A second mechanism that may explain the negative association between perceived stress
and breastfeeding duration is the protective effects of breastfeeding against stressors. The
response to stressors differs in breastfeeding mothers from mothers who do not breastfeed
(Groer, 2005; Groer et al., 2002; Mezzacappa & Katlin, 2002). For instance, a review of the
literature revealed that breastfeeding mothers had diminished reactivity to stress and
environmental stimuli (Groer et al., 2002), which means that breastfeeding mothers can endure
more stress that may result from trying to meet the demands of newborns. Furthermore, studies
indicated that breastfeeding mothers reported more positive mood and less perceived stress than
non-breastfeeding mothers (Groer, 2005; Mezzacappa & Katlin, 2002), possibly due to the role
of the breastfeeding hormone, prolactin (Groer & Davis, 2006). A recent randomized controlled
trial with 35 German women, diagnosed with posttraumatic stress disorder, showed that
intranasal oxytocin, a hormone that is released during breastfeeding, reduces symptoms of
posttraumatic stress disorder (Sack et al., 2017). These two mechanisms may explain why first
time Saudi Arabian mothers who perceived less stress were able to breastfeed throughout the
recommended six months after childbirth.

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The non-significant finding between perceived stress and breastfeeding exclusivity may
be a result of design limitations, given that maternal perceived stress in this study was
retrospectively measured after breastfeeding practice may have been discontinued. This nonsignificant finding could not be validated with the current literature due to the lack of research
that examined the association between perceived stress and breastfeeding exclusivity.
As mentioned previously, the finding partially supported the theory-based hypothesis of
the negative association between perceived stress and breastfeeding practice. Despite the
congruence of this findings with the literature (Dimitraki et al., 2016; Doulouger et al., 2013;
Zhu et al., 2013), causal inferences cannot be assumed due to the lack of evidence on the timeorder relationship between stress and breastfeeding outcomes. Furthermore, it is uncertain
whether maternal stress is a predictor of breastfeeding discontinuation and shorter-duration, or a
response (result) of breastfeeding practice due to breastfeeding-associated issues including
fatigue, breast encouragement, sleep disturbance, and pain. Additional studies are needed to
further explain the nature of the association between perceived stress and breastfeeding practice.
It is important to incorporate the assessment of maternal stress into the prenatal and postnatal
care to identify mothers at risk for breastfeeding discontinuation. Healthcare professionals need
to intervene early and address the new-mother concerns during the stressful transition to the
maternal role. The assessment of maternal stress within maternity care in the KSA is not a
common practice; thus, a change in practice protocol and policy is needed.
Aim 2. The second aim was to determine the association between social support and the
breastfeeding practice at six to twelve months after birth among first-time Saudi Arabian
mothers. It was hypothesized that first-time mothers who had higher levels of social support
would continue to exclusively breastfeed their infants throughout the first six months after birth

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than first-time mothers who had lower levels of social support. Two multinomial logistic
regression models were employed to examine the likelihood of engaging in different
breastfeeding practices using two different reference groups.
The current study found that first-time mothers who initiated breastfeeding and who had
higher levels of social support were more likely to continue exclusive or partial breastfeeding
until their infants were six months old than first-time mothers who had initiated breastfeeding
and who had lower levels of social support. However, social support was not related to
breastfeeding exclusivity. The results suggest that hypothesis two was partially supported; that is,
first-time mothers who had higher levels of social support were more likely to continue
breastfeeding until their infants were six months old than first-time mothers who had lower
levels of social support.
The significant association between social support and breastfeeding duration was
congruent with findings from different countries. A recent Cochrane systematic review of 73
randomized and quasi-randomized controlled trials showed a negative association between social
support and breastfeeding discontinuation (McFadden et al., 2017). The results of this systematic
review confirmed that all forms of support led to a decrease in cessation of exclusive
breastfeeding (RR 0.88, 95% CI 0.85 to 0.92); similar findings emerged in the current study.
Therefore, it is important to support breastfeeding mothers regularly during the postnatal visits,
and facilitate peer support for breastfeeding mothers.
Various sources can provide social support to breastfeeding mothers including family
members, friends, doctors, nurses, and lactation consultants. The largest percentage of
participants in the current study identified their mothers as the primary source of breastfeeding
support and education. Some studies’ findings indicated that support from a family member was

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positively associated with breastfeeding duration among mothers in Kuwait (Dashti et al., 2010;
Dashti, Scott, Edwards, & Al-Sughayer, 2014; Nassar et al., 2014). In contrast, studies from
Western countries identified professional support provided by doctors or nurses as the most
important source of breastfeeding support (Britton et al., 2007; Hannula, Kaunonen, & Tarkka,
2008; Jarlenski et al., 2014; McFadden et al., 2017). These variations in the support preference
between the Western and Eastern countries may be due to the strong family relationships in
Eastern culture (Kim, Sherman, & Taylor, 2008). Professional support becomes more effective
when accompanied by peer support (Kaunonen, Hannula, & Tarkka, 2012). Likewise, antenatal
support is insufficient to improve breastfeeding practice, and it is more effective when it
continues after childbirth (Babakazo et al., 2015). Thus, consistent support from family
members, health professionals, and peers (lay) is important for sustainment of breastfeeding
among first-time mothers in the KSA.
The non-significant association between social support and breastfeeding exclusivity was
consistent with a study’s findings from Kuwait that revealed a positive association between
grandmothers’ support and breastfeeding duration, yet a non-significant association between
grandmothers’ support and breastfeeding exclusivity (Dashti et al., 2014). In the provided
support to breastfeeding mothers, there may be little to no emphasis on the exclusivity of
breastfeeding, which may explain this finding. Recommendations and instructions provided to
new mothers from a family member may not always be congruent with the recommendations of
the WHO on breastfeeding practice. Dashti and colleagues (2014) further explained these
findings as a possible result of grandmothers’ encouragement to supplement with formula to
ensure that the infant is well-fed. Hence, breastfeeding Saudi Arabian mothers should not rely
solely on their mothers’ advice, but they should also be able to access evidence-based

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breastfeeding resources. Given that the largest percentage of participants in the current study
identified their mothers as the primary source of breastfeeding support and education, it is
important to include the grandmothers in the future breastfeeding research.
Aim 3. The third aim was to determine to what extent breastfeeding self-efficacy was
associated with the practice of breastfeeding at six to twelve months after birth among first-time
Saudi Arabian mothers who initiated breastfeeding. It was hypothesized that first-time mothers
who had higher levels of breastfeeding self-efficacy would continue to exclusively breastfeed
their infants throughout the first six months of life than first-time mothers who had lower levels
of breastfeeding self-efficacy. Two multinomial logistic regression models were employed to
examine the likelihood of engaging in different breastfeeding practices.
The findings indicated that breastfeeding self-efficacy was significantly associated with
both breastfeeding exclusivity and duration. The results suggest that the hypothesis was
supported; that is, mothers who had lower levels of breastfeeding self-efficacy were more likely
to discontinue breastfeeding altogether or to switch to partial breastfeeding during the first six
months after birth, than mothers who had higher levels of breastfeeding self-efficacy. Consistent
with this study’s findings, previous correlational studies from developed countries have
consistently found breastfeeding self-efficacy to be significantly associated with breastfeeding
exclusivity and duration (Babakazo et al., 2015; Bailey et al., 2008; de Jager et al., 2015; Loke &
Chan, 2013; Semenic et al., 2008). Furthermore, past research indicated that higher maternal
breastfeeding self-efficacy at two days postpartum was a significant predictor of exclusive
breastfeeding at six months postpartum (Henshaw et al., 2015). In addition, breastfeeding selfefficacy was a stronger correlate with exclusive breastfeeding duration at six-month postpartum
than when measured at two months (de Jager et al., 2015), which relates to the influence of

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successful past behavior. Therefore, it is important to encourage and reinforce the practice of
breastfeeding after childbirth and during the postnatal and well-baby visits.
Breastfeeding self-efficacy is an ongoing process that regulates mothers’ perceptions
about breastfeeding practice. A positive breastfeeding experience, characterized by a mother’s
satisfaction with meeting her infant’s nutritional needs, can shape a mother’s confidence in
breastfeeding. This confidence can be strengthened by positive feedback from healthcare
providers, which in turn can reinforce the mother’s decision regarding breastfeeding continuation
and exclusivity.
The positive association between breastfeeding self-efficacy and breastfeeding practice in
this study was also empirically supported in the literature. Three intervention studies showed that
breastfeeding self-efficacy interventions, such as workbooks and self-efficacy-enhancing
sessions, had positive effects on breastfeeding self-efficacy, exclusivity, and duration (Nichols et
al., 2009; Otsuka et al., 2014; Wu et al., 2014). These empirical findings, when considered in
relation to the results of the current study, suggest that breastfeeding self-efficacy is an important
modifiable factor that can be enhanced through intervention. Therefore, concrete efforts should
be taken by healthcare professionals to enhance breastfeeding self-efficacy after childbirth
through providing positive reinforcement for all postpartum Saudi Arabian women.
To the best of the PI’s knowledge, this is the first study to address breastfeeding selfefficacy among first-time Saudi Arabian mothers who initiated breastfeeding. As such it is
difficult to compare this study’s findings with others studies involving sample populations from
different societies and cultural contexts. However, the findings provide implications for nursing
research, practice, and policy which will be discussed later in this chapter.

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Additional Findings
Association among maternal psychosocial variables. Perceived stress had a strong
negative association with social support, indicating that first-time mothers who had higher levels
of social support tended to have lower levels of perceived stress. This finding is consistent with
other studies findings from developed countries that the influence of stress can be attenuated in
the presence of social support (Coburn, Gonzales, Luecken, & Crnic, 2016; Kingston, Heaman,
Fell, Dzakpasu, & Chalmers, 2012). Moreover, social support can moderate the effect of stress
on health outcomes. For example, a recent study with first-time Swiss mothers (N = 235)
revealed that the relationship between stress and health outcomes diminished through social
support (Razurel, Kaiser, Antonietti, Epiney, & Sellenet, 2017). However, the variation in tools
used to measure perceived stress and social support makes the comparison inconclusive across
studies.
Social support can mitigate stress by providing a sense of mastery and improving a
mother’s ability to cope with postpartum stressors (Gadalla, 2009; Schwarzer & Knoll, 2007).
Buffering effects become evident when a person has experienced support and stress in the same
context (Cohen & McKay, 1984). In the current study, perceived stress and social support were
examined in the same context of breastfeeding, which may strengthen the buffering mechanism
between perceived stress and social support. For instance, a study of 92 undergraduate students
investigated the buffering effects of perceived and received social support on stress (Cohen,
McGowan, Fooskas, & Rose, 1984). Consistent with the current study, the statistical analyses
strongly supported the stress-buffering effects of perceived social support (Cohen et al., 1984).
Therefore, it is important to include the element of social support in future research that aims to
promote the breastfeeding practice through the management of maternal stress.

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Perceived stress was also negatively associated with breastfeeding self-efficacy in this
study, suggesting that first-time mothers who had lower levels of perceived stress tended to have
higher breastfeeding self-efficacy than first-time mothers who had higher levels of perceived
stress. Findings from developed countries supported the significant negative association (p
< .001) between perceived stress and breastfeeding self-efficacy (Dennis, 2006; Dennis, 2003).
This is an important finding and relates to the theoretical framework of self-efficacy, where
stress is an important antecedent variable that can impact an individual’s beliefs in her perceived
ability to execute certain behavior (Bandura, 1977a, 1986).
There are several causes of stress in the first year after birth for first-time mothers
including financial stress, emotional stress (Dozier et al., 2012), sleep disturbances (Gardazi et
al., 2016), and physical changes to the mother’s body (Rallis et al., 2014). Dennis (1999)
emphasized the need to assess and address maternal stress to enhance breastfeeding self-efficacy.
Therefore, the association between maternal perceived stress and breastfeeding self-efficacy
needs to be considered and integrated into future breastfeeding-enhancing strategies in the KSA.
Moreover, clinicians need to address the maternal stress early during the postpartum period in
order to enhance mothers’ breastfeeding self-efficacy.
Social support in this sample was significantly positively associated with breastfeeding
self-efficacy, suggesting that mothers who had higher levels of social support tended to have
higher levels of breastfeeding self-efficacy than those who had lower levels of social support.
Consistent findings have been documented in the literature. A recent study revealed a significant
positive relationship between social support and breastfeeding self-efficacy among Iranian
postpartum women at four to six months postpartum (Faridvand, Mirghafourvand, Malakouti, &
Mohammad-Alizadeh-Charandabi, 2017). In addition, a study with expectant Chinese mothers

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(N = 201) revealed that five variables accounted for 34% of the variance in breastfeeding selfefficacy including perceived social support, previous breastfeeding experience, watching others
breastfeed, timing of maternal decision to breastfeed, and perceived husbands’ attitude toward
breastfeeding (Zhu, Chan, Zhou, Ye, & He, 2014). Therefore, it is important to incorporate the
element of social support into future breastfeeding research and programs that aim to promote
maternal confidence in breastfeeding.
The significant positive association between social support and breastfeeding selfefficacy was also supported by the theoretical framework of breastfeeding self-efficacy, based on
Bandura’s social-cognitive theory (Bandura, 1977a, 1977b; Dennis, 1999). The concept of social
support was embedded in the construct of “verbal persuasion” in the theoretical framework of
breastfeeding self-efficacy (Dennis, 1999). Social support is considered a facilitator to
breastfeeding self-efficacy.
Overall, the correlations among the three psychosocial variables of perceived stress,
social support, and breastfeeding self-efficacy were significant. The strong correlations among
the three psychosocial variables can potentially be explained by the following three reasons.
First, there were overlaps in the scale constructs among the three scale items. For example, item
8 on the Social Provisions Scale, “There was no one I can turn to for guidance in times of
stress,” indicates both a lack of social support and stress. In addition, the items from 4 to 8 on
the Perceived Stress Scale indicate breastfeeding self-efficacy. For example, Item 6 in the
perceived stress scale, “When you breastfeed/breastfed, how often have/had you found that you
could not cope with all the things that you had to do?,” is the opposite of Item 2 in the
Breastfeeding Self-efficacy Scale, “I can/could always successfully cope with breastfeeding like
I have with other challenging tasks”. Second, the three psychosocial scales demonstrated

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theoretically-related concepts. For instance, the correlation between perceived stress and
breastfeeding self-efficacy was examined as a measure for validity of the Breastfeeding Selfefficacy Scale (Dennis, 2003). Third, the participants were asked to think about their experience
during breastfeeding and respond to the three scales, which may have resulted in consistent
ratings based on their past thought processes.
Discussion of the overall conceptual framework. Three multinomial logistic regression
models including all three psychosocial variables were utilized to examine the likelihood of
engaging in different breastfeeding practices, using the same demographic control variables of
maternal age, employment status, household income, and educational level. Among the three
models, breastfeeding self-efficacy remained a significant factor of the breastfeeding practice (p
< .01), and resulted in a statistically significant improvement in the overall model fit. The
associations among selected psychosocial factors and breastfeeding practice in the conceptual
framework of this study were supported by the original conceptual framework of breastfeeding
self-efficacy, where only breastfeeding self-efficacy showed a direct relationship with
breastfeeding practice (Dennis, 1999). Therefore, breastfeeding self-efficacy is an essential
element to include in a breastfeeding intervention for first-time mothers who initiated
breastfeeding.
The findings from this study support the adapted conceptual framework used, and add to
the body of knowledge regarding theory-based psychosocial factors associated with
breastfeeding practice, which has not been examined among Saudi Arabian first-time mothers.
However, further research is warranted to support the current study findings using a larger
sample.

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Demographic characteristics. Participants in this study were of varied ages, incomes,
and educational levels. The mean age of participants was 27.2 years, which is somewhat similar
to reported average maternal ages in studies with Saudi Arabian mothers attending PCCs after
six months of infant age (Al-Madani et al., 2010; Amin et al., 2011). However, studies in the
KSA included mothers of different parity status, which makes the comparison of maternal ages
less relevant. The majority of participants had a low to medium household income of 4,000–
6,000 SAR (approximately $1,066– 1,600 USD), which is similar to the reported low household
income of Saudi Arabian mothers who were living in Jeddah and attending well-child clinics
(Fida & Al-Aama, 2003).
More than half of the mothers included in this study were not working and had no more
than a high school education. Mothers’ level of education and employment status in this study
were similar to the characteristics of Saudi Arabia mothers attending PCCs in a similar study
with a larger sample size of 671 mothers (Alzaheb, 2016b). In brief, mothers in this study were
predominantly not working outside the home, married, with a midrange household income and a
high school education. The study sample was relatively representative to the KSA population,
though it has limitations due to convenient sampling.
Breastfeeding practices. The vast majority of mothers (70%) initiated breastfeeding
within the first 24 hours after childbirth, which is consistent with findings from related studies
where at least 78% of Saudi Arabian mothers initiated breastfeeding (Amin et al., 2011; El
Mouzan et al., 2009; Shawky & Abalkhail, 2003). A recent study revealed that all Saudi Arabian
mothers included in the survey (N = 517) had no concerns about initiation of breastfeeding after
delivery (Alshebly & Sobaih, 2016). The high initiation rate among Saudi Arabian mothers
indicated their willingness to breastfeed their infants.

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In the current study, the proportions of mothers who exclusively or partially breastfed
their infants for the first six months of infant age were 27.5% and 30.0%, respectively. The
reported rates of exclusive breastfeeding at six months of infant’s age in the KSA ranged widely
from 0.8% to 37.5%, which was likely due to the lack of a standardized definition for
“exclusive” breastfeeding practice (Al-Jassir et al., 2004; Al-Jassir et al., 2006; Alshebly &
Sobaih, 2016; El-Gilany et al., 2011). The proportion of partial breastfeeding in the current study
was lower than the reported range of partial breastfeeding (42–76%) in national surveys (AlJassir et al., 2006; Murshid, 2006), which may be related to the use of different sample
populations including non-Saudi and multiparous mothers.
The largest proportion of the mothers in this study (72.5%) introduced formula, liquids,
or solids to infants as nutritional supplements during the first six months after childbirth.
Consistent with literature in the KSA (Al-Hreashy et al., 2008; Al-Jassir et al., 2006; Alshebly &
Sobaih, 2016; El Mouzan et al., 2009), as well as in other developed countries (Gatti, 2008), this
study provides further support of the “insufficient breast milk” as the most important reason for
discontinuing breastfeeding or supplementing with formula prior to the recommended six
months. Other reported reasons in this study were returning to work, introduction of formula in
the first day of life, and illness of the baby or mother. About half of mothers in two studies (N =
728) conducted in Jeddah consistently identified “insufficient breast milk” as the main reason for
breastfeeding cessation (Eldeek et al., 2012; Fida & Al-Aama, 2003). Nevertheless, a recent
study with 123 first-time Canadian mothers revealed no significant association between the
perception of “insufficient milk supply” and actual insufficient milk production as measured by
infant weight before and after each breastfeed (Galipeau, Dumas, & Lepage, 2017).

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There is a lack of evidence that supports any relationship between the perception of
insufficient milk and the presence of physiologic or physical issues that could interfere with
breastfeeding (Neifert, 2001). The explanation of “insufficient breast milk” as a predominant
reason for early breastfeeding discontinuation can be explained by less breast stimulation when
formula is being introduced to calm a crying or uncooperative baby (Wasser et al., 2011), which
in turns leads to a substantial decrease in milk supply (Al Juaid et al., 2014).
Another reason that may lead to the perception of “insufficient breast milk” is related to
mother’s interpretations of her infant cues. Mothers who have less breastfeeding experience and
knowledge may interpret normal infant signals such as infant crying and infant hunger cues as
meaning they have insufficient breast milk (Al-Hreashy et al., 2008). Moreover, infant
preference for unilateral breastfeeding is another documented issue among Saudi Arabian
mothers that could result in decreased milk supply (Al-Abdi, Al Omran, Al-Aamri, Al Nasser, &
Al Omran, 2015). Thus, healthcare professionals should assess the issue of “insufficient breast
milk”, and emphasize the importance of frequent breastfeeding to maintain the “breast milk
supply”.
Despite the non-significant associations between the perception of “insufficient breast
milk” and the three selected psychosocial variables, studies from other developed countries
identified a significant negative relationship between the perception of insufficient milk and
breastfeeding self-efficacy (McCarter-Spaulding & Kearney, 2001; Otsuka et al., 2008). In this
study, the variable of “insufficient breast milk” was one of the reasons of breastfeeding cessation
or formula supplementation, and it was accessible only to mothers who stopped breastfeeding or
partially breastfed their infants. The absence of the significant associations among the reported

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“insufficient breast milk” and other selected demographic and psychosocial variables may have
resulted from the homogeneity of participants who answered this question.
The practice of distributing free formula after childbirth in some hospitals may have a
major influence on breastfeeding practices. Two-thirds of mothers in this study did receive free
formula for their infants from a hospital, clinic, or other agency. The practice of providing
formula for mothers, who are capable of breastfeeding their infants, could encourage the use of
bottle feeding as a recommended and complete infant nutrition. In this study, a group of mothers
(n = 16, 14%) reported that the introduction of formula in the first day of life was a reason for
formula supplementation or early breastfeeding cessation. Similarly, approximately one-third of
women in Jeddah reported that the availability and the use of free formula after childbirth was a
barrier to breastfeeding (Mosalli et al., 2012). In addition, a qualitative study with six focus
groups (N =43) of American women reported that the availability of the free formula negatively
influenced their decision to breastfeed (Dunn, Kalich, Henning, & Fedrizzi, 2015). Therefore,
these findings necessitate the critical need for avoiding the provision of free milk formulas for
mothers after childbirth, and advocating for policy change.
The current practice in the majority of hospitals in the KSA is to care for healthy fullterm infants in the newborn nurseries and routinely supplement with formula (Albokhary &
James, 2014). This practice impedes the ability of mothers to practice breastfeeding on demand
and build their breastfeeding confidence. In fact, research shows that almost all mothers are
physiologically capable and ready to breastfeed their infants after childbirth (Wambach &
Riordan, 2014). Therefore, it is important to promote breastfeeding after childbirth through
rooming-in practice, and provide support and resources that enable breastfeeding Saudi Arabian
mothers to continue breastfeeding on demand.

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Demographic characteristics associated with breastfeeding practices. A nonsignificant association emerged between maternal age and the categories of breastfeeding
practice. In contrast, the vast majority of studies conducted in the KSA revealed that older
maternal age significantly aligned with longer duration of breastfeeding compared to younger
mothers (Al-Jassir et al., 2006; Al-Madani et al., 2010; Alzaheb, 2016a; Amin et al., 2011). In
addition, multiparous mothers were more likely to breastfeed for longer duration that
primiparous mothers (Al Juaid et al., 2014). The homogeneity of the study sample, which
included only primiparous mothers aged from 20-38 years, may explain the absence of
significant associations between maternal age and the categories of breastfeeding practice in the
current study.
The current study revealed a non-significant association between marital status and the
categories of breastfeeding practice. Almost all mothers in the present study were married, which
contributes to the non-significant findings between marital status and breastfeeding practice.
There is a lack of literature about the association between marital status and breastfeeding
practice in the KSA. However, a national survey revealed that married Saudi Arabian mothers
were more likely to breastfeed their infants than widowed or divorced mothers (Murshid, 2006).
Previous studies focused on examining the association between the type of childbirth and
breastfeeding initiation. Findings from previous studies revealed a negative association between
breastfeeding initiation and cesarean section compared to vaginal delivery among Saudi Arabian
mothers (Albokhary & James, 2014; Alzaheb, 2016b). In the current study, the type of childbirth
was not significantly associated with the categories of breastfeeding practice. This finding is
consistent with another study in the KSA that examined associations between type of childbirth
and breastfeeding practice at six months postpartum, and found non-significant associations

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between such variables (Al-Hreashy et al., 2008). The majority of mothers in this study (n = 133,
83.1%) had a vaginal delivery. The lack of variability in the type of childbirth in this sample may
further explain the non-significant finding between the type of childbirth and breastfeeding
practice.
The current study revealed a significant association between employment status and
categories of breastfeeding practice. Furthermore, non-working mothers had significantly lower
levels of perceived stress and higher level of breastfeeding self-efficacy than working mothers.
The majority of first-time mothers who exclusively breastfed throughout the first six months
were not working outside the home; in contrast, the vast majority of mothers who ceased
breastfeeding prior to the recommended six months had returned to full time work. Consistently,
other studies in the KSA also found that employed mothers tended to breastfeed less frequently
and for a shorter duration than mothers who were not employed (Alzaheb, 2016a; Amin et al.,
2011; El-Gilany et al., 2011). Thus, working Saudi Arabian mothers develop lower breastfeeding
self-efficacy with infrequent breastfeeding than non-working mothers. Al-Binali (2012) found
that work-related problems were the main reasons for stopping breastfeeding among 384
employed school teachers. Work-related responsibilities and problems could also explain the
significant association between perceived stress and working status among first-time Saudi
Arabian mothers. Although employed Saudi mothers are a minority in the KSA (10.1%; General
Authority for Statistics, 2016), this finding suggests a critical need to support employed mothers
with resources needed for continuing breastfeeding.
The current available policy allows for a total of one hour break time each day for
breastfeeding mother to breastfeed her infant for the first year after birth. However, this policy is
not valid for part-time mothers, and it has not been applied in all of workplaces. Therefore,

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policymakers and employers should work to formulate and initiate breastfeeding policies that
support breastfeeding in workplaces.
Maternal employment status was also positively associated with household income. Thus,
a significant association emerged between household income and categories of breastfeeding
practice. More than half of the mothers who exclusively breastfed their infants throughout the
first six months had low to medium household incomes, whereas the majority of those who
stopped breastfeeding had medium to high household incomes. These findings may indicate that
formula feeding is more affordable and desirable for higher-income Saudi Arabian mothers, and
emphasizes the need for including high-income families in breastfeeding promotion programs.
Consistent with these findings, other studies revealed that exclusive breastfeeding was more
prevalent among low-income Saudi Arabian mothers (al-Ayed & Qureshi, 1998; Alshebly &
Sobaih, 2016; Amin et al., 2011). In contrast, according to the CDC (2012), low-income mothers
in the USA had significantly lower rates of breastfeeding compared with high-income mothers.
These variations in the associations between household incomes and breastfeeding practices can
be explained in part by the resources available for low-income mothers. Low-income mothers in
the USA can receive milk formula through community nutrition programs; however, no such
programs are available for low-income mothers in the KSA.
There was a significant negative association between maternal education levels and
breastfeeding practice. The greater proportion of mothers who exclusively or partially breastfed
had a high school diploma, whereas more than half of mothers who discontinued breastfeeding
had at least a bachelor’s degree. These findings indicated that well-educated first-time Saudi
Arabian mothers tend to discontinue breastfeeding and supplement with formula. The vast
majority of studies conducted in the KSA consistently revealed negative associations between

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maternal education levels and breastfeeding exclusivity and duration (Al-Jassir et al., 2004;
Amin et al., 2011; El-Gilany et al., 2011; Mosalli et al., 2012; Murshid, 2006). In contrast,
studies from Western countries revealed that mothers with a higher educational level were more
likely to breastfeed than mothers with a lower educational level (Dennis, 2006; McQueen et al.,
2015). This inconsistency may be attributed to the influence of social norms. For instance, Saudi
Arabian mothers may avoid breastfeeding and introduce bottle feeding as a sign of
modernization (WBTi, 2012). This emphasizes the need for tailored breastfeeding promotion
programs for well-educated first-time Saudi Arabian mothers.
Maternal educational level was also significantly associated with the maternal
employment status. Thus, another possible reason for the significant negative associations
between breastfeeding practice and maternal educational levels is that mothers with a higher
educational level tend to be employed in a workplace that may not have a supportive
breastfeeding policy, which could be a reason for early breastfeeding cessation. In contrast, less
educated mothers are more likely to be housewives and not work outside the house; thus,
practice longer breastfeeding than those who work outside the home.
Study Strengths
As mentioned previously, this was the first study to address the associations among
breastfeeding practice and the psychosocial factors of perceived stress, social support, and
breastfeeding self-efficacy among first-time Saudi Arabian mothers. Thus, the findings
highlighted the pattern of breastfeeding practice in the KSA in relation to maternal psychosocial
factors. Moreover, the two scales of Social Provision and Breastfeeding Self-Efficacy were
translated and validated into Arabic, and the pertinent excellent psychometric properties were
reported in this study. The information on the Arabic versions of the scales will be helpful for
future research among Arab population.
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The study’s conceptual framework filled two major gaps in the applications of the
conceptual framework in the literature. First, the study’s conceptual framework assessed the
selected psychosocial factors as primary exposures; hence, it addressed the lack of literature
concerning associations among study variables with breastfeeding practice as an outcome.
Second, while existing literature focused on breastfeeding practice during the early postpartum
period, the propositions in the conceptual framework were examined at six to 12 months
postpartum with a sample of first-time mothers who initiated breastfeeding.
The rigor of the data collection procedures adds strength to the study findings. The data
were collected from four geographically-different PCCs, which allowed the study sample to be
more representative. The data collection procedure was standardized among the PCCs based on
the data collection protocol. Moreover, there were almost no missing data in the surveys due to
the use of electronic reminder strategy in Qualtrics.
Given that the study hypotheses were supported, the conceptual framework provided
insight and foundation for future research. This study provided important information on the
strengths and directions of the associations among the selected psychosocial variables and
breastfeeding practice. This information along with the study’s conceptual framework can be
used in future prospective research to provide in-depth examination of the associations among
the study variables, and draw inferences about causality to determine which factors influence the
other.
Very few studies have controlled for the past breastfeeding experience in the examination
of the association between breastfeeding self-efficacy and breastfeeding practice with controlling
for past experience or parity. Past breastfeeding experience can substantially influence
breastfeeding self-efficacy. It has been shown that multiparous mothers had a higher mean score

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of breastfeeding self-efficacy than first-time mothers (Blyth et al., 2002; McCarter-Spaulding &
Dennis, 2010). However, the sample in this study was limited to first-time mothers who initiated
breastfeeding, which added strength to the findings.
Study Limitations
The following limitations should be considered when interpreting the study’s findings.
This was a cross-sectional, correlational study that examined the associations among the study
variables. Therefore, causal inference cannot be assumed, based on the study findings.
Additional limitations in this study relate to limited variability in the study sample. Participants
in the current study comprised a non-random convenience sample confined to the city of Jeddah,
making it difficult to compare proportions of breastfeeding duration and exclusivity with
findings from national surveys. In addition, the sample was limited to first-time mothers of Saudi
Arabian nationality who initiated breastfeeding after childbirth. These sample characteristics
limited the generalizability of the findings to all populations in the KSA. Thus, the proportions of
exclusive and partial breastfeeding in the current study did not necessarily represent the
exclusive and partial breastfeeding rates in the KSA.
In this study, information on the major study variables and breastfeeding practices were
obtained based on a retrospective self-report surveys at six to twelve months postpartum; thus,
recall bias may exist. Recall bias is a major threat to the reliability of findings in studies with
cross-sectional correlational designs. However, several studies revealed that the collected
information regarding the practice of breastfeeding is valid and reliable particularly if collected
within one to 20 years after childbirth. Launer and colleagues (1992) conducted a retrospective
study with Bedouin Arab women (N = 318) to examine the accuracy of maternal recall of infant
feeding events and the time of breastfeeding cessation. The researchers of this retrospective
study interviewed women at 12 and 18 months after birth to inquire about their breastfeeding
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practices and compared the responses to the standard data collected at six months postpartum
(Launer et al., 1992). Launer and colleagues (1992) confirmed that the retrospective maternal
recall on infant feeding was accurate and could be used with confidence. Likewise, two
additional studies supported these findings and revealed that breastfeeding duration was
accurately recalled at three years (Li, Scanlon, & Serdula, 2005), and up to 20 years after
mothers gave birth (Natland, Andersen, Nilsen, Forsmo, & Jacobsen, 2012). Overall,
breastfeeding practice is a unique experience for first-time mothers that can be easily recalled.
Finally, the scales used to measure the psychosocial factors of social support, perceived
stress, and breastfeeding self-efficacy have some limitations. The total of the three scale scores
were used in the analysis with no cut-off points; thus, it was not possible to distinguish between
mothers at different levels of social support, stress, or breastfeeding self-efficacy. Furthermore,
the three scales were used to measure the pertinent variables retrospectively at six to 12 months
postpartum in relation to breastfeeding practice, making it hard to predict breastfeeding behavior
that might be discontinued before six months postpartum. To minimize the risk of recall bias, the
questionnaires included the phrase, “When you breastfeed/breastfed” multiple times in each
scale.
Implications and Recommendations for Future Nursing Research
Findings from this study lay the foundation for future nursing research by identifying the
theory-based factors that are associated with breastfeeding. Findings from this cross-sectional,
correlational study suggest that perceived stress, social support, and breastfeeding self-efficacy
are strongly associated with breastfeeding practices. The conceptual framework of this study can
be applied to guide future intervention studies. Future research can build on these findings by
developing effective breastfeeding interventions that incorporate these psychosocial variables.

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Breastfeeding-promoting programs should target mothers at high risk for early breastfeeding
cessation, especially well-educated and full-time employed Saudi Arabian mothers. Given that
grandmothers were identified as the most important source of support, researchers should include
them in the intervention program in the KSA.
It is recommended to replicate this study with a more diverse and larger sample. Future
studies may include national representative samples from various geographic regions in the
KSA. It would be also interesting to compare findings from this study to a study with a sample of
non-Saudi mothers who live in the KSA. In addition, researchers could expand this study by
including multiparous mothers.
The associations between selected psychosocial factors and breastfeeding practice are
complex. It has not been established whether maternal perceived stress and breastfeeding selfefficacy are a response or a result of breastfeeding practice. Understanding such associations is
important to refine the current theoretical frameworks. In addition, breastfeeding self-efficacy
progresses over time as a woman engages in breastfeeding her infant. Therefore, more
longitudinal studies that assess the pattern of breastfeeding self-efficacy over the postpartum
period are warranted.
Moreover, randomized controlled trials are needed to assess the feasibility of
breastfeeding intervention based on the three identified psychosocial factors. Future research
should expand the study findings by including other theory-based factors that may influence
breastfeeding practice such as breastfeeding knowledge and past experience. Although the role
of the father in supporting breastfeeding practice is important, it has not been fully understood
with Saudi Arabian population. Thus, future research may engage fathers to assess the influence
of paternal support during breastfeeding practice.

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Implications and Recommendations for Nursing Practice
Findings from this study generate several implications and recommendations for nursing
practice. In this study, mothers with lower perceived stress, higher social support, and higher
breastfeeding self-efficacy were more likely to continue breastfeeding until at least six months
postpartum. Breastfeeding has well-documented health benefits for infants and mothers (Victora
et al., 2016); however, mothers often face psychosocial issues that could prevent them from
breastfeeding. This section provides a discussion of the nursing implications based on the major
study findings that can be used by nurses, physicians, lactation consultants, and other healthcare
professionals.
Mothers in the postpartum period, particularly first-time mothers, are vulnerable to
stressors. Uncontrollable stress during the postpartum period can significantly negatively impact
breastfeeding practice (Doulouger et al., 2013), and it could lead to postpartum depression
(Brown et al., 2016). Therefore, it is important for healthcare providers, including nurses, to
assess perceived maternal stress after childbirth by using objective or subjective measures, such
as the Perceived Stress Scale (Cohen et al., 1983). Early intervention and management of stress
during the early postpartum period are necessary to improve breastfeeding practice in the KSA.
Given the significant positive association in this study between social support and
breastfeeding practice, the assessment for social support among breastfeeding mothers is an
important strategy to incorporate into postnatal care in the KSA. Supporting mothers’
breastfeeding practice plays an important role in improving the long-term health outcomes of
mothers and infants. The nurse or lactation consultant can arrange group meetings or peersupport programs where new mothers can meet and share their concerns about breastfeeding
with experienced mothers. In addition, the majority of working mothers in this sample
discontinued breastfeeding prior to the recommended six months. Therefore, multi-disciplinary
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efforts should be taken by employers to support breastfeeding mothers by creating programs in
the workplace to promote breastfeeding duration and exclusivity in the KSA.
Clinicians should work to empower Saudi Arabian mothers with reliable evidence-based
breastfeeding resources to promote the practice of breastfeeding. Furthermore, the role of nurses
is vital in facilitating and coordinating support for family members after childbirth. Nurses can
also offer different types of support in hospital and clinical settings. For example, nurses can
provide emotional support through praising, encouraging, and reassuring breastfeeding mothers
(McFadden et al., 2017). Moreover, nurses can provide educational support by providing
information on breastfeeding practice, storage, and advantages.
Findings from this study identified breastfeeding-self-efficacy as the most significant
correlate in breastfeeding practice. The confidence in the maintenance of exclusive breastfeeding
can significantly impact the duration of exclusive breastfeeding (de Jager et al., 2015). However,
the maintenance of breast milk supply depends on the frequency of breastfeeding not on the
duration (Neville & Morton, 2001). Therefore, it is important to encourage the mothers to
breastfeed their infants more often after childbirth to maintain their breast milk supply.
Furthermore, information on breast milk storage should be provided. Clinicians should reinforce
the practice of breastfeeding through re-assuring breastfeeding mothers that their infants
maintain proper weight gains.
Health professionals need to assess breastfeeding self-efficacy after childbirth to identify
mothers at high risk for breastfeeding cessation in the KSA. The short form of the Breastfeeding
Self-Efficacy Scale is applicable to use in the clinical practices (Dennis, 2003), and it can be
used as a diagnostic tool for mothers with low confidence. Moreover, items with low scores can
be used to identify the areas of weakness as well as guide interventions (Dennis & Faux, 1999).

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Healthcare professionals need to be aware of self-efficacy-enhancing strategies that can be used
in clinical settings to improve maternal confidence in breastfeeding practice, such as providing
workbooks, performing self-efficacy-enhancing meetings, helping mothers to ensure good infant
latching, and providing positive reinforcement.
Nurses need to address the complaints of insufficient breast milk among breastfeeding
Saudi Arabian mothers early to avoid breastfeeding discontinuation. Furthermore, it is important
to identify whether the perception of insufficient breast milk relates to a psychological or a
physiological issue (Lewis, 2009). It is also important for nurses to objectively assess insufficient
breast milk to refute or confirm this issue. Nurses can use objective measures to measure the
amount of breast milk, such as the breastfeeding meter.
Implications and Recommendations for Policy
Information gained from this study can be used by healthcare professionals to adopt the
WHO breastfeeding recommendations. All previously mentioned implications need to be
reinforced through policies and procedures in the clinical settings. Policies and strategies that
support and promote breastfeeding should be developed with a multidisciplinary team, including
social workers, physicians, nurses, and lactation consultants. The psychosocial factors are
important components to be considered in developing breastfeeding supporting policy. The
findings from this study can be integrated into practice by mandating the assessment of selected
psychosocial factors during the prenatal and postnatal care.
Hospital practices during early mother–infant interactions could have a significant
negative influence on a mother’s breastfeeding confidence. For example, providing supplemental
infant formula for mothers who are capable of practicing breastfeeding often discourages the
practice of breastfeeding and negatively impacts early infant-mother attachment. In addition, the
practice of separating the infants from their mothers in different rooms after birth is common in
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the KSA (Albokhary & James, 2014), which may contribute to the low rate of breastfeeding. The
practice of rooming-in enables mothers to practice breastfeeding on demand, receive support
from the clinicians on overcoming breastfeeding issues, and build their confidence before
discharge from the hospital. Thus, a policy that supports the practice of rooming-in where infant
and mothers remain together in the same room after birth is warranted to improve breastfeeding
practice in the KSA.
Every hospital in the KSA needs to activate the Baby-Friendly Hospital Initiative (BFHI).
The BFHI includes Ten Steps to Successful Breastfeeding that aim to improve breastfeeding
initiation, exclusivity and duration. Moreover, healthcare settings in the KSA should provide
anticipatory guidance for all mothers during prenatal visits to promote breastfeeding, during
postnatal visits to reinforce maternal confidence in breastfeeding practice, and during regular
infant well-visits to ensure that infants are receiving enough nutrition through breastfeeding.
Conclusion
This study’s findings add to the body of knowledge about the factors associated with
breastfeeding exclusivity and duration among first-time Saudi Arabian mothers who initiated
breastfeeding and who had infants six to 12 months of age. This study was guided by the
conceptual framework of breastfeeding self-efficacy (Dennis, 1999). The associations among
selected psychosocial variables and breastfeeding practice aligned with the study’s theoretical
framework. Moreover, the findings were congruent with previous research relevant to the
associations between breastfeeding practice and maternal stress (Dimitraki et al., 2016;
Doulouger et al., 2013; Zhu et al., 2013), social support (Britton et al., 2007; Hannula et al.,
2008; Jarlenski et al., 2014; McFadden et al., 2017), and breastfeeding self-efficacy (Babakazo et
al., 2015; Bailey et al., 2008; de Jager et al., 2015; Loke & Chan, 2013; Semenic et al., 2008).

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The correlations among selected psychosocial variables were significant, indicating that
these variables interplay and overlap in the underlying constructs. However, the tests of the
overall statistical models in this study revealed that the breastfeeding self-efficacy is the most
significant variable associated with breastfeeding practice. Secondary findings revealed that
breastfeeding practices were significantly more prevalent among mothers who were not working
outside the home, with a low-income and low level of education. These findings can be used as a
foundation for further inquiry that aims to improve breastfeeding practice within the KSA
population.
Despite mentioned limitations, this study provides numerous implications to nursing
research, practice, and policy. Clinicians can incorporate the assessment of psychosocial factors
into practice during prenatal and postnatal care. Hence, clinicians can identify mothers at risk for
early cessation of breastfeeding based on their psychosocial characteristics. Moreover, healthcare
providers can intervene early to encourage and support breastfeeding by addressing stressful
events, creating support groups, providing anticipatory guidance, and reinforcing maternal
confidence. It is imperative to disseminate study findings to the Ministry of Health in the KSA to
facilitate the collaboration of multidisciplinary teams. Future researchers can use the findings
from this study to identify target populations, and to develop effective breastfeeding
interventions.

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APPENDICES

130

APPENDIX A: Permission to use the Figure of Self-efficacy Framework from Published
Article.

131

APPENDIX B: Institutional Review Board (IRB) Approval from Michigan State University

132

APPENDIX C: Institutional Review Board (IRB) Approval from the Ministry of Health in
Saudi Arabia

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APPENDIX D: Protocol and Screening Questionnaire for Recruitment and Enrollment of
Participants
Title of the study: Factors Associated with Breastfeeding Practice among Saudi Arabian
Mothers.
Direction: The goal of this script is to provide data collectors with language to assist in
recruiting mothers. Please follow the following steps as you attempt to recruit and enroll mothers
with infants between 6 and 12 months of age.
Step1: Recruit potential participants by approaching them and saying: Hi, (Mom). I would like to
talk with you about participating in a research project with a doctoral student from Michigan
State University, USA. Participating in this research will help researchers improve the practice
of breastfeeding in Saudi Arabia. Participation is easy. If you choose to participate, you would
complete either an online or paper survey. After completion of the questionnaire, you will
receive a cash incentive in amount of (40 S.R.).Are you interested?
If the participant answers: Yes: great, continue to step 2
If the participant answers: No: Stop and thank them.
Step2: Now I need to ask you a few questions before we go any further.
Assess eligibility of potential participant to participate in the study by asking the following
questions. If the participant answers” NO” to any of the statements below, THANK THEM &
STOP. If the participant answered “YES” to ALL of the above question, she meets the eligibility
criteria. Continue to Step 3.

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SCREENING QUESTIONS

YES

NO

Q1: Do you read and speak Arabic?
Q2: Are you the mother of your baby?
Q3: Is this your first child?
Q4: Are you 18 years old or over?
Q5: Is your baby’s age between 6 to 12 months old?
Q6: Was your infant born full term (delivered any time after 37 weeks)?
Q7: Have you ever breastfed at any point of time after birth?
Q8: Is your infant healthy with no major feeding problems or medical
diagnoses that may interfere with breastfeeding?1
Additional question for tracking purpose:
Throughout the first six months after birth, how you describe your breastfeeding practice:
o Only breastfeeding (breastmilk) with no additional supplement (e.g., water, formula,
juices) up until your infant was 6 months old.
o Continued breastfeeding up until your infant 6 months old, but also sometimes fed
infant formula
o Breastfed, but stopped prior to 6 months.
1

If you are unsure whether a feeding problem counts as “major” please contact Salmah Alghamdi at
(0500088372 or algham25@msu.edu).

135

Step 3: Have participant sign the “Consent Form”. The participant is now enrolled. Provide the
participant with a copy of the consent form.
Step 4: Have participant complete the paper questionnaire OR online questionnaire on Qualtrics
using the iPad. If the participant asks a question for clarification of a word in the survey, you
may answer.
Step 5: Once the questionnaire is completed, give the participants a Thank You card with the
total cash incentive of (40 S.R.).
Step 6: Have participant sign the receipt for receiving the cash incentive.
Step 7: Staple or paperclip the consent form, incentive receipt and survey (if taken hardcopy)
and place in the lock-drop box.

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APPENDIX E: English and Arabic Consent Form
Title of Research Project: Factors Associated with Breastfeeding Practice among Saudi
Arabian Mothers.
Name of the Researchers: Salmah Alghamdi, PhD student, RN.
Purpose of the Research: The purpose of the study is to examine factors that may influence
breastfeeding practices among first time mothers. As part of this research, you will be asked to
read and complete the surveys. Your suggestions and feedback from this study may help
researchers improve the practice of breastfeeding in Jeddah, Saudi Arabia.
Description of Project: A sample of 160 mother-infant dyads will be recruited from
immunization clinics, well-child clinics, and physicians’ offices at four public primary care
centers (PCCs) in Jeddah, Saudi Arabia. Eligible mothers will be asked to fill out a survey about
their breastfeeding practice. It will take approximately 15–17 minutes for you to complete the
questionnaire.
You are able to participate in this study only if you have met all the following:
(1) Your age between18 years and 45 years
(2) You can read, understand and speak Arabic.
(3) You are first time mother
(4) Your infant was born full term (delivered any time after 37 weeks)
(5) Your infant’s age is 6 -12 months.
(6) You have started breastfeeding at any point in time after birth.
(7) You and your infant are healthy with no diagnosed medical conditions.
What you will do: You will be given the surveys that are related to breastfeeding and asked to
complete them.
Costs to Participants: There is no cost to participate in this study.
Compensation: After the completion of questionnaire, you will receive a total cash of 40 Saudi
Arabia Riyals SAR (about $10.67) .
Potential Benefits: You may not benefit directly as a result of taking part in this study,
however, your answers may contribute to the understanding of low rates of breastfeeding in
Saudi Arabia.

137

Potential Risks: We do not anticipate any risks to you for participating in this survey. No
medical tests or procedures will be performed. Participants could become stressed when trying to
recall information.
Privacy and Confidentiality: The mothers’ identities will not be evident in any reports,
presentations, or publications. Codes will be used to label study records rather than names. The
data collected for this study will be protected and kept confidential in a secure location and
password protected computer at MSU for a minimum of three years. Only the appointed
researchers and the MSU Human Research Protection Program (HRPP) will have access to the
data.
Participation is Voluntary: Participation in this survey study is entirely voluntary. Mothers can
stop any time with no penalty. You may choose not to answer some questions. Deciding to stop
participating in the study after saying yes will not affect any relationship or interfere with any
services, or benefits you or your infant are currently receiving.
Conflicts of Interest: No person with this study has any financial interest or other opportunity
for personal benefit related to the conduct of this study.
Contact Information: If you have any concerns or questions about this study, such as scientific
issues, how to do any part of it please contact the researcher Salmah Alghamdi, Jeddah Saudi
Arabia (0500088372), MSU College of Nursing, Bott Building (313-529-1562); email:
(algham25@msu.edu) at any time.
If you have questions or concerns about your roles and rights as a research participant, would
like to obtain information or offer input, or would like to register a complaint about this study,
you may contact, anonymously if you wish, the Michigan State University’s Human Research
Protection Program at 517-355-2180, Fax 517-432-4503, or e-mail irb@msu.edu or regular mail
at 408 West Circle Drive, Olds Hall Room 207, MSU, East Lansing, MI 48824.
DOCUMENTATION OF INFORMED CONSENT:
Your signature below means that you voluntarily agree to participate in this research study.
Signature

______________

Date ________________________

You will be given a copy of this form to keep

138

‫‪Arabic consent form‬‬

‫ﺍﺳﺘﻤﺎﺭﺓ ﻣﻮﺍﻓﻘﺔ ﻣﺸﺎﺭﻙ‬
‫ﻋﻧﻭﺍﻥ ﻣﺷﺭﻭﺡ ﺍﻟﺑﺣﺙ ﺍﻟﻌﻭﺍﻣﻝ ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺎﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﺑﻳﻥ ﺍﻻﻣﻬﺎﺕ ﺍﻟﺳﻌﻭﺩﻳﺎﺕ‬
‫ﺍﺳﻡ ﺍﻟﺑﺎﺣﺛﺔ‪ :‬ﺳﺎﻟﻣﺔ ﺍﻟﻐﺎﻣﺩﻱ‪ ،‬ﻁﺎﻟﺑﺔ ﺩﻛﺗﻭﺭﺍﻩ‪ ،‬ﻗﺳﻡ ﺗﻣﺭﻳﺽ ‪ ,‬ﺗﺧﺻﺹ ﺃﻁﻔﺎﻝ‬
‫ﺍﻟﻐﺭﺽ ﻣﻥ ﺍﻟﺑﺣﺙ‪ :‬ﺍﻟﻐﺭﺽ ﻣﻥ ﻫﺫﻩ ﺍﻟﺑﺣﺙ ﻫﻭ ﺩﺭﺍﺳﺔ ﺍﻟﻌﻼﻗﺔ ﺑﻳﻥ ﺍﻟﻌﻭﺍﻣﻝ ﺍﻻﺟﺗﻣﺎﻋﻳﺔ ﻭﺍﻟﻧﻔﺳﻳﻪ ﻣﺛﻝ ﺍﻟﺗﻭﺗﺭ ﻭﺍﻟﺩﻋﻡ ﺍﻻﺟﺗﻣﺎﻋﻲ‬
‫ﻭﺍﻟﻛﻔﺎءﺓ ﺍﻟﺫﺍﺗﻳﺔ ﻭﺑﻳﻥ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﻓﻲ ﻋﻳﻧﺔ ﻣﻥ ﺍﻻﻣﻬﺎﺕ ﺍﻟﺳﻌﻭﺩﻳﺎﺕ ﻟﻣﻥ ﻟﺩﻳﻬﻥ ﻣﻭﺍﻟﻳﺩ ﺭﺿﻊ ﻓﻲ ﻋﻣﺭ ﺳﺗﺔ ﺷﻬﻭﺭ‬
‫ﻭﺻﻑ ﺍﻟﻣﺷﺭﻭﻉ‪ :‬ﺟﻣﻊ ﻣﻌﻠﻭﻣﺎﺕ ﻋﻥ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﻭﺍﻟﻌﺎﻭﺍﻣﻝ ﺍﻟﺗﻲ ﻗﺩ ﺗﺅﺛﺭ ﻋﻠﻳﻬﺎ ﺑﻭﺍﺳﻁﺔ ﺍﺳﺗﺑﻳﺎﻥ ﻋﻥ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﻣﻥ ﻋﻳﻧﺔ‬
‫ﺗﺗﻛﻭﻥ ﻣﻥ ‪ 160‬ﻣﻥ ﺍﻻﻣﻬﺎﺕ ﺍﻟﻣﺭﺍﺟﻌﻳﻥ ﻟﻌﻳﺎﺩﺓ ﺍﻻﻁﻔﺎﻝ ﺍﻻﺻﺣﺎءﻣﻥ ﺍﻟﻣﺭﺍﻛﺯ ﺍﻟﺻﺣﻳﺔ ﻓﻲ ﺟﺩﺓ ﺍﻟﻣﻣﻠﻛﺔ ﺍﻟﻌﺭﺑﻳﺔ ﺍﻟﺳﻌﻭﺩﻳﺔ‪ .‬ﻣﻝء ﺍﻻﺳﺗﺑﻳﺎﻥ‬
‫ﺳﻭﻑ ﻳﺳﺗﻐﺭﻕ ﻣﻥ ‪ 17_15‬ﺩﻗﻳﻘﺔ ﺗﻘﺭﻳﺑﺎ‪.‬‬

‫ﺗﺳﺗﻁﻳﻊ ﺍﻻﻡ ﺍﻟﻣﺷﺎﺭﻛﺔ ﻓﻲ ﻫﺫﺍ ﺍﻟﻣﺷﺭﻭﻉ ﺍﻟﺑﺣﺛﻲ ﺇﺫﺍ‪:‬‬
‫)‪ (1‬ﺍﺫﺍﻻﻛﺎﻥ ﻋﻣﺭﻙ ﻣﺎﺑﻳﻥ ‪ 18‬ﺍﻟﻰ ‪45‬‬
‫)‪ (2‬ﺍﺫﺍﻛﻧﺗﻲ ﺗﺳﺗﻁﻳﻌﻳﻥ ﻗﺭﺍءﺓ ﺍﻟﻌﺭﺑﻳﺔ‪ ،‬ﻭﻓﻬﻣﻬﺎ‪ ،‬ﻭﺍﻟﺗﺣﺩﺙ ﺑﻬﺎ‪.‬‬
‫)‪ (3‬ﺍﺫﺍ ﻛﻧﺕ ﺍﻡ ﻟﻠﻣﺭﺓ ﺍﻻﻭﻟﻰ‬
‫)‪ (4‬ﺍﺫﺍ ﻛﺎﻥ ﺍﻟﺭﺿﻳﻊ ﻟﻳﺱ ﺧﺩﻳﺞ )ﺍﻛﻣﻝ ‪ 37‬ﺍﺳﺑﻭﻉ ﻋﻧﺩ ﺍﻟﻭﻻﺩﺓ(‬
‫)‪ (5‬ﻋﻣﺭ ﺍﻟﺭﺿﻳﻊ ﻣﺎﺑﻳﻥ ﺳﺗﺔ ﺍﺷﻬﺭ ﺍﻟﻰ ‪12‬ﺷﻬﺭﺍ‬
‫)‪ (6‬ﻗﺩ ﺳﺑﻖ ﻟﻼﻡ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‬
‫)‪ (7‬ﻟﻳﺱ ﻟﺩﻯ ﺍﻱ ﻣﻥ ﺍﻻﻡ ﺍﻭ ﺍﻟﺭﺿﻳﻊ ﺍﻱ ﻣﺷﺎﻛﻝ ﺻﺣﻳﺔ‬
‫ﻣﺎ ﻫﻭ ﺩﻭﺭﻙ ﻓﻲ ﻫﺫﻩ ﺍﻟﻣﺷﺭﻭﻉ ﺍﻟﺑﺣﺛﻲ ؟ ﺳﻧﻘﻭﻡ ﺑﺈﻋﻁﺎءﻙ ﺍﻻﺳﺗﺑﻳﺎﻥ ﻭﺳﻳﻁﻠﺏ ﻣﻧﻙ ﻣﻝء ﻭﺗﻛﻣﻠﺔ ﻫﺫﻩ ﺍﻻﺳﺗﺑﻳﺎﻧﺎﺕ‪.‬‬
‫ﺍﻟﺗﻛﺎﻟﻳﻑ ﺍﻟﺗﻲ ﺗﺗﻛﺑﺩﻫﺎ ﺍﻟﻣﺷﺎﺭﻛﺎﺕ‪ :‬ﻻ ﺗﺗﻛﺑﺩ ﺍﻟﻣﺷﺎﺭﻛﺔ ﺃﻱ ﺗﻛﻠﻔﺔ ﻟﻠﻣﺷﺎﺭﻛﺔ ﻓﻲ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺳﺔ‪.‬‬
‫ﺍﻟﻣﻛﺎﻓﺄﺓ‪ :‬ﺳﻭﻑ ﺗﺣﺻﻠﻳﻥ ﻋﻠﻰ ‪ 40‬﷼ ﺳﻌﻭﺩﻱ ﺑﻌﺩ ﺍﻻﻧﺗﻬﺎء ﻣﻥ ﺗﻌﺑﺋﺔ ﺍﻻﺳﺗﺑﻳﺎﻥ‪.‬‬
‫ﺍﻟﻣﻧﺎﻓﻊ ﺍﻟﻣﺣﺗﻣﻠﺔ‪ :‬ﻗﺩ ﻻ ﺗﺣﺻﻝ ﺍﻻﻡ ﺍﻧﺗﻔﺎﻋﺎ ﻣﺑﺎﺷﺭﺍ ﻧﺗﻳﺟﺔ ﻟﻣﺷﺎﺭﻛﺗﻬﺎ ﻓﻲ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺳﺔ‪ ،‬ﻭﻟﻛﻥ ﺍﺟﻭﺑﺗﻬﺎ ﻗﺩ ﺗﻔﻳﺩ ﺍﻻﺧﺭﻳﻥ‬
‫ﻭﺗﺳﺎﻋﺩﻫﻡ ﻓﻲ ﺗﺻﻣﻳﻡ ﺍﻟﺩﺭﺍﺳﺎﺕ ﺍﻟﻣﺳﺗﻘﺑﻠﻳﺔ ﻓﻲ ﺍﻟﻣﻣﻠﻛﺔ ﺍﻟﻌﺭﺑﻳﺔ ﺍﻟﺳﻌﻭﺩﻳﺔ‪.‬‬
‫ﺍﻟﻣﺧﺎﻁﺭ ﺍﻟﻣﺣﺗﻣﻠﺔ‪ :‬ﺗﻌﺩ ﺍﻟﻣﺧﺎﻁﺭ ﺍﻟﻣﺣﺗﻣﻠﺔ ﻣﻥ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺳﺔ ﻣﺧﺎﻁﺭ ﻁﻔﻳﻔﺔ‪ .‬ﻟﻥ ﻳﺗﻡ ﺍﺟﺭﺍء ﺃﻱ ﺍﺧﺗﺑﺎﺭﺍﺕ ﺍﻭ ﺇﺟﺭﺍءﺍﺕ ﻁﺑﻳﺔ‪.‬‬
‫ﺍﻟﺧﺻﻭﺻﻳﺔ ﻭﺍﻟﺳﺭﻳﺔ‪ :‬ﻟﻥ ﻳﺗﻡ ﺍﻅﻬﺎﺭ ﻫﻭﻳﺔ ﺍﻟﻣﺷﺎﺭﻛﺎﺕ ﻋﻧﺩ ﻛﺗﺎﺑﺔ ﺃﻱ ﺗﻘﺎﺭﻳﺭ‪ ،‬ﺍﻭ ﻋﻣﻝ ﺃﻱ ﻋﺭﻭﺽ‪ ،‬ﺍﻭ ﻋﻧﺩ ﺍﻟﻧﺷﺭ‪ .‬ﺳﻳﺗﻡ‬
‫ﺍﺳﺗﺧﺩﺍﻡ ﺭﻣﻭﺯ ﻟﺗﺻﻧﻳﻑ ﺳﺟﻼﺕ ﺍﻟﺩﺭﺍﺳﺔ ﺑﺩﻻ ﻣﻥ ﺍﺳﺗﺧﺩﺍﻡ ﺍﻷﺳﻣﺎء‪ .‬ﺳﻳﺗﻡ ﺣﻔﻅ ﻭﺣﻣﺎﻳﺔ ﺍﻟﺑﻳﺎﻧﺎﺕ ﺍﻟﻣﺟﻣﻌﺔ ﻣﻥ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺳﺔ ﻓﻲ‬
‫ﺳﺭﻳﺔ ﺗﺎﻣﺔ ﻓﻲ ﻣﻛﺎﻥ ﺁﻣﻥ ﻓﻲ ﺟﺎﻣﻌﺔ ﻭﻻﻳﺔ ﻣﻳﺗﺷﻐﺎﻥ ﻟﻣﺩﺓ ﺛﻼﺛﺔ ﺳﻧﻭﺍﺕ ﻋﻠﻰ ﺍﻷﻗﻝ‪ .‬ﻳﺳﻣﺢ ﻓﻘﻁ ﻟﻠﺑﺎﺣﺛﻳﻥ ﺍﻟﻣﻌﻧﻳﻳﻥ ﻭﺑﺭﻧﺎﻣﺞ ﺣﻣﺎﻳﺔ‬
‫ﺍﻟﻣﻭﺍﺭﺩ ﺍﻟﺑﺷﺭﻳﺔ ﺑﺟﺎﻣﻌﺔ ﻭﻻﻳﺔ ﻣﻳﺗﺷﻐﺎﻥ ﺑﺎﻟﺩﺧﻭﻝ ﻋﻠﻰ ﻫﺫﻩ ﺍﻟﺑﻳﺎﻧﺎﺕ ﻭﺍﻻﻁﻼﻉ ﻋﻠﻳﻬﺎ‪.‬‬
‫ﺍﻟﻣﺷﺎﺭﻛﺔ ﺗﻁﻭﻋﻳﺔ‪ :‬ﺗﻌﺩ ﻣﺷﺎﺭﻛﺗﻙ ﻣﺷﺎﺭﻛﺔ ﺗﻁﻭﻋﻳﺔ ﺗﻣﺎﻣﺎ‪ .‬ﻓﻳﻣﻛﻧﻙ ﺍﻟﺗﻭﻗﻑ ﻓﻲ ﺃﻱ ﻭﻗﺕ ﺩﻭﻥ ﻭﻗﻭﻉ ﺃﻱ ﺟﺯﺍء ﻋﻠﻳﻬﺎ‪ .‬ﻭﻳﻣﻛﻧﻙ ﺍﻥ‬
‫ﺗﻣﺗﻧﻌﻳﻥ ﻋﻥ ﺇﺟﺎﺑﺔ ﺑﻌﺽ ﺍﻷﺳﺋﻠﺔ‪ .‬ﻟﻥ ﻳﺅﺛﺭ ﻗﺭﺍﺭﻙ ﻓﻲ ﺍﻟﺗﻭﻗﻑ ﻋﻥ ﺍﻟﻣﺷﺎﺭﻛﺔ ﺑﺎﻟﺩﺭﺍﺳﺔ ﺑﻌﺩ ﺍﻥ ﻭﺍﻓﻘﺗﻲ ﻋﻠﻰ ﺍﻟﻣﺷﺎﺭﻛﺔ ﺑﻬﺎ ﻋﻠﻰ‬
‫ﺃﻱ ﻣﻥ ﺍﻟﺧﺩﻣﺎﺕ ﺍﻟﺗﻲ ﺗﺣﺻﻠﻳﻥ ﻋﻠﻳﻬﺎ ﻣﻥ ﻫﺫﺍ ﺍﻟﻣﺭﻛﺯ‪ .‬ﻓﺭﻓﺽ ﺍﻟﻣﺷﺎﺭﻛﺔ ﻻ ﻳﺗﺿﻣﻥ ﺗﻭﻗﻳﻊ ﺃﻱ ﺇﺟﺭﺍءﺍﺕ ﺟﺯﺍﺋﻳﺔ‪.‬‬

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‫ﺍﺧﺗﻼﻑ ﺍﻟﻣﺻﺎﻟﺢ‪ :‬ﻻ ﻳﻁﻣﺢ ﺃﻱ ﺷﺧﺹ ﻳﻘﻭﻡ ﻋﻠﻰ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺳﺔ ﻓﻲ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﺃﻱ ﻣﺻﻠﺣﺔ ﻣﺎﻟﻳﺔ ﺍﻭ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﺃﻱ‬
‫ﻓﺭﺹ ﺃﺧﺭﻯ ﻟﻠﻣﺻﻠﺣﺔ ﺍﻟﺷﺧﺻﻳﺔ ﺗﺗﻌﻠﻖ ﺑﺈﺟﺭﺍء ﻫﺫﻩ ﺍﻟﺩﺭﺍﺳﺔ‪.‬‬
‫ﺍﻷﺳﺋﻠﺔ‪ :‬ﺇﺫﺍ ﻛﺎﻧﺕ ﻟﺩﻳﻙ ﺍﻳﺔ ﺍﺳﺗﻔﺳﺎﺭﺍﺕ ﺍﻭ ﻣﺧﺎﻭﻑ ﺗﺗﻌﻠﻖ ﺑﺩﻭﺭﻙ ﺍﻭ ﺣﻘﻭﻗﻙ ﻛﻣﺷﺎﺭﻙ ﺑﺣﺛﻲ‪ ،‬ﺍﻭ ﺗﺭﻳﺩﻳﻥ ﺍﻥ ﺗﺣﺻﻠﻲ ﻋﻠﻰ ﺍﻳﺔ‬
‫ﻣﻌﻠﻭﻣﺎﺕ ﺍﻭ ﺗﻘﺩﻡ ﻣﻌﻁﻳﺎﺕ‪ ،‬ﺍﻭ ﺗﺭﻏﺏ ﻓﻲ ﺗﺳﺟﻳﻝ ﺷﻛﻭﻯ ﻋﻥ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺳﺔ‪ ،‬ﻳﻣﻛﻧﻙ ﺍﻟﺗﻭﺍﺻﻝ‪ ،‬ﺩﻭﻥ ﺫﻛﺭ ﺃﺳﻣﺎء‪ ،‬ﻣﻊ ﺑﺭﻧﺎﻣﺞ‬
‫ﺣﻣﺎﻳﺔ ﺍﻟﻣﻭﺍﺭﺩ ﺍﻟﺑﺷﺭﻳﺔ ﺑﺟﺎﻣﻌﺔ ﻭﻻﻳﺔ ﻣﻳﺗﺷﻐﺎﻥ ﻋﻠﻰ ﺭﻗﻡ ﺍﻟﻬﺎﺗﻑ ﺍﻟﺗﺎﻟﻲ‪ ، 517-355-2180:‬ﺍﻭ ﻋﻠﻰ ﻓﺎﻛﺱ ﺭﻗﻡ‬
‫‪ ، 517-432-4503‬ﺍﻭ ﻋﻠﻰ ﺍﻟﺑﺭﻳﺩ ﺍﻹﻟﻛﺗﺭﻭﻧﻲ ‪ irb@msu.edu‬ﺃﻭ ﺍﻟﺑﺭﻳﺩ ﺍﻟﻌﺎﺩﻱ ﻋﻠﻰ ﺍﻟﻌﻧﻭﺍﻥ ﺍﻟﺗﺎﻟﻲ‪:‬‬
‫‪408 West Circle Drive, Olds Hall Room 207, MSU, East Lansing, MI 48824‬‬
‫ﺇﺫﺍ ﻛﺎﻧﺕ ﻟﺩﻳﻙ ﺃﻱ ﻣﺧﺎﻭﻑ ﺍﻭ ﺍﺳﺗﻔﺳﺎﺭﺍﺕ ﻋﻥ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺳﺔ ﺍﻟﺑﺣﺛﻳﺔ‪ ،‬ﺑﺭﺟﺎء ﺍﻟﺗﻭﺍﺻﻝ ﻣﻊ ﺍﻟﺑﺎﺣﺛﺔ ‪ :‬ﺳﺎﻟﻣﺔ ﺍﻟﻐﺎﻣﺩﻱ‪ ،‬ﺟﺩﺓ‪ ،‬ﺍﻟﻣﻣﻠﻛﺔ‬
‫ﺍﻟﻌﺭﺑﻳﺔ ﺍﻟﺳﻌﻭﺩﻳﺔ )‪ ،(0500088372‬ﺟﺎﻣﻌﺔ ﻭﻻﻳﺔ ﻣﻳﺗﺷﻐﺎﻥ‪ ،‬ﻛﻠﻳﺔ ﺍﻟﺗﻣﺭﻳﺽ‪ ،‬ﺑﻭﺗﺑﻠﻳﺩﺝ)‪(3135291562‬؛ ﺑﺭﻳﺩ ﺇﻟﻛﺗﺭﻭﻧﻲ‪:‬‬
‫‪ algham25@msu.edu‬ﻓﻲ ﺃﻱ ﻭﻗﺕ‪.‬‬

‫ﻗﺑﻭﻝ ﺍﻟﻣﺷﺎﺭﻛﺔ ﻓﻲ ﺍﻟﺑﺣﺙ‪:‬‬
‫ﻟﻘﺩ ﻗﻣﺕ ﺑﻘﺭﺍءﺓ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﻭﺍﺭﺩﺓ ﻓﻲ ﺍﺳﺗﻣﺎﺭﺓ ﺍﻟﻣﻭﺍﻓﻘﺔ ﻋﻠﻰ ﺍﻟﻣﺷﺎﺭﻛﺔ ﺃﻣﺎﻣﻲ‪ .‬ﻭﻳﺩﻝ ﺗﻭﻗﻳﻌﻲ ﺍﺩﻧﺎﻩ ﻋﻠﻰ ﺭﻏﺑﺗﻲ ﻓﻲ ﺍﻟﻣﺷﺎﺭﻛﺔ‬
‫ﻓﻲ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺳﺔ ﺍﻟﺑﺣﺛﻳﺔ‪.‬‬
‫ﺍﻟﺗﻭﻗﻳﻊ ‪_________________ :‬‬
‫ﺍﻟﺗﺎﺭﻳﺦ‪_________________:‬‬
‫ﺳﻭﻑ ﻳﺗﻡ ﺍﻋﻁﺎءﻙ ﻧﺳﺧﺔ ﻣﻥ ﻫﺫﺍ ﺍﺍﻹﻗﺭﺍﺭ‬

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APPENDIX F: English And Arabic Version of Self- Administered Survey

Dear Mothers,
Welcome to the Breastfeeding Study! We appreciate you taking time to help us make the study the best it can be.
This survey will ask questions about your ideas, thoughts, and activities related to you and your baby. Try to answer
each question as best you can. There is no right or wrong answer.
Some of the questions might sound similar, but do be sure to answer each one so that we have complete information
from you.
All of your answers will be kept completely private and only my research team will have access to this information.

Demographic Questionnaire
1. Site:
•
•
•
•

1
2
3
4

2.Your Age (years) _______

3. Infant’s age
•
•
•
•
•
•
•

6 months
7 months
8 months
9 months
10 months
11 months
12 months

4. Sex of Infant: (please circle only one response)
• Male
• Female
5. Relationship Status: (please circle only one response)
• Married
• Divorced
• Widowed

141

6. Your employment status (outside of the home): (please circle only one response)
• Working full-time (at least 35 hours per week)
• Working part-time
• Not Working
7. How many people live in your household including yourself? ________
8. Do you live with any extended family member (e.g., mother, mother-in-law, grandmother)?
• Yes
• No
9. If you answered “yes” to the previous question, does she/he support and encourage you to breastfeed?
• Yes
• No
10. What best describes your household monthly income:
• SR3000 or Less
• SR 4000– SR 6000
• SR 7000– SR 12000
• SR13000 or More
• Don’t know
• Choose not to answer
11. Your highest educational level:
• Less than high school
• High school
• Bachelor’s degree
• Master degree or higher
12. How did you give birth?
• Vaginal delivery
• Caesarean section
13. Did your mother ever breastfeed?
•
•
•

Yes
NO
Don’t know

If answered “NO” or “Don’t know” skip question #14 and continue the survey
14. Did your mother breastfeed you throughout the first six months of your life?
•
•
•
•

Yes
No
Don’t know

142

Not at all confident

Not very confident

Sometimes confident

Confident

Very confident

Breastfeeding Self-Efficacy Scale–Short Form

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

6- I can/could always manage to breastfeed even if my
baby is crying

1

2

3

4

5

7- I can/could always keep wanting to breastfeed

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

For each of the following statements, please mark your
answer by circling the number that is closest to how
confident you feel/felt when you are/were breastfeeding.
There is no right or wrong answer.
WHEN YOU BREASTFEED/BREASTFED:
1- I can/could always determine that my baby is/was
getting enough milk
2- I can/could always successfully cope with
breastfeeding like I have with other challenging tasks
3- I can/could always breastfeed my baby without using
formula as a supplement
4- I can/could always ensure that my baby is properly
latched on for the entire feeding
5- I can/could always manage the breastfeeding situation
to my satisfaction
WHEN YOU BREASTFEED/BREASTFED:

8- I can/could always comfortably breastfeed with my
family members present
9- I can/could always be satisfied with my breastfeeding
experience
10- I can/could always deal with the fact that
breastfeeding can be time consuming
11- I can/could always finish feeding my baby on one
breast before switching to the other breast
12- I can/could always continue to breastfeed my baby for
every feeding
13- I can/could always manage to keep up with my baby’s
breastfeeding demands
14- I can/could always tell when my baby is finished
breastfeeding
©
Dr. Cindy-Lee Dennis

143

Strongly Agree

1. There are/were people I can depend on to help me if I really need it.

1

2

3

4

2. I feel/felt that I do not have close personal relationships with other
people.

1

2

3

4

3. There is/was no one I can turn to for guidance in times of stress.

1

2

3

4

4. There are/were people who enjoy the same social activities that I do.

1

2

3

4

5. I do/did not think other people respect my skills and abilities.

1

2

3

4

6. If something went wrong, no one would come to my assistance.

1

2

3

4

7. I have/had close relationships that provide me with a sense of emotional
security and well-being.

1

2

3

4

8. I have/had relationships where my competence and skills are recognized.

1

2

3

4

9. There is/was no one who shares my interests and concerns.

1

2

3

4

10. There is/was a trustworthy person I could turn to for advice if I were
having problems.

1

2

3

4

WHEN YOU BREASTFEED/BREASTFED:

Disagree

Agree

In answering the next set of questions, think about your relationship
with friends, family members, coworkers, and others when you
are/were breastfeeding. Please circle the number that is closest to what
extent you agree with each statement. There is no right or wrong
answer.

Strongly Disagree

Social Provisions Scale–Short Version

WHEN YOU BREASTFEED/BREASTFED:

Copyright by Daniel Russell and Carolyn Cutrona, 1984

144

Perceived Stress Scale

Never

Almost Never

Sometimes

Fairly Often

Very Often

The questions in this scale ask about your feelings and thoughts
during breastfeeding. In each case, you will be asked to indicate by
circling how often you felt or thought a certain way. There is no
right or wrong answer.

1. How often have/had you been upset because of something that
happened unexpectedly?

0

1

2

3

4

2. How often have/had you felt that you were unable to control the
important things in your life?

0

1

2

3

4

3. How often have/had you felt nervous and “stressed”?

0
0

1
1

2
2

3
3

4
4

0

1

2

3

4

6. How often have/had you found that you could not cope with all the
things that you had to do?

0

1

2

3

4

7. How often have/had you been able to control irritations in your life?

0

1

2

3

4

8. How often have /had you felt that you were on top of things?

0

1

2

3

4

9. How often have/had you been angered because of things that were
outside of your control?

0

1

2

3

4

10. How often have/had you felt difficulties were piling up so high that
you could not overcome them?

0

1

2

3

4

WHEN YOU BREASTFEED/BREASTFED:

4. When you are/were breastfeeding, how often have you felt confident
about your ability to handle your personal problems?
5. How often have/had you felt that things were going your way?

WHEN YOU BREASTFEED/BREASTFED:

145

Breastfeeding Practice Questionnaire

For each of the following set of statements, please circle the response that best describes your
breastfeeding experience, practice, and how long you breastfed your baby. Please circle or mark the best
tells us your experience.

1. Did you start breastfeeding within the first 24 hours after delivery?
•
•

Yes
No

2. Did you receive any free formula for your baby either from the hospital or clinic or other agencies?
•
•

Yes: If you answered YES, answer question #3.
No: If you answered NO, skip question #3 and go to question #4.

3. Did you use any of the free formula for your baby?
•
•

Yes
No

4. During pregnancy, did you have any type of breastfeeding education?
•
•

Yes
No

5. After delivery, have you had any help and/or support for breastfeeding and ensuring good latching?
•
•
•
•

Yes: If you answered YES, answer question #6.
No: If you answered NO, skip question #6 and go to question #7.

6. If you answered “Yes” to the previous question (#5), please circle from whom you received
breastfeeding help, and/or support for breastfeeding after childbirth? (Circle all that apply)
•
•
•
•
•
•
•
•
•

Nurse
Doctor
Lactation consultant
Mother
Grandmother
Sister
Husband
Friend
Other: (please identify) _________

146

7. Have you received any education to continue breastfeeding for the first 6 months?
•
•

Yes
No

8. Have you received any education to breastfeed exclusively without supplementing formula?
•
•

Yes
No: If you answered NO, skip question #9 and go to question #10.

9. If you answered “Yes” to the previous question, please circle from whom you received education on
breastfeeding duration and exclusivity? (Circle all that apply)
•
•
•
•
•
•
•
•
•

Nurse
Doctor
Lactation consultant
Mother
Grandmother
Sister
Husband
Friend
Other: (please identify) _________

10. For how long did you breastfeed your infant:
•
•
•
•
•
•
•
•

Less than a month.
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months

If you chose 6 months or more than six months go to question#11, If you chose any of the first 6 options
(THAT IS, less than a month to 5 months’) for the above question, then skip#11 and continue the survey

147

11. How would you describe your breastfeeding practice with your baby:
• I fed my baby only breastmilk with no additional supplement (e.g., water, formula, juices,
solids) for the entire first 6 months of age.
• I sometimes fed my baby some formula or/and other food supplement (solids) before my
baby was 6 months old
If you chose the first option for the previous question, this is the end of this survey.
Thank you for your participation!
If you chose the second option please continue with the survey.

12. What are the reason(s) you stopped breastfeeding or supplemented with formula: (Check all that
apply.)
• Insufficient milk
• Return to work
• New pregnancy
• Sickness of baby or mother
• Introduction of the formula in the first day of life
• Other ____________________(Identify)
• Not applicable/ did not stop breastfeeding
13. What is the most important reason you stopped breastfeeding or supplemented with formula?
(Check only one.)
•
•
•
•
•
•
•

Insufficient milk
Return to work
New pregnancy
Sickness of baby or mother
Introduction of the formula in the first day of life
Other ____________________(Identify)
Not applicable/ did not stop breastfeeding

148

14. How old was your baby when you began formula feeding?
• Younger than one month
• 1 month
• 2 months
• 3 months
• 4 months
• 5 months
• 6 months
• Not yet started

15. If you gave your baby any type of liquid supplements prior to 6 months of infant’s age, what kind of
liquid supplement(s) did you give (Circle all that apply)
•
•
•
•
•

I have not provided any type of liquid supplements
Water
Juice
Herbal tea
Other ____________________(Identify)

16. If your baby has started eating any type of solid foods prior to 6 months of age, how old was your
baby when s/he first started eating solid foods?
• Not yet started solid food.
• Younger than one month
• 1 month
• 2 months
• 3 months
• 4 months
• 5 months
• 6 months
• Older than 6 months

You have completed the questionnaire. Thank you!
Your participation is appreciated!

149

‫ﺍﺳﺗﺑﻳﺎﻥ ﺩﻳﻣﻭﻏﺭﺍﻓﻲ‬
‫ﺍﺳﻡ ﺍﻟﻣﺭﻛﺯ__________‬
‫ﺗﺎﺭﻳﺦ ﺍﻟﻳﻭﻡ__________‬

‫ﺇﻥ ﺍﻷﺳﺋﻠﺔ ﺍﻟﺗﺎﻟﻳﺔ ﺗﺧﺑﺭﻧﻲ ﻋﻥ ﺍﻟﻧﺳﺎء ﺍﻟﻣﺷﺎﺭﻛﻳﻥ ﻓﻲ ﻫﺫﺍ ﺍﻟﻣﺷﺭﻭﻉ‪ .‬ﺳﺗﺑﻘﻰ ﻛﻝ ﺇﺟﺎﺑﺎﺗﻙ ﺳﺭﻳﺔ ﺗﻣﺎﻣﺎ ﻭﻟﻥ ﻳﻁﻠﻊ ﻋﻠﻳﻬﺎ ﺍﺣﺩ ﺳﻭﻯ‬
‫ﺍﻟﺑﺎﺣﺙ‪.‬‬
‫‪ -1‬ﺭﻗﻡ ﺍﻟﻣﺭﻛﺯﺍﻟﺻﺣﻲ‬
‫•‬
‫•‬
‫•‬
‫•‬

‫‪1‬‬
‫‪2‬‬
‫‪3‬‬
‫‪4‬‬

‫‪ -2‬ﻋﻣﺭﻙ )ﺳﻧﺔ(_______‬
‫‪ -3‬ﻋﻣﺭ ﺍﻟﺭﺿﻳﻊ‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬

‫‪ 6‬ﺍﺷﻬﺭ‬
‫‪ 7‬ﺍﺷﻬﺭ‬
‫‪ 8‬ﺍﺷﻬﺭ‬
‫‪ 9‬ﺍﺷﻬﺭ‬
‫‪ 10‬ﺍﺷﻬﺭ‬
‫‪ 11‬ﺷﻬﺭﺍ‬
‫‪ 12‬ﺷﻬﺭﺍ‬

‫‪ -4‬ﺟﻧﺱ ﺍﻟﺭﺿﻳﻊ )ﻳﺭﺟﻰ ﻭﺿﻊ ﺩﺍﺋﺭﺓ ﻭﺍﺣﺩﺓ(‪:‬‬
‫•‬
‫•‬

‫ﺫﻛﺭ‬
‫ﺃﻧﺛﻰ‬

‫‪ -5‬ﺍﻟﺣﺎﻟﺔ ﺍﻻﺟﺗﻣﺎﻋﻳﺔ ‪:‬‬
‫•‬
‫•‬
‫•‬

‫ﻣﺗﺯﻭﺟﺔ‬
‫ﻣﻁﻠﻘﺔ‬
‫ﺃﺭﻣﻠﺔ‬

‫‪150‬‬

‫‪ -6‬ﻭﺿﻊ ﺍﻟﻌﻣﻝ ﺍﻟﺧﺎﺹ ﺑﻙ )ﺧﺎﺭﺝ ﺍﻟﻣﻧﺯﻝ(‪:‬‬
‫•‬
‫•‬
‫•‬

‫ﺍﻟﻌﻣﻝ ﺑﺩﻭﺍﻡ ﻛﺎﻣﻝ )‪ 35‬ﺳﺎﻋﺔ ﻋﻠﻰ ﺍﻷﻗﻝ ﻓﻲ ﺍﻷﺳﺑﻭﻉ(‬
‫ﺍﻟﻌﻣﻝ ﺑﺩﻭﺍﻡ ﺟﺯﺋﻲ‬
‫ﻻ ﻳﻌﻣﻝ‬

‫‪ -7‬ﻛﻡ ﻋﺩﺩ ﺍﻷﺷﺧﺎﺹ ﺍﻟﺫﻳﻥ ﻳﻌﻳﺷﻭﻥ ﻓﻲ ﻣﻧﺯﻟﻙ ﻣﻌﻙ؟ ________‬
‫‪ -8‬ﻫﻝ ﺗﻌﻳﺵ ﻣﻊ ﺍﺣﺩ ﻣﻥ ﺍﻓﺭﺍﺩ ﻣﻥ ﺍﻟﻌﺎﺋﻠﺔ ﺍﻭ ﺍﻷﻗﺎﺭﺏ ﻣﺛﻝ ﺍﻡ ﺍﻟﺯﻭﺝ ﺍﻻﻡ ﺍﻭ ﺍﻟﺟﺩﺓ‪:‬‬
‫•‬
‫•‬

‫ﻧﻌﻡ‬
‫ﻻ‬

‫‪ -9‬ﺇﺫﺍ ﻛﺎﻧﺕ ﺍﻹﺟﺎﺑﺔ ﺏ "ﻧﻌﻡ" ﻋﻠﻰ ﺍﻟﺳﺅﺍﻝ ﺍﻟﺳﺎﺑﻖ‪ ،‬ﻫﻝ ﺍﺣﺩﻫﻡ ﻗﺩﻡ ﻟﻙ ﺩﻋﻡ ﻭﺗﺷﺟﻳﻊ ﻟﻠﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ؟‬
‫•‬
‫•‬

‫ﻧﻌﻡ‬
‫ﻻ‬

‫‪ -10‬ﻛﻡ ﻫﻭ ﺍﻟﺩﺧﻝ ﺍﻟﺷﻬﺭﻱ ﻟﻸﺳﺭﺓ‪:‬‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬

‫‪ 3000‬﷼ ﺳﻌﻭﺩﻱ ﺍﻭ ﺍﻗﻝ‬
‫ﻣﺎﺑﻳﻥ ‪ 4000‬ﺍﻟﻰ ‪ 6999‬﷼ ﺳﻌﻭﺩﻱ‬
‫ﻣﺎﺑﻳﻥ ‪ 7000‬ﺍﻟﻰ ‪ 12000‬﷼ ﺳﻌﻭﺩﻱ‬
‫ﺃﻛﺛﺭ ﻣﻥ ‪ 13000‬﷼ ﺳﻌﻭﺩﻱ‬
‫ﻻ ﺃﻋﺭﻑ‬
‫ﻻ ﺍﺭﻏﺏ ﻓﻲ ﺍﻹﺟﺎﺑﺔ‬

‫‪ -11‬ﻣﺎﻫﻭ ﻣﺳﺗﻭﺍﻙ ﺍﻟﺗﻌﻠﻳﻣﻲ ‪:‬‬
‫•‬
‫•‬
‫•‬
‫•‬

‫ﺩﻭﻥ ﺍﻟﻣﺭﺣﻠﺔ ﺍﻟﺛﺎﻧﻭﻳﺔ‬
‫ﺍﻟﻣﺭﺣﻠﺔ ﺍﻟﺛﺎﻧﻭﻳﺔ‬
‫ﺩﺭﺟﺔ ﺍﻟﺑﻛﺎﻟﻭﺭﻳﻭﺱ‬
‫ﺩﺭﺟﺔ ﺍﻟﻣﺎﺟﺳﺗﻳﺭ ﺃﻭ ﺃﻋﻠﻰ‬

‫‪151‬‬

‫‪ -12‬ﻛﻳﻑ ﻛﺎﻧﺕ ﻁﺭﻳﻘﺔ ﺍﻟﻭﻻﺩﺓ‪:‬‬
‫•‬
‫•‬

‫ﻭﻻﺩﺓ ﻁﺑﻳﻌﻳﺔ ﻣﻬﺑﻠﻳﺔ‬
‫ﻋﻣﻠﻳﺔ ﻗﻳﺻﺭﻳﺔ‬

‫‪ -13‬ﻫﻝ ﻛﺎﻧﺕ ﺍﻣﻙ ﺗﺭﺿﻊ ﺭﺿﺎﻋﺔ ﻁﺑﻳﻌﻳﺔ‪:‬‬
‫•‬
‫•‬
‫•‬

‫ﻧﻌﻡ‬
‫ﻻ‬
‫ﻻ ﺍﻋﻠﻡ‬

‫‪ -14‬ﺍﺫﺍ ﺍﺟﺑﺕ" ﻧﻌﻡ" ﻋﻠﻰ ﺍﻟﺳﻭﺍﻝ ﺍﻟﺳﺎﺑﻖ‪ ،‬ﻫﻝ ﻛﺎﻧﺕ ﺍﻣﻙ ﺗﺭﺿﻊ ﺭﺿﺎﻋﺔ ﻁﺑﻳﻌﻳﺔ ﻟﻔﺗﺭﺓ ‪ 6‬ﺷﻬﻭﺭ؟‬
‫•‬
‫•‬
‫•‬

‫ﻧﻌﻡ‬
‫ﻻ‬
‫ﻻ ﺍﻋﻠﻡ‬

‫‪152‬‬

‫ﻣﻘﻳﺎﺱ ﺍﻟﻛﻔﺎءﺓ ﺍﻟﺫﺍﺗﻳﺔ ﻓﻲ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ – ﻧﻣﻭﺫﺝ ﻣﺧﺗﺻﺭ‬

‫‪4‬‬
‫‪5‬‬

‫ﻟﺳﺕ ﻭﺍﺛﻘﺔ ﺇﻁﻼﻗﺎ‬

‫‪3‬‬

‫ﻟﺳﺕ ﻭﺍﺛﻘﺔ ﺟﺩﺍ‬

‫‪2‬‬

‫‪1‬‬

‫‪2‬‬

‫‪3‬‬

‫‪4‬‬

‫‪5‬‬

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‫‪5‬‬

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‫‪5‬‬

‫ﻭﺍﺛﻘﺔ ﺃﺣﻳﺎﻧﺎ‬

‫‪1‬‬

‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ﺗﺣﺩﻳﺩ ﻓﻳﻣﺎ ﺇﺫﺍ ﻛﺎﻥ ﻁﻔﻠﻲ ﻳﺣﺻﻝ ﻋﻠﻰ ﺍﻟﻛﻣﻳﺔ ﺍﻟﻛﺎﻓﻳﺔ ﻣﻥ‬
‫ﺍﻟﺣﻠﻳﺏ‬
‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ً ﺍﻟﺗﻛﻳﻑ ﻣﻊ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﻛﻣﺎ ﺃﺗﻛﻳﻑ ﻣﻊ ﺃﻱ ﺗﺣ ٍﺩ‬
‫ﺁﺧﺭ‬
‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ﺇﺭﺿﺎﻉ ﻁﻔﻠﻲ ﺭﺿﺎﻋﺔ ﻁﺑﻳﻌﻳﺔ ﺩﻭﻥ ﺇﻋﻁﺎﺋﻪ ﺍﻟﺣﻠﻳﺏ‬
‫ﺍﻟﺻﻧﺎﻋﻲ ﻛ ُﻣﻛ ّﻣﻝ‬
‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ﺍﻟﺗﺄﻛﺩ ﻣﻥ ﺃﻥ ﻁﻔﻠﻲ ﻳﻠﺗﻘﻡ ﺍﻟﺣﻠﻣﺔ ﺑﺈﺣﻛﺎﻡ ﻁﻭﺍﻝ ﻓﺗﺭﺓ‬
‫ﺇﺭﺿﺎﻋﻪ‬
‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ﺇﺩﺍﺭﺓ ﺃﻭﺿﺎﻉ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﺇﻟﻰ ﺍﻟﺣﺩ ﺍﻟﺫﻱ ﻳﺭﺿﻳﻧﻲ‬

‫‪1‬‬

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‫ﻭﺍﺛﻘﺔ‬

‫ﻋﻧﺩﻣﺎ ﻛﻧﺗﻲ ﺗﺭﺿﻌﻳﻥ ﻁﻔﻠﻙ ‪:‬‬

‫ﻭﺍﺛﻘﺔ ﺟﺩﺍ‬

‫ﻟﻛﻝ ﻣﻥ ﺍﻟﻌﺑﺎﺭﺍﺕ ﺍﻟﺗﺎﻟﻳﺔ‪ ،‬ﺍﻟﺭﺟﺎء ﺍﺧﺗﻳﺎﺭ ﺍﻹﺟﺎﺑﺔ ﺍﻟﺗﻲ ﺗﻌﺑﺭ ﺑﺎﻟﺷﻛﻝ ﺍﻷﻓﺿﻝ‬
‫ﻋﻥ ﻣﺩﻯ ﺛﻘﺗﻙ ﻓﻲ ﺇﺭﺿﺎﻉ ﻁﻔﻠﻙ ﺍﻟﺣﺩﻳﺙ ﺍﻟﻭﻻﺩﺓ ﺭﺿﺎﻋﺔ ﻁﺑﻳﻌﻳﺔ‪ .‬ﺍﻟﺭﺟﺎء‬
‫ﺍﻹﺷﺎﺭﺓ ﺇﻟﻰ ﺇﺟﺎﺑﺗﻙ ﺑﻭﺿﻊ ﺩﺍﺋﺭﺓ ﺣﻭﻝ ﺍﻟﺭﻗﻡ ﺍﻷﻗﺭﺏ ﻹﺣﺳﺎﺳﻙ ﺍﺛﻧﺎء ﻓﺗﺭﺓ‬
‫ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﺣﻳﺙ ﺃﻧﻪ ﻟﻳﺱ ﻫﻧﺎﻙ ﺇﺟﺎﺑﺔ ﺻﺣﻳﺣﺔ ﺃﻭ ﺇﺟﺎﺑﺔ ﺧﺎﻁﺋﺔ‬

‫ﻋﻧﺩﻣﺎ ﻛﻧﺗﻲ ﺗﺭﺿﻌﻳﻥ ﻁﻔﻠﻙ ‪:‬‬
‫‪6‬‬

‫ﺃﺳﺗﻁﻳﻊ ﺍﻟﻣﺩﺍﻭﻣﺔ ﻓﻲ ﺇﺭﺿﺎﻉ ﻁﻔﻠﻲ ﺭﺿﺎﻋﺔ ﻁﺑﻳﻌﻳﺔ ﺣﺗﻰ ﻟﻭ ﻛﺎﻥ ﻳﺑﻛﻲ‬

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‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ﺍﻻﺳﺗﻣﺭﺍﺭ ﻓﻲ ﺍﻟﺭﻏﺑﺔ ﺑﺈﺭﺿﺎﻉ ﻁﻔﻠﻲ ﺭﺿﺎﻋﺔ ﻁﺑﻳﻌﻳﺔ‬

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‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ﺇﺭﺿﺎﻉ ﻁﻔﻠﻲ ﺑﺭﺍﺣﺔ ﺣﺗﻰ ﻓﻲ ﻅﻝ ﻭﺟﻭﺩ ﺃﻓﺭﺍﺩ ﺃﺳﺭﺗﻲ‬

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‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ﺃﻥ ﺃﻛﻭﻥ ﺭﺍﺿﻳﺔ ﻋﻥ ﺗﺟﺭﺑﺗﻲ ﻣﻊ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‬

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‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ﺍﻟﺗﻛﻳﻑ ﻣﻊ ﺣﻘﻳﻘﺔ ﺃﻥ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﺗﺳﺗﻐﺭﻕ ﻭﻗﺗﺎ ً‬
‫ﻁﻭﻳﻼً‬
‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ً ﺇﻧﻬﺎء ﺇﺭﺿﺎﻉ ﻁﻔﻠﻲ ﻣﻥ ﺛﺩﻱ ﻭﺍﺣﺩ ﻗﺑﻝ ﺍﻻﻧﺗﻘﺎﻝ ﺇﻟﻰ ﺍﻟﺛﺩﻱ‬
‫ﺍﻵﺧﺭ‬
‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ً ﺍﻻﺳﺗﻣﺭﺍﺭ ﻓﻲ ﺇﺭﺿﺎﻉ ﻁﻔﻠﻲ ﻁﺑﻳﻌﻳﺎ ﻓﻲ ﻛﻝ ﺭﺿﻌﺔ‬

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‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ﺗﻠﺑﻳﺔ ﺍﺣﺗﻳﺎﺟﺎﺕ ﻁﻔﻠﻲ ﻣﻥ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‬

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‫ﺃﺳﺗﻁﻳﻊ ﺩﺍﺋﻣﺎ ﺃﻥ ﺃﻗﻭﻝ ﻓﻳﻣﺎ ﺇﺫﺍ ﻛﺎﻥ ﻁﻔﻠﻲ ﻗﺩ ﺃﻧﻬﻰ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‬

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‫ﻣﻘﻳﺎﺱ ﺍﻟﻣﺅﻥ ﺍﻻﺟﺗﻣﺎﻋﻳﺔ – ﻧﻣﻭﺫﺝ ﻣﺧﺗﺻﺭ‬

‫ﻻ ﺃﻭﺍﻓﻖ ﺑﺷﺩﺓ‬

‫ﻻ ﺃﻭﺍﻓﻖ‬

‫ﺃﻭﺍﻓﻖ‬

‫ﻋﻧﺩﻣﺎ ﻛﻧﺗﻲ ﺗﺭﺿﻌﻳﻥ ﻁﻔﻠﻙ ‪:‬‬

‫ﺃﻭﺍﻓﻖ ﺑﺷﺩﺓ‬

‫ﺧﻼﻝ ﺇﺟﺎﺑﺗﻙ ﻋﻥ ﻣﺟﻣﻭﻋﺔ ﺍﻷﺳﺋﻠﺔ ﺍﻟﺗﺎﻟﻳﺔ‪ ،‬ﻓﻛﺭﻱ ﺑﻌﻼﻗﺗﻙ ﺍﻟﺣﺎﻟﻳﺔ ﻣﻊ ﺍﻷﺻﺩﻗﺎء‬
‫ﻭﺃﻓﺭﺍﺩ ﺍﻟﻌﺎﺋﻠﺔ ﻭﺯﻣﻼء ﺍﻟﻌﻣﻝ ﻭﻏﻳﺭﻫﻡ ﺃﺛﻧﺎء ﻓﺗﺭﺓ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‪ .‬ﺍﻟﺭﺟﺎء‬
‫ﻭﺿﻊ ﺩﺍﺋﺭﺓ ﺣﻭﻝ ﺍﻟﺭﻗﻡ ﺍﻷﻗﺭﺏ ﻟﻠﺩﺭﺟﺔ ﺍﻟﺗﻲ ﺗﺻﻑ ﻋﻼﻗﺗﻙ ﺍﻟﺣﺎﻟﻳﺔ ﻣﻊ ﺍﻵﺧﺭﻳﻥ‪.‬‬
‫ﻟﻳﺱ ﻫﻧﺎﻙ ﺇﺟﺎﺑﺔ ﺻﺣﻳﺣﺔ ﺃﻭ ﺇﺟﺎﺑﺔ ﺧﺎﻁﺋﺔ‪.‬‬

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‫ﻫﻧﺎﻙ ﺃﺷﺧﺎﺹ ﺃﺳﺗﻁﻳﻊ ﺍﻻﻋﺗﻣﺎﺩ ﻋﻠﻳﻬﻡ ﻟﻣﺳﺎﻋﺩﺗﻲ ﺇﺫﺍ ﺍﺣﺗﺟﺕ ﻓﻌﻼ ﺇﻟﻰ ﺫﻟﻙ‬

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‫ﺃﺷﻌﺭ ﺃﻧﻪ ﻟﻳﺱ ﻟﺩﻱ ﻋﻼﻗﺎﺕ ﺷﺧﺻﻳﺔ ﻭﺛﻳﻘﺔ ﻣﻊ ﺍﻷﺷﺧﺎﺹ ﺍﻵﺧﺭﻳﻥ‬

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‫ﻟﻳﺱ ﻫﻧﺎﻙ ﻣﻥ ﺃﻟﺟﺄ ﺇﻟﻳﻪ ﻹﺭﺷﺎﺩﻱ ﻓﻲ ﺃﻭﻗﺎﺕ ﺍﻟﺿﻐﻭﻁ‬

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‫ﻫﻧﺎﻙ ﺃﺷﺧﺎﺹ ﻳﺳﺗﻣﺗﻌﻭﻥ ﺑﻧﻔﺱ ﺍﻷﻧﺷﻁﺔ ﺍﻻﺟﺗﻣﺎﻋﻳﺔ ﺍﻟﺗﻲ ﺃﻗﻭﻡ ﺑﻬﺎ‬

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‫ﻻ ﺃﻋﺗﻘﺩ ﺑﺄﻥ ﺍﻵﺧﺭﻳﻥ ﻳﺣﺗﺭﻣﻭﻥ ﻣﻬﺎﺭﺍﺗﻲ ﻭﻗﺩﺭﺍﺗﻲ‬

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‫ﻋﻧﺩﻣﺎ ﻛﻧﺗﻲ ﺗﺭﺿﻌﻳﻥ ﻁﻔﻠﻙ ‪:‬‬
‫‪6‬‬

‫ﺇﺫﺍ ﺣﺻﻠﺕ ﻣﺷﻛﻠﺔ ﻣﺎ‪ ،‬ﻓﻠﻥ ﻳﺣﺿﺭ ﺃﺣﺩ ﻟﻣﺳﺎﻋﺩﺗﻲ‬

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‫ﻟﺩﻱ ﻋﻼﻗﺎﺕ ﻭﺛﻳﻘﺔ ﺗﻣﻧﺣﻧﻲ ﺇﺣﺳﺎﺳﺎ ﺑﺎﻷﻣﺎﻥ ﺍﻟﻌﺎﻁﻔﻲ ﻭﺍﻟﺳﻌﺎﺩﺓ‬

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‫ﻟﺩﻱ ﻋﻼﻗﺎﺕ ﻣﻊ ﺃﺷﺧﺎﺹ ﻳﻘﺩﺭﻭﻥ ﻛﻔﺎءﺗﻲ ﻭﻣﻬﺎﺭﺍﺗﻲ‬

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‫ﻟﻳﺱ ﻫﻧﺎﻙ ﺃﺣﺩ ﻳﺷﺎﺭﻛﻧﻲ ﺍﻫﺗﻣﺎﻣﺎﺗﻲ ﻭﻣﺧﺎﻭﻓﻲ‬

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‫ﻫﻧﺎﻙ ﺷﺧﺹ ﺟﺩﻳﺭ ﺑﺎﻟﺛﻘﺔ ﺃﺳﺗﻁﻳﻊ ﺍﻟﻠﺟﻭء ﺇﻟﻳﻪ ﻟﻠﺣﺻﻭﻝ ﻋﻠﻰ ﺍﻟﻣﺷﻭﺭﺓ ﻓﻲ‬
‫ﺣﺎﻝ ﻭﺍﺟﻬﺕ ﺃﻳﺔ ﻣﺷﺎﻛﻝ‬

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‫‪154‬‬

‫ﻣﻘﻳﺎﺱ ﺗﺻﻭﺭ ﺍﻟﺗﻭﺗﺭ‬

‫‪4‬‬

‫اﱃ أي ﻣﺪى أﺣﺴﺴﺖ ﻟﺜﻘﺔ ﰲ ﻗﺪرﺗﻚ ﻋﻠﻰ اﻟﺘﻌﺎﻣﻞ ﻣﻊ ﻣﺸﺎﻛﻠﻚ اﳋﺎﺻﺔ ؟‬

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‫اﱃ أي ﻣﺪى أﺣﺴﺴﺖ أن اﻷﻣﻮر ﺗﺴﲑ ﻛﻤﺎ ﺗﺮﻳﺪ ؟‬

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‫ﺍﻁﻼﻗﺎ ً )ﺃﺑﺪﺍً(‬

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‫اﱃ أي ﻣﺪى أﺣﺴﺴﺖ ﻟﺘﻮﺗﺮ و اﻟﻀﻐﻂ اﻟﻨﻔﺴﻲ ؟‬

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‫ﻋﻧﺩﻣﺎ ﻛﻧﺗﻲ ﺗﺭﺿﻌﻳﻥ ﻁﻔﻠﻙ ‪:‬‬

‫ﻧﺎﺩﺭﺍ‬

‫‪2‬‬

‫اﱃ أي ﻣﺪى أﺣﺴﺴﺖ ﺑﻌﺪم اﻟﻘﺪرة ﻋﻠﻰ اﻟﺘﺤﻜﻢ ﰲ اﻷﻣﻮر اﳍﺎﻣﺔ ﲝﻴﺎﺗﻚ ؟‬

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‫ﻧﺮﺟﻮ ﻣﻨﻚ ﺍﻻﺟﺎﺑﺔ ﻟﻜﻞ ﻣﻦ ﺍﻟﻌﺒﺎﺭﺍﺕ ﺍﻟﺘﺎﻟﻴﺔ ﺑﻮﺿﻊ ﺩﺍﺋﺮﺓ ﺣﻮﻝ ﺍﻟﺮﻗﻢ ﺍﻷﻧﺴﺐ‬

‫ﺃﺣﻴﺎﻧﺎ ً‬

‫ﻛﺜﻴﺮﺍ ً‬

‫ﺩﺍﺋﻤﺎ )ﻓﻲ ﺃﻏﻠﺐ ﺍﻷﺣﻴﺎﻥ(‬

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‫اﱃ أي ﻣﺪى أﺣﺴﺴﺖ ﻻﻧﺰﻋﺎج ﺑﺴﺒﺐ ﺣﺪوث أﻣﺮ ﻏﲑ ﻣﺘﻮﻗﻊ ؟‬

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‫ﺍﻷﺳﺌﻠﺔ ﺍﻟﺘﺎﻟﻴﺔ ﺗﺴﺘﻔﺴﺮ ﻋﻦ ﻣﺸﺎﻋﺮﻙ ﻭ ﺃﻓﻜﺎﺭﻙ ﺧﻼﻝ ﻓﺘﺮﺓ ﺍﻟﺮﺿﺎﻋﺔ‬
‫ﺍﻟﻄﺒﻴﻌﻴﺔ‪.‬‬

‫ﻋﻧﺩﻣﺎ ﻛﻧﺗﻲ ﺗﺭﺿﻌﻳﻥ ﻁﻔﻠﻙ ‪:‬‬
‫‪6‬‬

‫اﱃ أي ﻣﺪى وﺟﺪت ﻧﻔﺴﻚ ﻏﲑ ﻗﺎدر ﻋﻠﻰ اﻟﺘﺄﻗﻠﻢ ﻣﻊ ﻛﻞ اﻷﻣﻮر اﻟﻮاﺟﺐ ﻋﻠﻴﻚ‬

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‫اﻟﻘﻴﺎم ‪F‬ﺎ ؟‬
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‫إﱃ أي ﻣﺪى ﲤﻜﻨﺖ ﻣﻦ اﻟﺘﺤﻜﻢ ﰲ اﻷﻣﻮر اﻟﱵ ﺗﺰﻋﺠﻚ ؟‬

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‫اﱃ أي ﻣﺪى أﺣﺴﺴﺖ ‪M‬ﻧﻚ ﲤﻠﻚ زﻣﺎم اﻷﻣﻮر ) ﻣﺴﻴﻄﺮ ﻋﻠﻰ ﻛﺎﻓﺔ أﻣﻮرك( ؟‬

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‫اﱃ أي ﻣﺪى أﺣﺴﺴﺖ ﻟﻐﻀﺐ ﺑﺴﺒﺐ أﻣﻮر ﺧﺎرﺟﺔ ﻋﻦ ﲢﻜﻤﻚ ؟‬

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‫‪ 10‬إﱃ أي ﻣﺪى أﺣﺴﺴﺖ ‪M‬ن اﻟﺼﻌﺎب ﺗﱰاﻛﻢ ﻋﻠﻴﻚ ﻟﺪرﺟﺔ أﻧﻚ ﱂ ﺗﻌﺪ ﺗﺴﺘﻄﻴﻊ‬
‫اﻟﺘﻐﻠﺐ ﻋﻠﻴﻬﺎ ؟‬

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‫ﺍﺳﺗﺑﻳﺎﻥ ﻋﻥ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‬

‫ﻟﻛﻝ ﻣﻥ ﺍﻟﻣﺟﻣﻭﻋﺔ ﺍﻟﺗﺎﻟﻳﺔ ﻣﻥ ﺍﻟﺑﻳﺎﻧﺎﺕ‪ ،‬ﻳﺭﺟﻰ ﻭﺿﻊ ﺩﺍﺋﺭﺓ ﺣﻭﻝ ﺍﻹﺟﺎﺑﺔ ﺍﻟﺗﻲ ﺗﺻﻑ ﺗﺟﺭﺑﺗﻙ ﻓﻲ ﻣﻣﺎﺭﺳﺔ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‪.‬‬
‫ﻳﺭﺟﻰ ﻭﺿﻊ ﺩﺍﺋﺭﺓ ﺃﻭ ﻋﻼﻣﺔ ﻋﻠﻰ ﺃﻓﺿﻝ ﺇﺟﺎﺑﻪ ﻋﻠﻰ ﺍﻷﺳﺋﻠﺔ ﺍﻟﺗﺎﻟﻳﺔ‪ .‬ﻻ ﺗﻭﺟﺩ ﺇﺟﺎﺑﺔ ﺻﺣﻳﺣﺔ ﺃﻭ ﺧﺎﻁﺋﺔ‬

‫‪ -1‬ﻫﻝ ﺑﺩﺃﺗﻲ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﻓﻲ ﻏﺿﻭﻥ ﺍﻝ ‪ 24‬ﺳﺎﻋﺔ ﺍﻷﻭﻟﻰ ﺑﻌﺩ ﺍﻟﻭﻻﺩﺓ؟‬
‫•‬
‫•‬

‫ﻧﻌﻡ‬
‫ﻻ‬

‫‪ -2‬ﻫﻝ ﺣﺻﻠﺗﻲ ﻋﻠﻰ ﺭﺿﻌﺎﺕ ﺻﻧﺎﻋﻳﺔ ﻟﻁﻔﻠﻙ ﻣﺟﺎﻧﺎ؟‬
‫•‬
‫•‬

‫ﻧﻌﻡ‬
‫ﻻ‬

‫‪ -3‬ﺍﺫﺍ ﺍﺟﺑﺗﻲ ﺑﻧﻌﻡ ﻋﻠﻰ ﺍﻟﺳﻭﺍﻝ ﺍﻟﺳﺎﺑﻖ ﻫﻝ ﺍﺳﺗﺧﺩﻣﺗﻲ ﺍﻱ ﻣﻥ ﺍﻟﺭﺿﻌﺎﺕ ﺍﻟﺻﻧﺎﻋﻳﺔ ﺍﻟﻣﺟﺎﻧﻳﺔ؟‬
‫•‬
‫•‬

‫ﻧﻌﻡ‬
‫ﻻ‬

‫‪ -4‬ﺧﻼﻝ ﻓﺗﺭﺓ ﺍﻟﺣﻣﻝ‪ ،‬ﻫﻝ ﺗﻠﻘﻳﺗﻲ ﺍﻱ ﺗﻌﻠﻳﻡ ﻋﻥ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ؟‬
‫•‬
‫•‬

‫ﻧﻌﻡ‬
‫ﻻ‬

‫‪ -5‬ﺑﻌﺩ ﺍﻟﻭﻻﺩﺓ‪ ،‬ﻫﻝ ﺗﻠﻘﻳﺗﻲ ﺃﻱ ﻧﻭﻉ ﻣﻥ ﺍﻟﺗﻌﻠﻳﻡ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‪ ،‬ﻭﺍﻟﻣﺳﺎﻋﺩﺓ‪ ،‬ﺃﻭ ﺩﻋﻡ ﻟﻣﻣﺎﺭﺳﺔ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ؟‬
‫•‬
‫•‬

‫ﻧﻌﻡ‬
‫ﻻ‬

‫‪156‬‬

‫‪ -6‬ﺇﺫﺍ ﻛﺎﻧﺕ ﺍﻹﺟﺎﺑﺔ "ﻧﻌﻡ" ﻋﻠﻰ ﺍﻟﺳﺅﺍﻝ ﺍﻟﺳﺎﺑﻖ )ﺭﻗﻡ ‪ ،(5‬ﻳﺭﺟﻰ ﻭﺿﻊ ﺩﺍﺋﺭﺓ ﻣﻥ ﺍﻟﺫﻱ ﺯﻭﺩﻙ ﺑﺎﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻭ ﺩﻋﻣﻙ ﻭﺷﺟﻌﻙ‬
‫ﻟﻠﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‪ ،‬ﻣﺳﺎﻋﺩﺓ‪ ،‬ﻭ ‪ /‬ﺃﻭ ﺍﻟﺩﻋﻡ ﺑﻌﺩ ﺍﻟﻭﻻﺩﺓ؟ )ﺩﺍﺋﺭﺓ ﻋﻠﻰ ﻛﻝ ﻣﺎ ﻳﻧﻁﺑﻖ(‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬

‫ﻣﻣﺭﺿﺔ‬
‫ﻁﺑﻳﺏ‬
‫ﻣﺳﺗﺷﺎﺭﺓ ﺭﺿﺎﻋﺔ‬
‫ﺃﻡ‬
‫ﺟﺩﺓ‬
‫ﺃﺧﺕ‬
‫ﺯﻭﺝ‬
‫ﺻﺩﻳﻖ‬
‫________ﺍﺧﺭﻳﻥ )ﻳﺭﺟﻰ ﺍﻟﺗﺣﺩﻳﺩ(‬

‫‪ -7‬ﺑﻌﺩ ﺍﻟﻭﻻﺩﺓ‪ ،‬ﻫﻝ ﺗﻠﻘﻳﺗﻲ ﺃﻱ ﻧﻭﻉ ﻣﻥ ﺍﻟﺗﻌﻠﻳﻡ ﻋﻥ ﻓﺗﺭﺓ ﺍﺳﺗﻣﺭﺍﺭ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﺍﻟﻰ ‪ 6‬ﺷﻬﻭﺭ ؟‬
‫•‬
‫•‬

‫ﻧﻌﻡ‬
‫ﻻ‬

‫‪ -8‬ﻫﻝ ﺗﻠﻘﻳﺗﻲ ﺍﻱ ﺗﻌﻠﻳﻣﺎﺕ ﻋﻥ ﺍﺭﺿﺎﻉ ﻣﻭﻟﻭﺩﻙ ﺭﺿﺎﻋﺔ ﻁﻳﻳﻌﻳﺔ ﻓﻘﻁ ﺑﺩﻭﻥ ﺣﻠﻳﺏ ﺻﻧﺎﻋﻲ‪:‬‬
‫•‬
‫•‬

‫ﻧﻌﻡ‬
‫ﻻ‬

‫‪ -9‬ﺇﺫﺍ ﻛﺎﻧﺕ ﺍﻹﺟﺎﺑﺔ "ﻧﻌﻡ" ﻋﻠﻰ ﺍﻟﺳﺅﺍﻝ ﺍﻟﺳﺎﺑﻖ‪ ،‬ﻳﺭﺟﻰ ﻭﺿﻊ ﺩﺍﺋﺭﺓ ﻣﻥ ﺍﻟﺫﻱ ﺯﻭﺩﻙ ﺑﺎﻟﻣﻌﻠﻭﻣﺎﺕ ؟ )ﺩﺍﺋﺭﺓ ﻋﻠﻰ ﻛﻝ ﻣﺎ‬
‫ﻳﻧﻁﺑﻖ(‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬

‫ﻣﻣﺭﺿﺔ‬
‫ﻁﺑﻳﺏ‬
‫ﻣﺳﺗﺷﺎﺭﺓ ﺭﺿﺎﻋﺔ‬
‫ﺃﻡ‬
‫ﺟﺩﺓ‬
‫ﺃﺧﺕ‬
‫ﺯﻭﺝ‬
‫ﺻﺩﻳﻖ‬
‫________ﺍﺧﺭﻳﻥ )ﻳﺭﺟﻰ ﺍﻟﺗﺣﺩﻳﺩ(‬

‫‪157‬‬

‫‪ -10‬ﻟﻣﺩﺓ ﻛﻡ ﺷﻬﺭ ﺍﺭﺿﻌﺗﻲ ﻁﻔﻠﻙ؟‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬

‫ﺃﻗﻝ ﻣﻥ ﺷﻬﺭ ﻭﺍﺣﺩ‬
‫ﺷﻬﺭ ﻭﺍﺣﺩ‬
‫ﺷﻬﺭﻳﻥ‬
‫ﺛﻼﺛﺔ ﺍﺷﻬﺭ‬
‫ﺍﺭﺑﻌﺔ ﺍﺷﻬﺭ‬
‫ﺧﻣﺳﺔ ﺍﺷﻬﺭ‬
‫ﺳﺗﺔ ﺍﺷﻬﺭ‬
‫ﺍﻛﺛﺭ ﻣﻥ ‪ 6‬ﺍﺷﻬﺭ‬
‫ﺇﺫﺍ ﺍﺧﺗﺭﺕ ‪ 6‬ﺃﺷﻬﺭ ﺃﻭ ﺃﻛﺛﺭ ﻣﻥ ﺳﺗﺔ ﺃﺷﻬﺭ ﺍﻧﺗﻘﻠﻲ ﺍﻟﻰ ﺍﻟﺳﺅﺍﻝ )‪ (11‬ﻹﻛﻣﺎﻝ ﺍﻻﺳﺗﺑﻳﺎﻥ ﻭ ﺍﺫﺍ ﺍﺧﺗﺭﺗﻲ ﺍﻱ ﻣﻥ‬
‫ﺍﻟﺧﻳﺎﺭﺍﺕ ﺍﻟﺳﺕ ﺍﻻﻭﻟﻰ ﻋﻠﻰ ﺍﻟﺳﻭﺍﻝ ﺍﻟﺳﺎﺑﻖ )ﺃﻱ‪ ،‬ﺃﻗﻝ ﻣﻥ ﺷﻬﺭ‪ -‬ﺇﻟﻰ ‪ 5‬ﺃﺷﻬﺭ( ﺗﺧﻁﻲ ﺳﺅﺍﻝ ﺭﻗﻡ ‪ 11‬ﻭﺍﻛﻣﻠﻲ‬
‫ﺍﻻﺳﺗﺑﻳﺎﻥ‬

‫‪ -11‬ﻛﻳﻑ ﺗﺻﻔﻳﻥ ﻣﻣﺎﺭﺳﺗﻙ ﻟﻠﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‪:‬‬
‫• ﺃﻧﺎ ﺍﻏﺫﻱ ﻁﻔﻠﻲ ﻓﻘﻁ ﺣﻠﻳﺏ ﺍﻷﻡ ﺑﻭﺍﺳﻁﺔ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﻣﻊ ﻋﺩﻡ ﻭﺟﻭﺩ ﻏﺫﺍء ﺇﺿﺎﻓﻲ )ﻣﺛﻝ ﻭﺍﻟﻣﻳﺎﻩ ﻭﺍﻟﻌﺻﺎﺋﺭ ﻭﺍﻟﻣﻭﺍﺩ‬
‫ﺍﻟﺻﻠﺑﺔ( ﻟﻛﺎﻣﻝ ‪ 6‬ﺃﺷﻬﺭ ﺍﻷﻭﻟﻰ ﻣﻥ ﺍﻟﻌﻣﺭ‪.‬‬
‫• ﺃﻧﺎ ﻓﻲ ﺑﻌﺽ ﺍﻷﺣﻳﺎﻥ ﺍﻏﺫﻱ ﻣﻭﻟﻭﺩﻱ ﺣﻠﻳﺏ ﺻﻧﺎﻋﻲ ﺃﻭ ‪ /‬ﻭﻏﻳﺭﻫﺎ ﻣﻥ ﺍﻟﻣﻛﻣﻼﺕ ﺍﻟﻐﺫﺍﺋﻳﺔ ﻗﺑﻝ ﺍﻥ ﻳﻛﻣﻝ ‪ 6‬ﺍﺷﻬﺭ‪.‬‬

‫ﺇﺫﺍ ﺍﺧﺗﺭﺕ "ﺍﻟﺧﻳﺎﺭ ﺍﻻﻭﻝ" ﻋﻠﻰ ﺍﻟﺳﺅﺍﻝ ﺍﻟﺳﺎﺑﻖ‪ ،‬ﻓﻬﻭ ﻧﻬﺎﻳﺔ ﺍﻻﺳﺗﺑﻳﺎﻥ‬
‫ﺃﺷﻛﺭﻛﻡ ﻋﻠﻰ ﻣﺷﺎﺭﻛﺗﻛﻡ‬
‫ﻭﺇﺫﺍ ﻛﺎﻧﺕ ﺍﻹﺟﺎﺑﺔ "ﺍﻟﺧﻳﺎﺭ ﺍﻟﺛﺎﻧﻲ"‪ ،‬ﻳﺭﺟﻰ ﺍﻻﺳﺗﻣﺭﺍﺭ ﻓﻲ ﻣﻝء ﺍﻻﺳﺗﻣﺎﺭﺓ‬

‫‪ -12‬ﻣﺎ ﻫﻲ ﺍﻷﺳﺑﺎﺏ ﺍﻟﺗﻲ ﺩﻋﺗﻙ ﻟﻠﺗﻭﻗﻑ ﻋﻥ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﺍﻭ ﺍﻟﺗﺯﻭﻳﺩ ﺑﺎﻟﺣﻠﻳﺏ ﺍﻟﺻﻧﺎﻋﻲ )ﺍﺧﺗﺎﺭﻱ ﻛﻝ ﻣﺎﻳﻧﻁﺑﻖ(‪:‬‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬

‫ﺣﻠﻳﺏ ﺍﻻﻡ ﻏﻳﺭ ﻛﺎﻓﻲ‬
‫ﺍﻟﻌﻭﺩﺓ ﺇﻟﻰ ﺍﻟﻌﻣﻝ‬
‫ﺍﻟﺣﻣﻝ ﺍﻟﺟﺩﻳﺩ‬
‫ﻣﺭﺽ ﺍﻟﻁﻔﻝ ﺃﻭ ﺍﻷﻡ‬
‫ﺇﺩﺧﺎﻝ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﺻﻧﺎﻋﻳﺔ ﻓﻲ ﺍﻟﻳﻭﻡ ﺍﻷﻭﻝ ﻣﻥ ﺍﻟﺣﻳﺎﺓ‬
‫ﺃﺧﺭﻯ _______________ )ﺣﺩﺩﻱ(‬
‫ﻻﻳﻧﻁﺑﻖ\ ﻟﻡ ﺍﺗﻭﻗﻑ ﻋﻥ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‬

‫‪158‬‬

‫‪ -13‬ﻣﺎ ﻫﻲ ﺍﻫﻡ ﺍﻷﺳﺑﺎﺏ ﺍﻟﺗﻲ ﺩﻋﺗﻙ ﻟﻠﺗﻭﻗﻑ ﻋﻥ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ ﺍﻭ ﺍﻟﺗﺯﻭﻳﺩ ﺑﺎﻟﺣﻠﻳﺏ ﺍﻟﺻﻧﺎﻋﻲ )ﺍﺧﺗﺎﺭﻱ ﺧﻳﺎﺭ ﻭﺍﺣﺩ(‪:‬‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬

‫ﺣﻠﻳﺏ ﺍﻻﻡ ﻏﻳﺭ ﻛﺎﻓﻲ‬
‫ﺍﻟﻌﻭﺩﺓ ﺇﻟﻰ ﺍﻟﻌﻣﻝ‬
‫ﺍﻟﺣﻣﻝ ﺍﻟﺟﺩﻳﺩ‬
‫ﻣﺭﺽ ﺍﻟﻁﻔﻝ ﺃﻭ ﺍﻷﻡ‬
‫ﺇﺩﺧﺎﻝ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﺻﻧﺎﻋﻳﺔ ﻓﻲ ﺍﻟﻳﻭﻡ ﺍﻷﻭﻝ ﻣﻥ ﺍﻟﺣﻳﺎﺓ‬
‫ﺃﺧﺭﻯ _______________ )ﺣﺩﺩﻱ(‬
‫ﻻﻳﻧﻁﺑﻖ\ ﻟﻡ ﺍﺗﻭﻗﻑ ﻋﻥ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﻁﺑﻳﻌﻳﺔ‬

‫‪ -14‬ﻛﻡ ﻛﺎﻥ ﻋﻣﺭ ﺍﻟﺭﺿﻳﻊ ﻋﻧﺩ ﺑﺩء ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﺻﻧﺎﻋﻳﺔ‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬

‫ﺍﻗﻝ ﻣﻥ ﺷﻬﺭ ﻭﺍﺣﺩ‬
‫ﺷﻬﺭ ﻭﺍﺣﺩ‬
‫ﺷﻬﺭﻳﻥ‬
‫ﺛﻼﺛﺔ ﺍﺷﻬﺭ‬
‫ﺍﺭﺑﻌﺔ ﺍﺷﻬﺭ‬
‫ﺧﻣﺳﺔ ﺍﺷﻬﺭ‬
‫ﺳﺗﺔ ﺍﺷﻬﺭ‬
‫ﻟﻡ ﻳﺑﺩﺍ ﺍﻟﺭﺿﺎﻋﺔ ﺍﻟﺻﻧﺎﻋﻳﺔ ﺑﻌﺩ‬

‫‪ -15‬ﻣﺎ ﻫﻭ ﻧﻭﻉ ﺍﻟﻣﻛﻣﻼﺕ ﺍﻟﻐﺫﺍﺋﻳﺔ ﺍﻟﺳﺎﺋﻠﺔ ﺍﻟﺗﻲ ﺃﺩﺧﻠﺕ ﻟﻁﻌﺎﻡ ﺍﻟﻁﻔﻝ ﻗﺑﻝ ‪ 6‬ﺍﺷﻬﺭ ﻣﻥ ﻋﻣﺭ ﺍﻟﺭﺿﻳﻊ؟ )ﺍﺧﺗﺎﺭﻱ ﻛﻝ ﻣﺎﻳﻧﻁﺑﻖ(‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬

‫ﻻﻳﻧﻁﺑﻖ ﺍﻟﺳﺅﺍﻝ‬
‫ﻣﺎء‬
‫ﻋﺻﻳﺭ‬
‫ﺷﺎﻱ ﺃﻋﺷﺎﺏ‬
‫ﺃﺧﺭﻯ ______________ )ﺣﺩﺩﻱ(‬

‫‪159‬‬

‫‪ -16‬ﺍﺫﺍ ﺑﺩﺃ ﻁﻔﻠﻙ ﺍﻻﻛﻝ ﻗﺑﻝ ‪ 6‬ﺍﺷﻬﺭ ﻛﻡ ﻛﺎﻥ ﻋﻣﺭ ﺍﻟﺭﺿﻳﻊ ﻋﻧﺩ ﺗﻘﺩﻳﻡ ﺍﻱ ﻧﻭﻉ ﻣﻥ ﻁﻌﺎﻡ ﺍﻻﻁﻔﺎﻝ ‪:‬‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬

‫ﻟﻡ ﻳﺑﺩﺃ ﺍﻟﻁﻌﺎﻡ ﺑﻌﺩ‬
‫ﺍﻗﻝ ﻣﻥ ﺷﻬﺭ ﻭﺍﺣﺩ‬
‫ﺷﻬﺭ ﻭﺍﺣﺩ‬
‫ﺷﻬﺭﻳﻥ‬
‫ﺛﻼﺛﺔ ﺍﺷﻬﺭ‬
‫ﺍﺭﺑﻌﺔ ﺍﺷﻬﺭ‬
‫ﺧﻣﺳﺔ ﺍﺷﻬﺭ‬
‫ﺳﺗﺔ ﺍﺷﻬﺭ‬
‫ﺍﻛﺛﺭ ﻣﻥ ‪ 6‬ﺷﻬﻭﺭ‬

‫ﻟﻘﺩ ﺍﻛﻣﻠﺗﻲ ﺍﻻﺳﺗﺑﻳﺎﻥ‬
‫ﺷﻛﺭﺍ ﺟﺯﻳﻼ ﻋﻠﻰ ﻣﺷﺎﺭﻛﺗﻙ‬

‫‪160‬‬

APPENDIX G: The Permission to use the Validated Arabic Version of the Perceived Stress
Scale-10 item.

161

162

APPENDIX H: The Permission to use the Social Provisions Scale

163

164

APPENDIX I: The Permission To Use the Breastfeeding Self-Efficacy Scale

165

166

APPENDIX J: Assessment of Content Validity Index
Breastfeeding Self-Efficacy Scale–Short Form

Breastfeeding Self-Efficacy is defined as a woman’s confidence in her ability to successfully breastfeed her baby.
Please rate the relevancy of the following items as related to the definitions above by circling your answer.

Items

Not
Relevant

Somewhat
Relevant

Very
Relevant

Comments

1. I can/could always determine that my baby
is/was getting enough milk
2. I can/could always successfully cope with
breastfeeding like I have with other challenging
tasks
3. I can/could always breastfeed my baby without
using formula as a supplement
4. I can/could always ensure that my baby is
properly latched on for the entire feeding
5. I can/could always manage the breastfeeding
situation to my satisfaction
6. I can/could always manage to breastfeed even if
my baby is crying

1

2

3

4

5

6

7

8

9

10

1

2

3

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10

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10

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10

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7

8

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10

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10

7. I can/could always keep wanting to breastfeed

1

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8

9

10

8. I can/could always comfortably breastfeed with

1

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3

4

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8

9

10

167

my family members present
9. I can/could always be satisfied with my
breastfeeding experience
10. I can/could always deal with the fact that
breastfeeding can be time consuming
11. I can/could always finish feeding my baby on
one breast before switching to the other breast
12. I can/could always continue to breastfeed my
baby for every feeding
13. I can/could always manage to keep up with my
baby’s breastfeeding demands
14. I can/could always tell when my baby is
finished breastfeeding
©
Dr. Cindy-Lee Dennis

1

2

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9

10

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10

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10

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8

9

10

Other comments (if any) :
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

168

Social Provisions Scale–Short Version

Social support is defined as any form of social resources or helping relationships that are provided or perceived as available
Please rate the relevancy of the following items as related to the definitions above by circling your answer.

Items

Not
Relevant

Somewhat
Relevant

Very
Relevant

1. There are/were people I can depend on to help
me if I really need it.

1

2

3

4

5

6

7

8

9

10

2. I feel/felt that I do not have close personal
relationships with other people.

1

2

3

4

5

6

7

8

9

10

3. There is/was no one I can turn to for guidance in
times of stress.

1

2

3

4

5

6

7

8

9

10

4. There are/were people who enjoy the same social
activities that I do.

1

2

3

4

5

6

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8

9

10

5. I do/did not think other people respect my skills
and abilities.

1

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3

4

5

6

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8

9

10

169

Comments

6. If something went wrong, no one would come to
my assistance.

1

2

3

4

5

6

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8

9

10

7. I have/had close relationships that provide me
with a sense of emotional security and well-being.

1

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8

9

10

8. I have/had relationships where my competence
and skills are recognized.

1

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3

4

5

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10

9. There is/was no one who shares my interests and
concerns.

1

2

3

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5

6

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8

9

10

10. There is/was a trustworthy person I could turn
to for advice if I were having problems.

1

2

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4

5

6

7

8

9

10

Copyright by Daniel Russell and Carolyn Cutrona, 1984

Other comments (if any) :
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

170

REFERENCES

171

REFERENCES

Abusaad, F. E., & El-Gilany, A. H. (2011). Exclusive breastfeeding and infant morbidity in
Sakaka City, Saudi Arabia. Middle East Journal of Nursing, 5(6), 3-8.
Al-Abdi, S. Y., Al Omran, S. A., Al-Aamri, M. A., Al Nasser, M. H., & Al Omran, A. M.
(2015). Prevalence and characteristics of infant's unexplained breast preference for
nursing one breast: A self-administered survey. Breastfeeding Medicine, 10(10), 474-480.
doi:10.1089/bfm.2015.0116
al-Ayed, I. H., & Qureshi, M. I. (1998). Breastfeeding practices in urban Riyadh. Journal of
Tropical Pediatrics, 44(2), 113-117.
Al-Binali, A. M. (2012). Breastfeeding knowledge, attitude and practice among school teachers
in Abha female educational district, southwestern Saudi Arabia. International
Breastfeeding Journal, 7(1), 10-10. doi:10.1186/1746-4358-7-10
Al-Hourani, H. M., Henry, C. J. K., & Lightowler, H. J. (2003). Prevalence of overweight among
adolescent females in the United Arab Emirates. American Journal of Human Biology :
The Official Journal of the Human Biology Council, 15(6), 758-764.
doi:10.1002/ajhb.10212
Al-Hreashy, F. A., Tamim, H. M., Al-Baz, N., Al-Kharji, N. H., Al-Amer, A., Al-Ajmi, H., &
Eldemerdash, A. A. (2008). Patterns of breastfeeding practice during the first 6 months of
life in Saudi Arabia. Saudi Medical Journal, 29(3), 427-431.
Al-Isa, A. N. (2004). Body mass index, overweight and obesity among Kuwaiti intermediate
school adolescents aged 10-14 years. European Journal of Clinical Nutrition, 58(9),
1273-1277. doi:10.1038/sj.ejcn.1601961
Al-Jassir, M., El-Bashir, B., & Moizuddin, S. (2004). Surveillance of infant feeding practices in
Riyadh city. Annals of Saudi Medicine, 24(2), 136-140.
Al-Jassir, M., Moizuddin, S. K., & Al-Bashir, B. (2003). A review of some statistics on
breastfeeding in Saudi Arabia. Nutrition and Health, 17(2), 123.
Al-Jassir, M. S., El-Bashir, B. M., Moizuddin, S. K., & Abu-Nayan, A. A. (2006). Infant feeding
in Saudi Arabia: Mothers' attitudes and practices. Eastern Mediterranean Health Journal,
12(1-2), 6-13.
Al-Madani, M., Vydelingum, V., & Lawrence, J. (2010). Saudi mothers’ expected intentions and
attitudes toward breast-feeding. ICAN: Infant, Child, & Adolescent Nutrition, 2(3), 187198. doi:10.1177/1941406410369699

172

al-Mazrou, Y. Y., Aziz, K. M., & Khalil, M. (1994). Breastfeeding and weaning practices in
Saudi Arabia. Journal of Tropical Pediatrics, 40(5), 267.
al-Nasser, A. N., Bamgboye, E. A., & Alburno, M. K. (1991). A retrospective study of factors
affecting breast feeding practices in a rural community of Saudi Arabia. East African
Medical Journal, 68(3), 174-180.
Al-Othaimeen, A. I. (2007). Obesity: An emerging problem in Saudi Arabia. Analysis of data
from the National Nutrition Survey. Eastern Mediterranean Health Journal, 13(2), 441448.
Al-Yousif, G., Sabra, A., Sebiany, A., & Hafez, A. (2011). Predictors of breastfeeding practices
in primary health care facilities at Al-Khobar city, Eastern Saudi Arabia. The Egyptian
Journal of Community Medicine, 29(3), 13-24.
Al Juaid, D. A. M., Binns, C. W., & Giglia, R. C. (2014). Breastfeeding in Saudi Arabia: a
review. International Breastfeeding Journal, 9(1), 1-18. doi:10.1186/1746-4358-9-1
Albokhary, A. A., & James, J. P. (2014). Does cesarean section have an impact on the successful
initiation of breastfeeding in Saudi Arabia? Saudi Medical Journal, 35(11), 1400-1403.
Aldosari, F., Bello, A., & Alhidary, I. (2015). Rural-urban migration in the kingdom of Saudi
Arabia: A critical analysis. Revista Kasmera, 43(2), 33-46.
Aldosari, M. S., & Pufpaff, L. A. (2014). Sources of stress among parents of children with
intellectual disabilities: A preliminary investigation in Saudi Arabia. The Journal of
Special Education Apprenticeship, 3(1), 1-21.
Alemayehu, T., Haidar, J., & Habte, D. (2009). Determinants of exclusive breastfeeding
practices in Ethiopia. Ethiopian Journal of Health Development, 23(1), 12.
doi:10.4314/ejhd.v23i1.44832
Alshebly, M., & Sobaih, B. (2016). Attitudes of Saudi mothers towards breastfeeding. Sudanese
Journal of Paediatrics, 16(1), 31-36.
Alsuwaida, N. (2016). Women's education in Saudi Arabia. Journal of International Education
Research, 12(4), 111. doi:10.19030/jier.v12i4.9796
Alwelaie, Y. A., Alsuhaibani, E. A., Al-Harthy, A. M., Radwan, R. H., Al-Mohammady, R. G.,
& Almutairi, A. M. (2010). Breastfeeding knowledge and attitude among Saudi women
in Central Saudi Arabia. Saudi Medical Journal, 31(2), 193-198.
Alzaheb, R. A. (2016a). Factors associated with the early introduction of complementary feeding
in Saudi Arabia. International Journal of Environmental Research and Public Health,
13(7). doi:10.3390/ijerph13070702

173

Alzaheb, R. A. (2016b). Factors associated with the initiation of breastfeeding within the first 48
hours of life in Tabuk, Saudi Arabia. International Breastfeeding Journal, 11, 21.
doi:10.1186/s13006-016-0079-4
Amin, T., Hablas, H., & Al Qader, A. A. (2011). Determinants of initiation and exclusivity of
breastfeeding in Al Hassa, Saudi Arabia. Breastfeeding Medicine, 6(2), 59-68.
doi:10.1089/bfm.2010.0018
Aubuchon-Endsley, N. L., Kennedy, T. S., Gilchrist, M., Thomas, D. G., & Grant, S. (2015).
Relationships among socioeconomic status, dietary intake, and stress in breastfeeding
women. Journal of the Academy of Nutrition & Dietetics, 115(6), 939-946.e931 931p.
doi:10.1016/j.jand.2014.12.017
Avery, A., Zimmermann, K., Underwood, P. W., & Magnus, J. H. (2009). Confident
commitment is a key factor for sustained breastfeeding. Birth, 36(2), 141-148.
doi:10.1111/j.1523-536X.2009.00312.x
Babakazo, P., Donnen, P., Akilimali, P., Ali, N., & Okitolonda, E. (2015). Predictors of
discontinuing exclusive breastfeeding before six months among mothers in Kinshasa:A
prospective study. International Breastfeeding Journal, 10(1), 19. doi:10.1186/s13006015-0044-7
Bahkali, S., Alkharjy, N., Alowairdy, M., Househ, M., Da'ar, O., & Alsurimi, K. (2015). A social
media campaign to promote breastfeeding among Saudi women: A web-based survey
study. Studies in Health Technology and Informatics, 213, 247-250.
Bailey, J., Clark, M., & Shepherd, R. (2008). Duration of breastfeeding in young women:
psychological influences. British Journal of Midwifery, 16(3), 172-178 177p.
Balogun, O., Dagvadorj, A., Anigo, K., Ota, E., & Sasaki, S. (2015). Factors influencing
breastfeeding exclusivity during the first 6 months of life in developing countries: A
quantitative and qualitative systematic review. Maternal & Child Nutrition, 11(4), 433451 419p. doi:10.1111/mcn.12180
Bandura, A. (1977a). Self-efficacy: Toward a unifying theory of behavioral change.
Psychological Review, 84(2), 191-215. doi:http://dx.doi.org/10.1037/0033-295X.84.2.191
Bandura, A. (1977b). Social learning theory. Englewood Cliffs, N.J: Prentice Hall.
Bandura, A. (1986). Social foundations of thought and action: a social cognitive theory.
Englewood Cliffs, N.J: Prentice-Hall.
Bandura, A., Cioffi, D., Taylor, C. B., & Brouillard, M. E. (1988). Perceived self-efficacy in
coping with cognitive stressors and opioid activation. Journal of Personality and Social
Psychology, 55(3), 479-488. doi:10.1037/0022-3514.55.3.479

174

Bartick, M., & Reinhold, A. (2010). The burden of suboptimal breastfeeding in the United
States: A pediatric cost analysis. Pediatrics, 125(5), e1048-1056. doi:10.1542/peds.20091616
Batterjee, M. (2010). A fading art: Understanding breast-feeding in the Middle East.
CreateSpace Independent Publishing Platform.
Ben Loubir, D., Serhier, Z., Battas, O., Agoub, M., & Bennani Othmani, M. (2014). Evaluation
of psychometric properties of the Arabic version of PSS stress measuring scale in the
moroccan population. SAGE Open, 4(4), 215824401456435.
doi:10.1177/2158244014564353
Bevan, G., & Brown, M. (2014). Interventions in exclusive breastfeeding: A systematic review.
British Journal of Nursing, 23(2), 86-89 84p.
Black, R. E., Morris, S. S., & Bryce, J. (2003). Where and why are 10 million children dying
every year? The Lancet, 361(9376), 2226-2234. doi:http://dx.doi.org/10.1016/S01406736(03)13779-8
Blyth, R., Creedy, D. K., Dennis, C., Moyle, W., Pratt, J., & De Vries, S. M. (2002). Effect of
maternal confidence on breastfeeding duration: An application of breastfeeding selfefficacy theory. Birth: Issues in Perinatal Care, 29(4), 278-274 271p.
Blyth, R. J., Creedy, D. K., Dennis, C., Moyle, W., Pratt, J., De Vries, S. M., & Healy, G. N.
(2004). Breastfeeding duration in an Australian population: The influence of modifiable
antenatal factors. Journal of Human Lactation, 20(1), 30-38 39p.
Britton, C., McCormick, F. M., Renfrew, M. J., Wade, A., & King, S. E. (2007). Support for
breastfeeding mothers. Cochrane Database Syst Rev(1), Cd001141.
doi:10.1002/14651858.CD001141.pub3
Brown, A., Rance, J., & Bennett, P. (2016). Understanding the relationship between
breastfeeding and postnatal depression: The role of pain and physical difficulties. Journal
of Advanced Nursing, 72(2), 273-282. doi:10.1111/jan.12832
Cai, X., Wardlaw, T., & Brown, D. W. (2012). Global trends in exclusive breastfeeding.
International Breastfeeding Journal, 7, 12.
Centers for Disease Control and Prevention (CDC). (2012). Rates of any and exclusive
breastfeeding by socio-demographics among children born in 2012. Retrieved from
http://www.cdc.gov/breastfeeding/data/nis_data/rates-any-exclusive-bf-socio-dem2012.htm
Chaaya, M., Osman, H., Naassan, G., & Mahfoud, Z. (2010). Validation of the Arabic version of
the Cohen perceived stress scale (PSS-10) among pregnant and postpartum women. BMC
Psychiatry, 10(1), 111-111. doi:10.1186/1471-244X-10-111
175

Chen, A., & Rogan, W. J. (2004). Breastfeeding and the risk of postneonatal death in the United
States. Pediatrics, 113(5), e435-e439. doi:10.1542/peds.113.5.e435
Coburn, S., Gonzales, N., Luecken, L., & Crnic, K. (2016). Multiple domains of stress predict
postpartum depressive symptoms in low-income Mexican American women: The
moderating effect of social support. Archives of Women's Mental Health, 19(6), 10091018. doi:10.1007/s00737-016-0649-x
Cohen, L. H., McGowan, J., Fooskas, S., & Rose, S. (1984). Positive life events and social
support and the relationship between life stress and psychological disorder. American
Journal of Community Psychology, 12(5), 567-587.
Cohen, S., Brittney, L., Gottlieb, B. H., & Fetzer, I. (2000). Social support measurement and
intervention: A guide for health and social scientists. Oxford, New York: Oxford
University Press.
Cohen, S., Janicki-Deverts, D., & Miller, G. E. (2007). Psychological stress and disease. JAMA:
The Journal of the American Medical Association, 298(14), 1685-1687.
doi:10.1001/jama.298.14.1685
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress.
Journal of Health and Social Behavior, 24(4), 385-396.
Cohen, S., & McKay, G. (1984). Social support, stress and the buffering hypothesis: A
theoretical analysis. In A. Baum, S. E. Taylor, & J. E. Singer (Eds.), Handbook of
psychology and health (pp. 253-267). Hillsdale, NJ: Erlbaum
Cohen, S., & Williamson, G. (1988). Perceived stress in a probability sample of the U.S. In S.
Spacapam & S. Oskamp (Eds.), The social psychology of health: Claremont Symposium
on Applied Social Psychology. Newbury Park, CA: Sage.
Coyl, D. D., Roggman, L. A., & Newland, L. A. (2002). Stress, maternal depression, and
negative mother–infant interactions in relation to infant attachment. Infant Mental Health
Journal, 23(1‐2), 145-163.
Cutrona, C. E., & Russell, D. W. (1987). The provisions of social relationships and adaptation to
stress. In W. H. Jones & D. Perlman (Eds.), A research annual (pp. 37–67). Advances in
Personal Relationships Greenwich, Conn: JAI Press Inc.
Cutrona, C. E., & Troutman, B. R. (1986). Social support, infant temperament, and parenting
self-efficacy: A mediational model of postpartum depression. Child Development, 57(6),
1507-1518.

176

Dashti, M., Scott, J. A., Edwards, C. A., & Al-Sughayer, M. (2010). Determinants of
breastfeeding initiation among mothers in Kuwait. International Breastfeeding Journal,
5, 7. doi:10.1186/1746-4358-5-7
Dashti, M., Scott, J. A., Edwards, C. A., & Al-Sughayer, M. (2014). Predictors of breastfeeding
duration among women in Kuwait: Results of a prospective cohort study. Nutrients, 6(2),
711-728 718p. doi:10.3390/nu6020711
de Jager, E., Broadbent, J., Fuller-Tyszkiewicz, M., Nagle, C., McPhie, S., & Skouteris, H.
(2015). A longitudinal study of the effect of psychosocial factors on exclusive
breastfeeding duration. Midwifery, 31(1), 103-111 109p. doi:10.1016/j.midw.2014.06.009
de Jager, E., Skouteris, H., Broadbent, J., Amir, L., & Mellor, K. (2013). Psychosocial correlates
of exclusive breastfeeding: A systematic review. Midwifery, 29(5), 506-518.
doi:http://dx.doi.org/10.1016/j.midw.2012.04.009
Debes, A. K., Kohli, A., Walker, N., Edmond, K., & Mullany, L. C. (2013). Time to initiation of
breastfeeding and neonatal mortality and morbidity: A systematic review. BMC Public
Health, 13 Suppl 3, S19. doi:10.1186/1471-2458-13-s3-s19
Dennis, C.-L., Gagnon, A., Van Hulst, A., Dougherty, G., & Wahoush, O. (2013). Prediction of
duration of breastfeeding among migrant and Canadian-born women: Results from a
multi-center study. The Journal of Pediatrics, 162(1), 72-79.
doi:http://dx.doi.org/10.1016/j.jpeds.2012.06.041
Dennis, C. (2006). Identifying predictors of breastfeeding self‐efficacy in the immediate
postpartum period. Research in Nursing & Health, 29(4), 256-268.
doi:10.1002/nur.20140
Dennis, C. L. (1999). Theoretical underpinnings of breastfeeding confidence: A self-efficacy
framework. Journal of Human Lactation, 15(3), 195-201.
Dennis, C. L. (2002). Breastfeeding initiation and duration: A 1990-2000 Literature Review.
Journal of Obstetric, Gynecologic, & Neonatal Nursing, 31(1), 12-32.
doi:10.1111/j.1552-6909.2002.tb00019.x
Dennis, C. L. (2003). The breastfeeding self-efficacy scale: Psychometric assessment of the short
form. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 32(6), 734-744.
doi:10.1177/0884217503258459
Dennis, C. L., & Faux, S. (1999). Development and psychometric testing of the Breastfeeding
Self-Efficacy Scale. Research in Nursing & Health, 22(5), 399-409.
doi:10.1002/(SICI)1098-240X

177

Dennis, C. L., Heaman, M., & Mossman, M. (2011). Psychometric testing of the breastfeeding
self-efficacy scale-short form among adolescents. Journal of Adolescent Health Care, 49.
doi:10.1016/j.jadohealth.2010.12.015
Dewey, K. G. (2001). Maternal and fetal stress are associated with impaired lactogenesis in
humans. Journal of Nutrition, 131(11), 3012s-3015s.
Dimitraki, M., Tsikouras, P., Manav, B., Gioka, T., Koutlaki, N., Zervoudis, S., & Galazios, G.
(2016). Evaluation of the effect of natural and emotional stress of labor on lactation and
breast-feeding. Archives of Gynecology and Obstetrics, 293(2), 317-328.
doi:10.1007/s00404-015-3783-1
Doulouger, K., Panagopoulou, E., & Montgomery, A. (2013). The impact of maternal stress on
initiation and establishment of breastfeeding. Journal of Neonatal Nursing, 19(4), 162167 166p. doi:10.1016/j.jnn.2013.02.003
Dozier, A. M., Nelson, A., & Brownell, E. (2012). The relationship between life stress and
breastfeeding outcomes among low-income mothers. Advances in Preventive Medicine,
2012, 902487. doi:10.1155/2012/902487
Dunn, R., Kalich, K., Henning, M., & Fedrizzi, R. (2015). Engaging field-based professionals in
a qualitative assessment of barriers and positive contributors to breastfeeding using the
social ecological model. Maternal & Child Health Journal, 19(1), 6-16 11p.
doi:10.1007/s10995-014-1488-x
Eastin, A., & Sharma, M. (2015). Using social cognitive theory to predict breastfeeding in
African-American Women. American Journal of Health Studies, 30(4), 196.
Eidelman, A. I., & Schanler, R. J. (2012). Breastfeeding and the use of human milk: An analysis
of the American Academy of Pediatrics 2012 Breastfeeding Policy Statement.
Breastfeeding Medicine, 7(5), 323-324. doi:10.1089/bfm.2012.0067
El-Gilany, A.-H., Shady, E., & Helal, R. (2011). Exclusive breastfeeding in Al-Hassa, Saudi
Arabia. Breastfeeding Medicine, 6, 209-213.
El Mouzan , M., Al Omar, A. A., Al Salloum, A. A., Al Herbish, A. S., & Qurachi, M. M.
(2009). Trends in infant nutrition in Saudi Arabia: Compliance with WHO
recommendations. Annals of Saudi medicine, 29(1), 20-23.
Eldeek, B. S., Tayeb, S. O., & Habiballah, S. B. (2012). Knowledge, attitudes and practice of
mothers toward breast feeding at Well Baby Clinic, King Abdulaziz University Hospital.
Journal of American Science, 8, 157-162.
Faridvand, F., Mirghafourvand, M., Malakouti, J., & Mohammad-Alizadeh-Charandabi, S.
(2017). Relationship between social support and breastfeeding self-efficacy among
women in Tabriz, Iran. British Journal of Midwifery, 25(2), 103-109.
178

Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009). Statistical power analyses using
G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods,
41(4), 1149-1160. doi:10.3758/brm.41.4.1149
Fawcett, J., & Desanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and
Evaluation of Nursing Models and Theories (3rd ed). Philadelphia, PA: F. A. Davis.
Fida, N. M., & Al-Aama, J. Y. (2003). Pattern of infant feeding at a University Hospital in
western Saudi Arabia. Saudi Medical Journal, 24(7), 725-729.
Finkelstein, E. A., Fiebelkorn, I. C., & Wang, G. (2003). National medical spending attributable
to overweight and obesity: How much, and who's paying? Health Affairs, W3-219-w213226.
Gadalla, T. M. (2009). Determinants, correlates and mediators of psychological distress: A
longitudinal study. Social Science & Medicine, 68(12), 2199-2205.
doi:10.1016/j.socscimed.2009.03.040
Galipeau, R., Dumas, L., & Lepage, M. (2017). Perception of not having enough milk and actual
milk production of first-time breastfeeding mothers: Is there a difference? Breastfeeding
Medicine, N.PAG-N.PAG. doi:10.1089/bfm.2016.0183
Gardazi, S. F., Mobeen, N., & Syeda Ahsan Ali, G. (2016). Causes of stress and burnout among
working mothers in Pakistan. The Qualitative Report, 21(5), 916.
Gartner, L. M., Morton, J., Lawrence, R. A., Naylor, A. J., O'Hare, D., Schanler, R. J., &
Eidelman, A. I. (2005). Breastfeeding and the use of human milk. Pediatrics, 115(2),
496-506. doi:10.1542/peds.2004-2491
Gatti, L. (2008). Maternal perceptions of insufficient milk supply in breastfeeding. Journal of
Nursing Scholarship, 40(4), 355-363. doi:10.1111/j.1547-5069.2008.00234.x
Gittner, L., Ludington-Hoe, S., & Haller, H. (2014). Infant obesity and severe obesity growth
patterns in the first two years of life. Maternal & Child Health Journal, 18(3), 613-624.
doi:10.1007/s10995-013-1285-y
Glanz, K., Rimer, B. K., & Viswanath, K. (2008). Health behavior and health education:
Theory, research, and practice (Vol. 4th;4. Aufl.;4;). San Francisco, CA: Jossey-Bass.
Glassman, M. E., McKearney, K., Saslaw, M., & Sirota, D. R. (2014). Impact of breastfeeding
self-efficacy and sociocultural factors on early breastfeeding in an urban, predominantly
dominican community. Breastfeeding Medicine, 9, 301-307 307p.
doi:10.1089/bfm.2014.0015

179

General Authority for Statistics. (2016). Labor force survey. Retrieved from
http://www.stats.gov.sa/sites/default/files/so-lfs-06-2016-ar_0_1.pdf
Saudi Arabian General Authority for statistics. (2016).Population and housing. Retrieved
September30, 2016 from http://www.cdsi.gov.sa/en/indicators/1
Goodnite, P. M. (2014). Stress: A concept analysis. Nursing Forum, 49(1), 71-74.
doi:10.1111/nuf.12044
Gottlieb, B. H., & Bergen, A. E. (2010). Social support concepts and measures. Journal of
Psychosomatic Research, 69(5), 511-520. doi:10.1016/j.jpsychores.2009.10.001
Groer, M. W. (2005). Differences between exclusive breastfeeders, formula-feeders, and
controls: A study of stress, mood, and endocrine variables. Biological Research For
Nursing, 7(2), 106-117. doi:10.1177/1099800405280936
Groer, M. W., & Davis, M. W. (2006). Cytokines, infections, stress, and dysphoric moods in
breastfeeders and formula feeders. Journal of Obstetric Gynecology Neonatal Nursing,
35(5), 599-607. doi:10.1111/j.1552-6909.2006.00083.x
Groer, M. W., Davis, M. W., & Hemphill, J. (2002). Postpartum stress: Current concepts and the
possible protective role of breastfeeding. Journal of Obstetric Gynecology Neonatal
Nursing, 31(4), 411-417.
Habib, F., Hanafi, M. I., & El-Sagheer, A. (2011). Antenatal care in primary health care centres
in Medina, Saudi Arabia, 2009: A cross-sectional study. Eastern Mediterranean Health
Journal 17(3), 196-202.
Hamdan, A., & Tamim, H. (2012). The relationship between postpartum depression and
breastfeeding. International Journal of Psychiatry in Medicine, 43(3), 243-259.
Hammen, C. (2005). Stress and depression. Annual Review of Psychology., 1, 293-319.
Hannula, L., Kaunonen, M., & Tarkka, M. (2008). A systematic review of professional support
interventions for breastfeeding. Journal of Clinical Nursing, 17(9), 1132-1143.
doi:10.1111/j.1365-2702.2007.02239.x
Haroon, S., Das, J. K., Salam, R. A., Imdad, A., & Bhutta, Z. A. (2013). Breastfeeding
promotion interventions and breastfeeding practices: A systematic review. BMC Public
Health. doi:10.1186/1471-2458-13-S3-S20
Hauck, F. R., Thompson, J. M., Tanabe, K. O., Moon, R. Y., & Vennemann, M. M. (2011).
Breastfeeding and reduced risk of sudden infant death syndrome: A meta-analysis.
Pediatrics, 128(1), 103-110. doi:10.1542/peds.2010-3000

180

Hauff, L. E., Leonard, S. A., & Rasmussen, K. M. (2014). Associations of maternal obesity and
psychosocial factors with breastfeeding intention, initiation, and duration. American
Journal of Clinical Nutrition, 99(3), 524-534 511p. doi:10.3945/ajcn.113.071191
Healthy People. (2016). Breastfeeding Report Card. Retrieved from
https://www.healthypeople.gov/2020/data-source/breastfeeding-report-card
Henderson, J. J., Evans, S. F., Straton, J. A., Priest, S. R., & Hagan, R. (2003). Impact of
postnatal depression on breastfeeding duration. Birth, 30(3), 175-180.
Henshaw, E. J., Fried, R., Siskind, E., Newhouse, L., & Cooper, M. (2015). Breastfeeding selfefficacy, mood, and breastfeeding outcomes among primiparous women. Journal of
Human Lactation, 31(3), 511-518. doi:10.1177/0890334415579654
Hewitt, P. L., Flett, G. L., & Mosher, S. W. (1992). The Perceived Stress Scale: Factor structure
and relation to depression symptoms in a psychiatric sample. Journal of Psychopathology
and Behavioral Assessment, 14(3), 247-257.
Hibel, L. C., Mercado, E., & Trumbell, J. M. (2012). Parenting stressors and morning cortisol in
a sample of working mothers. Journal of Family Psychology, 26(5), 738-746.
doi:10.1037/a0029340
Horne, R. S. C., Parslow, P. M., Ferens, D., Watts, A. M., & Adamson, T. M. (2004).
Comparison of evoked arousability in breast and formula fed infants. Archives of Disease
in Childhood, 89(1), 22-25.
Hulley, S. B., Cummings, S. R., Browner, W. S., Grady, D. G., & Newman, T. B. (2013).
Designing clinical research. Lippincott Williams & Wilkins.
Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., . . . Lau, J. (2007).
Breastfeeding and maternal and infant health outcomes in developed countries. Evidence
report/technology assessment (Full Report)(153), 1-186.
James, D. C., & Lessen, R. (2009). Position of the American Dietetic Association: Promoting
and supporting breastfeeding. Journal of the American Dietetic Association, 109(11),
1926-1942.
Jana, A. (2006). Interventions for promoting the initiation of breastfeeding. The WHO
Reproductive Health Library; Geneva: World Health Organization. Retrieved from
https://extranet.who.int/rhl/topics/pregnancy-and-childbirth/care-afterchildbirth/interventions-promoting-initiation-breastfeeding
Jarlenski, M., McManus, J., Diener-West, M., Schwarz, E. B., Yeung, E., & Bennett, W. L.
(2014). Association between support from a health professional and breastfeeding
knowledge and practices among obese women: Evidence from the infant practices study
II. Women's Health Issues, 24(6), 641-648. doi:10.1016/j.whi.2014.08.002
181

Jevitt, C. M., Groer, M. W., Crist, N. F., Gonzalez, L., & Wagner, V. D. (2012). Postpartum
stressors: A content analysis. Issues in Mental Health Nursing, 33(5), 309-318.
doi:10.3109/01612840.2011.653658
Jones, J. R., Kogan, M. D., Singh, G. K., Dee, D. L., & Grummer-Strawn, L. M. (2011). Factors
associated with exclusive breastfeeding in the United States. Pediatrics, 128(6), 11171125 1119p. doi:10.1542/peds.2011-0841
Kaunonen, M., Hannula, L., & Tarkka, M.-T. (2012). A systematic review of peer support
interventions for breastfeeding. Journal of Clinical Nursing, 21(13/14), 1943-1954
1912p. doi:10.1111/j.1365-2702.2012.04071.x
Khan, J., Vesel, L., Bahl, R., & Martines, J. (2015). Timing of breastfeeding initiation and
exclusivity of breastfeeding during the first month of life: Effects on neonatal mortality
and morbidity-a systematic review and meta-analysis. Maternal & Child Health Journal,
19(3), 468-479 412p. doi:10.1007/s10995-014-1526-8
Kim, H. S., Sherman, D. K., & Taylor, S. E. (2008). Culture and social support. American
Psychologist, 63(6), 518.
Kingston, D., Heaman, M., Fell, D., Dzakpasu, S., & Chalmers, B. (2012). Factors associated
with perceived stress and stressful life events in pregnant women: Findings from the
Canadian maternity experiences survey. Maternal and Child Health Journal, 16(1), 158168. doi:10.1007/s10995-010-0732-2
Koupil, I., & Toivanen, P. (2008). Social and early-life determinants of overweight and obesity
in 18-year-old Swedish men. International Journal of Obesity, 32(1), 73-81.
Kramer, M. S., Kakuma, R. (2002). The optimal duration of exclusive breastfeeding (Review).
Cochrane database of systematic reviews, 1, 11-12
Krenz-Niedbala, M., Koscinski, K., Puch, E. A., Zelent, A., Breborowicz, A., Krenz-Niedbała,
M., . . . Bręborowicz, A. (2015). Is the relationship between breastfeeding and childhood
risk of asthma and obesity mediated by infant antibiotic treatment? Breastfeeding
Medicine, 10, 326-333 328p. doi:10.1089/bfm.2014.0173
Kronborg, H., & Væth, M. (2004). The influence of psychosocial factors on the duration of
breastfeeding. Scandinavian Journal of Public Health, 32(3), 210-216 217p.
Launer, L. J., Forman, M. R., Hundt, G. L., Sarov, B., Chang, D., Berendes, H. W., & Naggan,
L. (1992). Maternal recall of infant feeding events is accurate. Journal of Epidemiology
and Community Health (1979-), 46(3), 203-206. doi:10.1136/jech.46.3.203
Lazarus, R. S. (2006). Stress and emotion: A new synthesis (Vol. illustratition). New York:
Springer.
182

Lee, E.-H. (2012). Review of the psychometric evidence of the perceived stress scale. Asian
Nursing Research, 6(4), 121-127 127p. doi:10.1016/j.anr.2012.08.004
Lewis, J. A. (2009). Maternal perceptions of insufficient milk supply in breastfeeding. MCN, The
American Journal of Maternal/Child Nursing, 34(4), 264-264.
doi:10.1097/01.NMC.0000357926.38421.f6
Li, J., Kendall, G. E., Henderson, S., & Downie, J. (2008). Maternal psychosocial well-being in
pregnancy and breastfeeding duration. Acta Pediatrica (Oslo).
Li, R., Scanlon, K. S., & Serdula, M. K. (2005). The validity and reliability of maternal recall of
breastfeeding practice. Nutrition Reviews, 63(4), 103-110.
Liu, C. C., Chen, Y. C., Yeh, Y. P., & Hsieh, Y. S. (2012). Effects of maternal confidence and
competence on maternal parenting stress in newborn care. Journal of Advanced Nursing,
68(4), 908-918. doi:10.1111/j.1365-2648.2011.05796.x
Loke, A. Y., & Chan, L. K. (2013). Maternal breastfeeding self-efficacy and the breastfeeding
behaviors of newborns in the practice of exclusive breastfeeding. Journal of Obstetric,
Gynecology and Neonatal Nursing, 42(6), 672-684. doi:10.1111/1552-6909.12250
McCarter-Spaulding, D., & Gore, R. (2009). Breastfeeding self-efficacy in women of African
descent. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 38(2), 230243. doi:10.1111/j.1552-6909.2009.01011.x
McCarter-Spaulding, D. E., & Kearney, M. H. (2001). Parenting self-efficacy and perception of
insufficient breast milk. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 30(5),
515-522. doi:10.1111/j.1552-6909.2001.tb01571.x
McFadden, A., Gavine, A., Renfrew, M. J., Wade, A., Buchanan, P., Taylor, J. L., . . .
MacGillivray, S. (2017). Support for healthy breastfeeding mothers with healthy term
babies. Cochrane Database Syst Rev, 2, Cd001141.
doi:10.1002/14651858.CD001141.pub5
McQueen, K., Sieswerda, L. E., Montelpare, W., & Dennis, C.-L. (2015). Prevalence and factors
affecting breastfeeding among aboriginal women in northwestern Ontario. JOGNN:
Journal of Obstetric, Gynecologic & Neonatal Nursing, 44(1), 51-68 18p.
doi:10.1111/1552-6909.12526
McQueen, K. A., Dennis, C. L., Stremler, R., & Norman, C. D. (2011). A pilot randomized
controlled trial of a breastfeeding self-efficacy intervention with primiparous mothers.
Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(1), 35-46.
doi:10.1111/j.1552-6909.2010.01210.x

183

Meedya, S. (2010). Factors that positively influence breastfeeding duration to 6 months: A
literature review. Women and Birth : Journal of the Australian College of Midwives,
23(4), 135-145.
Mezzacappa, E. S., & Katlin, E. S. (2002). Breast-feeding is associated with reduced perceived
stress and negative mood in mothers. Health Psychology, 21(2), 187-193.
Miller, L. J. (2002). Postpartum depression. JAMA: Journal of the American Medical
Association, 287(6), 762-765.
Mosalli, R., El-Azim, A. A. A., Qutub, M. A., Zagoot, E., Janish, M., & Paes, B. A. (2012).
Perceived barriers to the implementation of a baby friendly initiative in Jeddah, Saudi
Arabia. Saudi Medical Journal, 33(8), 895-900.
Murshid, E. (2006). Infant feeding practices of Saudi mothers in five different regions of Saudi
Arabia. Saudi Dental Journal, 18(2), 78-85.
Nabulsi, M. (2011). Why are breastfeeding rates low in Lebanon? A qualitative study. BMC
Pediatrics, 11(1), 75-75. doi:10.1186/1471-2431-11-75
Nafee Elsayed, H. M., & Al-Dossary, L. A. (2016). Exclusive Breastfeeding, Prevalence and
maternal concerns: Saudi and Egyptian Mothers. Journal of Education and Practice,
7(3), 5-11.
Nassar, M. F., Abdel-Kader, A. M., Al-Refaee, F. A., Mohammad, Y. A., Al Dhafiri, S., Gabr,
S., & Al-Qattan, S. (2014). Breastfeeding practice in Kuwait: Determinants of success
and reasons for failure. Eastern Mediterranean Health Journal, 20(7), 409-415.
Natland, S. T., Andersen, L. F., Nilsen, T. I. L., Forsmo, S., & Jacobsen, G. W. (2012). Maternal
recall of breastfeeding duration twenty years after delivery. BMC Medical Research
Methodology, 12, 179.
Neifert, M. R. (2001). Prevention of breastfeeding tragedies. The Pediatric Clinics of North
America, 48(2), 273-297. doi:10.1016/S0031-3955(08)70026-9
Neville, M. C., & Morton, J. (2001). Physiology and endocrine changes underlying human
lactogenesis II. The Journal of Nutrition, 131(11), 3005S-3008S.
Nichols, J., Schutte, N. S., Brown, R. F., Dennis, C., & Price, I. (2009). The impact of a selfefficacy intervention on short-term breast-feeding outcomes. Health Education &
Behavior, 36(2), 250-258 259p. doi:10.1177/1090198107303362
O'Brien, M., Buikstra, E., Fallon, T., & Hegney, D. (2009). Exploring the influence of
psychological factors on breastfeeding duration, phase 1: Perceptions of mothers and
clinicians. Journal of Human Lactation : Official Journal of International Lactation
Consultant Association, 25(1), 55-63. doi:10.1177/0890334408326071
184

Ogbeide, D. O., Siddiqui, S., Al Khalifa, I. M., & Karim, A. (2004). Breastfeeding in a Saudi
Arabian community: Profile of parents and influencing factors. Saudi Medical Journal,
25(5), 580-584.
Ogden, C. L., Carroll, M. D., Lawman, H. G., Fryar, C. D., Kruszon-Moran, D., Kit, B. K., &
Flegal, K. M. (2016). Trends in obesity prevalence among children and adolescents in the
United States, 1988-1994 through 2013-2014. JAMA: Journal of the American Medical
Association, 315(21), 2292-2299. doi:10.1001/jama.2016.6361
Otsuka, K., Dennis, C., Tatsuoka, H., & Jimba, M. (2008). The relationship between
breastfeeding self-efficacy and perceived insufficient milk among Japanese mothers.
JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 37(5), 546-555 510p.
doi:10.1111/j.1552-6909.2008.00277.x
Otsuka, K., Taguri, M., Dennis, C.-L., Wakutani, K., Awano, M., Yamaguchi, T., & Jimba, M.
(2014). Effectiveness of a breastfeeding self-efficacy intervention: do hospital practices
make a difference? Maternal and Child Health Journal, 18(1), 296-306.
doi:10.1007/s10995-013-1265-2
Patel, S., & Patel, S. (2015). The effectiveness of lactation consultants and lactation counselors
on breastfeeding outcomes. Journal of Human Lactation, 0890334415618668.
Patenaude, E. M., Knol, L. L., & Turner, L. W. (2015). Social cognitive theory constructs
associated with mothers’ breastfeeding in public comfort levels: Results from a national
study. The Journal of the Academy of Nutrition and Dietetics, 115(9, Supplement), A82.
doi:http://dx.doi.org/10.1016/j.jand.2015.06.295
Peltola, M. J., Yrttiaho, S., Puura, K., Proverbio, A. M., Mononen, N., Lehtimäki, T., &
Leppänen, J. M. (2014). Motherhood and oxytocin receptor genetic variation are
associated with selective changes in electrocortical responses to infant facial expressions.
Emotion (15283542), 14(3), 469-477 469p. doi:10.1037/a0035959
Peterson, S. J., & Bredow, T. S. (2017). Middle range theories: Application to nursing research
and practice (Vol. 4th). Philadelphia: Wolters Kluwer.
Polit, D. F., & Beck, C. T. (2006). The content validity index: Are you sure you know what's
being reported? Critique and recommendations. Research in Nursing & Health, 29(5),
489-497.
Rallis, S., Skouteris, H., McCabe, M., & Milgrom, J. (2014). The transition to motherhood:
Towards a broader understanding of perinatal distress. Women & Birth, 27(1), 68-71.
doi:10.1016/j.wombi.2013.12.004

185

Razurel, C., Bruchon-Schweitzer, M., Dupanloup, A., Irion, O., & Epiney, M. (2011). Stressful
events, social support and coping strategies of primiparous women during the postpartum
period: a qualitative study. Midwifery, 27(2), 237-242. doi:10.1016/j.midw.2009.06.005
Razurel, C., Kaiser, B., Antonietti, J.-P., Epiney, M., & Sellenet, C. (2017). Relationship
between perceived perinatal stress and depressive symptoms, anxiety, and parental selfefficacy in primiparous mothers and the role of social support. Women & Health, 57(2),
154-172. doi:10.1080/03630242.2016.1157125
Reynolds, D., Hennessy, E., & Polek, E. (2014). Is breastfeeding in infancy predictive of child
mental well-being and protective against obesity at 9 years of age? Child: Care, Health &
Development, 40(6), 882-890 889p. doi:10.1111/cch.12126
Rippeyoung, P. L., & Noonan, M. C. (2012). Is breastfeeding truly cost free? Income
consequences of breastfeeding for women. American Sociological Review, 77(2), 244267.
Sack, M., Spieler, D., Wizelman, L., Epple, G., Stich, J., Zabav, M., . . . Zaba, M. (2017).
Intranasal oxytocin reduces provoked symptoms in female patients with posttraumatic
stress disorder despite exerting sympathomimetic and positive chronotropic effects in a
randomized controlled trial. BMC Medicine, 15, 1-11. doi:10.1186/s12916-017-0801-0
Salam, A. A. (2013). Population and household census, kingdom of Saudi Arabia 2010: Facts
and figures. International Journal of Humanities and Social Science, 3(16).
Salem, L. Y. A., & Al Madani, M. M. (2015). Pregnant & lactating mothers' attitudes and
practice of the ten steps to successful breastfeeding at King Fahd Hospital of University
(kfhu) Khobar, Saudi Arabia: Appraisal of baby friendly hospital initiatives. Journal of
Education and Practice, 6(11), 9-18.
Sankar, M. J., Sinha, B., Chowdhury, R., Bhandari, N., Taneja, S., Martines, J., & Bahl, R.
(2015). Optimal breastfeeding practices and infant and child mortality: A systematic
review and meta-analysis. Acta Paediatrica, 104(467), 3-13. doi:10.1111/apa.13147
Schwarzer, R., & Knoll, N. (2007). Functional roles of social support within the stress and
coping process: A theoretical and empirical overview. International Journal of
Psychology, 42(4), 243-252. doi:10.1080/00207590701396641
Segerstrom, S. C., & Miller, G. E. (2004). Psychological stress and the human immune system: a
meta-analytic study of 30 years of inquiry. Psychological Bulletin, 130(4), 601-630.
doi:10.1037/0033-2909.130.4.601
Semenic, S., Loiselle, C., & Gottlieb, L. (2008). Predictors of the duration of exclusive
breastfeeding among first-time mothers. Research in Nursing & Health, 31(5), 428-441.
doi:10.1002/nur.20275

186

Shawky, S., & Abalkhail, B. A. (2003). Maternal factors associated with the duration of breast
feeding in Jeddah, Saudi Arabia. Paediatric and Perinatal Epidemiology, 17(1), 91-96.
doi:10.1046/j.1365-3016.2003.00468.x
Silk, K. J., Horodynski, M. A., Rienzo, M., Mercer, L., Olson, B., & Aldrich, R. (2010).
Strategies to increase health literacy in the infant feeding series (TIFS): A six-lesson
curriculum for low-income mothers. Health Promotion Practice, 11(2), 226-234.
doi:10.1177/1524839908326380
Souza, E., & Fernandes, R. Á. (2014). Breastfeeding self-efficacy: A cohort study. Acta Paulista
de Enfermagem, 27(5), 465-470 466p. doi:10.1590/1982-0194201400076
StataCorp. (2015). Stata statistical software (Version 14). College Station,
TX: StataCorp LP.
Strathearn, L., Mamun, A. A., Najman, J. M., & O'Callaghan, M. J. (2009). Does breastfeeding
protect against substantiated child abuse and neglect? A 15-year cohort study. Pediatrics,
123(2), 483-493 411p. doi:10.1542/peds.2007-3546
Stuebe, A. M., & Schwarz, E. B. (2010). The risks and benefits of infant feeding practices for
women and their children. Journal of Perinatology, 30(3), 155-162.
doi:10.1038/jp.2009.107
Ministry of Health in the Kingdom of Saudi Arabia. (2016). Ministry statistics and indicators.
Retrieved from http://www.moh.gov.sa/en/pages/default.aspx
The United Nations Children Funds (UNICEF). (2015). Nutrition: Breastfeeding. Retrieved from
http://www.u444nicef.org/nutrition/index_24824.html
The United Nations Children's Emergency Fund (UNICEF). (2013). Improving child nutrition:
the achievable imperative for global progress. New York: UNICEF. Retrieved from
http://data.unicef.org/corecode/uploads/document6/uploaded_pdfs/corecode/NutritionRep
ort_April2013_Final_29.pdf
The United Nations Children's Emergency Fund (UNICEF). (2010). Improving exclusive
breastfeeding practices by using communication for development in infant and young
child feeding programs. Retrieved from http://internationalbreastfeedingjournal.
biomedcentral.com/articles/10.1186/s13006-014-0027-0
The World Breastfeeding Trends Initiative (WBTi). (2012). Kingdom of Saudi Arabia. Retrieved
from http://www.worldbreastfeedingtrends.org/GenerateReports/report/WBTi-KSA2012.pdf
Thibeau, S., D'Apolito, K., Minnick, A. F., Dietrich, M. S., Kane, B., Cooley, S., & Groer, M.
(2016). Relationships of maternal stress with milk immune components in african

187

american mothers of healthy term infants. Breastfeeding Medicine, 11, 6-14.
doi:10.1089/bfm.2015.0117
Thulier, D., & Mercer, J. (2009). Variables associated with breastfeeding duration. JOGNN:
Journal of Obstetric, Gynecologic & Neonatal Nursing, 38(3), 259-268.
doi:10.1111/j.1552-6909.2009.01021.x
Twum-Danso, A., & Ame, R. K. (2012). Childhoods at the intersection of the local and the
global. London, UK: Palgrave Macmillan.
Venkatesh, K., Phipps, M., Triche, E., & Zlotnick, C. (2014). The relationship between parental
stress and postpartum depression among adolescent mothers enrolled in a randomized
controlled prevention trial. Maternal & Child Health Journal, 18(6), 1532-1539.
doi:10.1007/s10995-013-1394-7
Victora, C. G., Bahl, R., Barros, A. J. D., França, G. V. A., Horton, S., Krasevec, J., . . . Lancet
Breastfeeding Series, G. (2016). Breastfeeding in the 21st century: Epidemiology,
mechanisms, and lifelong effect. Lancet (London, England), 387(10017), 475-490.
doi:10.1016/S0140-6736(15)01024-7
Wambach, K., & Riordan, J. (2014). Breastfeeding and human lactation: Jones & Bartlett
Publishers.
Wang, Y. C., McPherson, K., Marsh, T., Gortmaker, S. L., & Brown, M. (2011). Health and
economic burden of the projected obesity trends in the USA and the UK. The Lancet,
378(9793), 815-825. doi:http://dx.doi.org/10.1016/S0140-6736(11)60814-3
Wasser, H., Bentley, M., Borja, J., Goldman, B. D., Thompson, A., Slining, M., & Adair, L.
(2011). Infants perceived as "fussy" are more likely to receive complementary foods
before 4 months. Pediatrics, 127(2), 229-237. doi:10.1542/peds.2010-0166
Weimer, J. P. (2001). The economic benefits of breastfeeding: A review and analysis. Retrieved
from http://www.aeped.es/sites/default/files/6-economic_benefits.pdf
Weinstock, M. (2005). The potential influence of maternal stress hormones on development and
mental health of the offspring. Brain, behavior, and immunity, 19(4), 296-308.
World Health Organization. (2016). Exclusive breastfeeding. Retrieved from
http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/
World Health Organization. (2016). Why can’t we give water to a breastfeeding baby before the
6 months, even when it is hot? Retrived from
http://www.who.int/features/qa/breastfeeding/en/
World Health Organization. (2015). 10 facts on breastfeeding. Retrived from
http://www.who.int/features/factfiles/breastfeeding/en/
188

World Health Organization (WHO) & UNICEF. (2009). Baby-friendly hospital initiative:
Revised, updated and expanded for integrated care preface for the 2009 BFHI materials.
Retrieved on June 6th, 2016 from
http://apps.who.int/iris/bitstream/10665/43593/1/9789241594967_eng.pdf
Wu, D. S., Hu, J., McCoy, T. P., & Efird, J. T. (2014). The effects of a breastfeeding selfefficacy intervention on short-term breastfeeding outcomes among primiparous mothers
in Wuhan, China. Journal of Advanced Nursing, 70(8), 1867-1879.
doi:10.1111/jan.12349
Yu, W. (2011). New mother’s guide to breastfeeding. American Academy of Pediatrics. New
York, NY: Bantam.
Zhu, J., Chan, W., Zhou, X., Ye, B., & He, H. (2014). Predictors of breast feeding self-efficacy
among Chinese mothers: A cross-sectional questionnaire survey. Midwifery, 30(6), 705711. doi:10.1016/j.midw.2013.12.008
Zhu, P., Hao, J., Jiang, X., Huang, K., & Tao, F. (2013). New insight into onset of lactation:
mediating the negative effect of multiple perinatal biopsychosocial stress on
breastfeeding duration. Breastfeeding Medicine, 8, 151-158 158p.
doi:10.1089/bfm.2012.0010
Zhu, X., Tian, J., Chen, G., & Christensson, K. (2014). Predictors of breastfeeding exclusivity in
three cities of China. Breastfeeding Medicine, 9, 103-104 102p.
doi:10.1089/bfm.2013.0053

189