Knowledge, Intention, Practice, and Perceived Barriers of Breastfeeding among Married Working Women in Kuwait

Background: The objectives of this study were: 1) to demonstrate the knowledge of married working women regarding benefits of breastfeeding; 2) to documenttheir intention and practice of breastfeeding; and 3) to identify the barriers of breastfeedingamong thesewomen. Methods:This cross-sectional study was conducted during March-April 2014 amongmarried working class women of childbearing age (21-40 years). The participants were recruited from seven faculties of Kuwait University and four private universities which represented the working class women in Kuwait. Data were collected by usinga self-administered questionnaire. Results: Sixty-nine percent of the women strongly agreed that breastfeeding should begin within the first hour of birth. About 70% planned to breastfeed their children, and 28% strongly agreed to continue it for 6 months. The actual practice of breastfeeding longer than 6 months was significantly higher among nonKuwaitis than Kuwaitis (61.5% vs. 29.7%, p<0.001). Embarrassment and time and social constraints were considered two major barriers of breastfeeding. The scores for the perceived barriers were significantly lower among women with higher education and women of non-Kuwaiti nationals. Conclusion:The study demonstrated possible barriers against breastfeeding which should help health planners in promoting breastfeeding in a society with low rates of breastfeeding. Knowledge, Intention, Practice, and Perceived Barriers of Breastfeeding among Married Working Women in Kuwait Publication History: Received: January 24, 2016 Accepted: May 02, 2016 Published: May 05, 2016

In spite of the large amount of evidence on benefits of breastfeeding, little is known about breastfeeding rates, intention, and barriers in the Middle East region [2].In Kuwait, efforts of promoting breastfeeding have been limited and inadequate [6].A large cross-sectional survey conducted in 1989 among women in Kuwait reported a breastfeeding initiation rate of 86% and exclusive breastfeeding of about 60%.The proportion of children breastfeeding at six months in Kuwait ranges from 35% to 44%, which is well below the international targets [6].The reasons of such a poor rate of breastfeeding in Kuwait have not been investigated.Factors influencing breastfeeding have been investigated worldwide [2,3,5,8,10].The literature suggests that successful breastfeeding depends on multiple factors related to the mother, infant, and the supportive environment [1].Breastfeeding duration has been attributable to maternal age, level of maternal education, maternal smoking and obesity, early return to work, and the introduction of pacifiers, all have been shown to be negatively associated with breastfeeding [2,3,7,10].Furthermore, a study published in 2002 showed the success of a motivational video in promoting breastfeeding and reducing some of the perceived barriers of breastfeeding among low income women in Mississippi [11].
In order to identify some of the contributing factors to poor breastfeeding rates in Kuwait, this studyaimed to evaluate the prevalence of knowledge of benefits of breastfeeding, the intention, practice, and perceived barriers of breastfeeding among married women of childbearing age.

Study setting and the population
This was a cross-sectional study conducted among married women of childbearing age who were staff members working at seven faculties of Kuwait University and four private universities in Kuwait.The faculty units were selected randomly, and then the participants were enrolled on a first-come first-serve basis after taking written informed consent.The study was approved by the Human Subject Ethics Committee of the Kuwait University, and the Dean of the respective faculties.

Survey instrument
A self-administered questionnaire comprising of 60 closedended pre-coded questions was used.The content validity of the questionnaire was evaluated by information gathered from published reports.The questionnaire consisted of data on demographics, knowledge about the importance of breastfeeding, attitudes and International Journal of

Mitra*
Department of Community Medicine and Behavioural Sciences, Faculty of Medicine, Kuwait University, Kuwait practice towards breastfeeding, and three known barriers of breastfeeding such as embarrassment, time and social constraints, and lack of social support.The attitude and practice questions were adopted from the Iowa Infant Feeding Attitude Scale (IIFAS) and the Infant Feeding Intention Scale (IFIS) [12], and the barrier questions were obtained from a study done in Mississippi by one of the investigators(AM) [11].Information about breastfeeding knowledge and intention were collected using Likert scales.For each of the three indices of barriers, there were four statements, with a total of 12, all recorded in Likert scales.The questionnaire was written in English and in Arabic.The questionnaire was pretested among 12 subjects to know about the time required to complete the questionnaire, the clarity of the questions, and for easy reading of the questions.On an average, it took about 10 minutes to complete the questionnaire.

Sample size estimation
Baseline data were used from published reports [11,2], and the sample size was calculated using the formulan= z² pq/d², where p is the proportion, q is 1-p, and d is the expected precision.With a 95% confidence interval, 5% precisionand an estimated 10% dropout, the required sample size for the study was 362.

Statistical methods
All surveys were preceded, and data were entered and analyzed using SPSSversion 22 for windows (SPSS Inc., Chicago, IL).A descriptive analysis was performed for demographic variables, and breastfeeding knowledge and intention.Proportion of women who practiced breastfeeding were compared by the nationality using Chi-Square test.For the barrier questions, a numerical score was computed for each index by assigning 1 point if the woman responded to the survey item in a way suggesting a barrier, and 0 points if she responded to the survey item otherwise.For example, one of the survey items to identify embarrassmentbarrier was as follows: "I would feel embarrassed if I pump my breast at work".For this item, if the woman answers either "Very much agree" or "Some what agree' , she gets 1 point, meaning that she experiences embarrassment as a barrier.If she answers either "Somewhat disagree" or "Very much disagree" she gets 0 point.Thus, for each index someone with a lower score means less perceived barrier and vise versa.The barrier scores were compared among women of differing levels of education and by nationality by using Mann Whitney U test because of the nonnormal distribution of the scores.A p-value of ≤ 0.05 was considered statistically significant.

Results
The number of samples was increased to 376 to havemore power of the study.Although the anticipated dropout rate was 10%, only 5 (1.3%) were actually dropped out from the analysis because of lack of information for the major variables.This yielded a response rate of 98.7% (371/376).

Demographics
Table 1 shows that the mean ± SD age of the participants was 32.7 ± 4.8 years, and 61.7% were Kuwaitis.Eighty percent had a monthly income of more than 1,000 Kuwaiti Dinar (KD)(more than US $3,300).About 21% had an education level of diploma or less, 52% had a bachelor degree, and 31.5% had a postgraduate degree.About 91% were not pregnant at the time of interview.About 54%of the participantshad 1-2 children.The mean ± SD age of the last child was 4.5 ± 3.7 years.

Knowledge about breastfeeding and formula feeding
About 69% of the participants strongly agreed that breastfeeding should begin within the first hour of birth.Of the benefits, 70% or more strongly agreed that breastfeeding protects infants from common childhood illnesses, increases mother-infant bonding, and that breastfeeding is more easily digested and convenient than using formula (Table 2).More than 65% women agreed than breastfeeding is a natural contraceptive within the first six months of birth, and almost a similar proportion of respondents opined that a breastfed child would have a higher level of intelligence quotient (IQ).

Intention of breastfeeding
Table 3 shows that 69.5% of the women intended to try breastfeeding.However, the proportion of women willing to breastfeed declined with the increasing duration of breastfeeding.For example, 83% wanted to breastfeed for one month, 76% intended it for three months, and only 59% mentioned it for 6 months.

Breastfeeding practice: Relationship with nationality and education
When actual practice of breastfeeding was assessed, there was no statistical difference in breastfeeding between Kuwaitis and non-Kuwaitis.However, when duration of breastfeeding was considered, significantly more non-Kuwaitis than Kuwaitis breastfed their babies for longer than 6 months (61.5% vs. 29.7%,respectively, p<0.001) (Table 4).When education was considered, more educated women (with postgraduate degrees) breastfed their babies longer than 6 months compared to those with less education (bachelor or less) (61.0% vs. 32.5%,respectively, p< 0.001) (data not shown).

Barriers of breastfeeding: Relationship with nationality and education
Of the embarrassment indices, the most common barriers included 1) feeling of embarrassment if breasts are pumped at work (85.5%); 2) feeling of shyness in breastfeeding outside the home (74.9%); and 3) the fear that people would see the breasts (60.7%) (Table 5).Among the members of social support, the more frequently mentioned persons were the husband (84.7%) and friends (79.2%).
Scores of the barriers were further compared between nationality and educational levels.Fig. 1 shows that scores of time and social constraints (p< 0.001) and of lack of social support (p = 0.003) were significantly lower among non-Kuwaitis than Kuwaitis, meaning that Kuwaitis perceived more barriers than non-Kuwaitis.The score due to embarrassment barrier was also lower among non-Kuwaitis but it was not statistically significant when compared with the score of Kuwaitis for the same barrier.
Similarly, women with a higher educational level (postgraduate degrees) showed a lower score of barriers in all the three indicators of embarrassment (p = 0.007), time and social constraints (p = 0.006), and lack of social support (p = 0.001)compared to those for the women with a bachelor degree or less education (Figure 2).
Breastfeeding increases mother/infant bonding 321 ( Breastmilk is more easily digested than formula 324 (

Methods
In this study, education was found as a key factor in the decision making of breastfeeding among women of childbearing age in Kuwait.Higher education was also associated with a longer duration of breastfeeding.For example, women with postgraduate degree practiced breastfeeding longer than the other groups.A significantly more proportion of non-Kuwaiti women practiced breastfeeding longer than 6 months than Kuwaitis.Among the barriers, embarrassment and time and social constraints were considered two major barriers irrespective of education and nationality.
Education has been emphasized in the literature many often as an important factor for breastfeeding.In 2006, a study conducted in Netherlands reported that 95.5% of highest-educated mothers initiated breastfeeding, whereas 73.1% in the lowest-educated mothers initiated breastfeeding [10].Other studies reported a linear association between women's level of education and the rate of breastfeeding [3,13].A study conducted in the Phillipinesreported that mothers with secondary level or less education stopped breastfeeding at an earlier age [14].Similar findings were also reported from Middle East countries.In Iran, education of pregnant mothers was significantly associated with their knowledge about breastfeeding [15].The most frequent source of obtaining information among this population was health centers' personnel, followed by family and friends.In the United Arab Emirates, the initiation rate of breastfeeding was very high (98%), and the mean duration was 8.6 months [16].Among the determinants of breastfeeding, multiparity and mother's education were significantly related to the breastfeeding duration (p < 0.001).On the contrary, women with higher education and higher income were less likely to breastfeed in a study in the north of Jordan [17].This could be explained by the western influence of formula feeding among the higher educated and economically rich people.
The present study demonstrated that significantly more non-Kuwaiti women breastfed all of their children compared to their Kuwaiti counterparts.A study done inIreland showed that breastfeeding intiation rates of the non-Irish nationals were significantly higher than the Irish nationals (80% vs. 47%, respectively) [18].Both Kuwaitis and non-Kuwaitis have introduced formula feeding in the first three months in this study.This finding is consistent with several others which showed that, in practice, women would introduce formula or other milk within the first 3 months of breastfeeding [19,20].
Women inour study, regardless of their nationality and educational level, identified embarrassment as the majorbarrier to breastfeeding.Similarly, social stigma and embarrassment were described as barriers of breastfeeding in a study conducted among adolescent mothers and pregnant adolescents in an urban community in of United States [21].This study revealed that women, regardless of their educational level,opined against public breastfeeding.Most respondents in this study were not comfortable in practcing breastfeeding infront of their female friends.This may be partly attributable to the local culture.However, a study carried out in New York City also had similar findings that women do not prefer to breastfeed in public places [22].In an earlier study in Kuwait, paternal support for breastfeeding was positively associated with breastfeeding initiation [6].In a study carried out in Mississippi showed similar results of a sense of embarrasment, specifically about pumping women's breast at school or work, breastfeeding outside their homes, and breastfeeding in front of family members [11].In theMississippi study, time and social constraints presented barriers to fewer women than the embarrasment issues.In the present study, embarrasment barrier was the most common and lack of social support was perceived the least common barrier.
There were some limitations of this study.Because it was a crosssectional study, no causal relationship could be established between breastfeeding and the associated factors.The study was carried out only among married working-class women; so the results cannot be generalized to the whole population.However, this study was unique because, to our knowledge, there were no such studies done among married women in Kuwait.

Conclusion
In this study, about 70% of the married working class women in Kuwait intended to breastfeed their babies.However, the actual practice of breastfeeding for longer than 6 months was only 30% among Kuwaitis and 62% among the non-Kuwaiti women.This study demonstrated that embarrassment and time and social constraints were significantly more common barriers of breastfeeding.In addition, the perceived barriers were less noticeable among women with higher educational levels.
Based on these findings, it is suggested to increase public awareness of exclusive breastfeeding through organized mass media and outreach health campaigns, especially targeting less educated women.

Figure 1 :
Figure 1: Mann-Whitney U test for p-values.Figure 2: Mann-Whitney U test for p-values.

Figure 2 :
Figure 1: Mann-Whitney U test for p-values.Figure 2: Mann-Whitney U test for p-values.

Table 2 :
Participants' knowledge about breastfeeding (Number and percentage).

Table 4 :
Comparison of practice of breastfeeding according to nationality *Chi-Square Test

Table 5 :
Perceived barriers of breastfeeding among the participants.