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Rates of ever breastfeeding, early initiation, and exclusive breastfeeding in

Saudi Arabia: A narrative review

Article · December 2024

DOI: 10.23750/abm.v95i6.15898

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Acta Biomed 2024; Vol. 95, N. 6: e2024131 DOI: 10.23750/abm.v95i6.15898 © Mattioli 1885

Review

Rates of ever breastfeeding, early initiation, and exclusive

breastfeeding in Saudi Arabia: A narrative review
Mohammed S Aldossary 1, Bayan A AlAsmari 2, Afnan M Almuaddi 3, Shahad M Alhajri 4,
Mervat M El Dalatony 5
1
General Directorate of Research and Studies, Ministry of Health, Riyadh, Saudi Arabia; 2General Directorate of Research and
Studies, Ministry of Health, Riyadh, Saudi Arabia; 3General Directorate of Research and Studies, Ministry of Health, Riyadh,
Saudi Arabia; 4General Directorate of Research and Studies, Ministry of Health, Riyadh, Saudi Arabia; 5Department of Public
Health and Community Medicine University of Menoufia, Shebin El Kom, Egypt

Abstract. Background and aim: Every infant and child has the right to good nutrition according to the “Con-
vention on the Rights of the Child”. Hence, Optimal breastfeeding is so critical that it could save the lives of
over 820 000 children under the age of 5 years each year. Breastmilk is the ideal food for infants. However,
contrary to the World Health Organization (WHO) recommendations, global breastfeeding rates remain
below the target. Aim: Hence, this review aimed to update and assess the reported rates of ever breastfeeding,
early initiation of breastfeeding (EIBF), and exclusive breastfeeding (EBF) in recent Saudi Arabian studies
(2018–2023). Methods: Databases were searched for recent breastfeeding-related studies published between
January 2018 and June 2023. This review comprised 18 cross-sectional studies. Results: The reported rates of
ever breastfeeding ranged from 64.7% to 97.5%, and the EIBF rates ranged from 13.9% to 85.1%. In addition,
16.3%–45.7% of women practiced EBF for their infants’ first 6 months of life. Conclusions: Breastfeeding rates
reported by women in various regions of Saudi Arabia are lower than the current WHO recommendations.
Our results thus demonstrate the significant geographic and temporal data heterogeneity in breastfeeding
practices in Saudi Arabia. Recommendations are made to enhance these rates. (www.actabiomedica.it)

Key words: child, woman, breastfeeding, Saudi Arabia

Background during the second year of life (2). The World Health
Organization (WHO) and United Nations Children’s
Every infant and child has the right to good nu- Funds (UNICEF) monitor several global indicators of
trition according to the “Convention on the Rights breastfeeding practices. Ever breastfeeding initiation
of the Child” (1) Hence, Optimal breastfeeding is (i.e., “ever breastfeeding”) refers to infants having been
so critical that it could save the lives of over 820 000 breastfed even for a short period. Early initiation of
children under the age of 5 years each year. Breast- breastfeeding (EIBF) is a global indicator that, accord-
milk is the ideal food for infants. It is safe, clean and ing to the WHO, refers to the percentage of newborns
contains antibodies which help protect against many breastfed within 1 hour of birth in a specific time (3).
common childhood illnesses. Breastmilk provides all The WHO has defined exclusive breastfeeding (EBF),
the energy and nutrients that the infant needs for the which is another global indicator, as the percentage
first months of life, and it continues to provide up of infants aged 0–5 months (<6 months) who are fed
to half or more of a child’s nutritional needs during exclusively with breast milk (4). Globally, despite the
the second half of the first year, and up to one third WHO and UNICEF recommendations, breastfeeding
2 Acta Biomed 2024; Vol. 95, N. 6: e2024131

still tends to be below the expected levels, and only Methods

fewer than half of infants under 6 months old are ex-
clusively breastfed. Moreover, the EIBF is still below We obtained such objectives through search-
the 2025 target of 50% (5). Currently, Saudi Arabia has ing (PubMed/Medline, ScienceDirect, Scopus, and
no systematic surveillance system that shares and com- Google Scholar) for recent breastfeeding-related stud-
piles data nationally for breastfeeding (6,7). According ies published between January 2018 and June 2023. The
to a systematic review published in 2014, breastfeed- search word “Breastfeeding,” “Breast feeding,” “Breast-
ing practices were reported to be inadequate and un- fed,” “Breast fed,” or “Breast milk” was combined with
favorable. Despite the high reported rates (commonly the search term “Saudi,” “Saudi Arabia,” or “Middle
above 90%) of breastfeeding initiation overall among East.” This search was enhanced by manual searches of
Saudi women, low EBF rates have been extensively reference lists from each relevant publication identi-
reported (8). Since the time of that review, various as- fied. We included all English-language studies report-
pects of breastfeeding practices have been widely ex- ing the rates of ever breastfeeding, EIBF, and/or EBF
plored in Saudi Arabia. The Saudi Ministry of Health for up to 6 months among women in Saudi Arabia.
(MOH) created a maternal health passport that covers Studies targeting a special population, such as women
various areas of maternal and child health, including with a systemic disease, were excluded.
breastfeeding. This passport includes documents that
provide breastfeeding advice during the prenatal and
postnatal periods. Breastfeeding counseling is also Results
included in MOH well-baby clinics for women dur-
ing visits on the first 6 months of the infants’ life (9). This review included 18 cross-sectional studies.
As part of the Saudi Childbirth Initiative, the MOH An analytical cross-sectional study of women living
launched the mother-and-Baby-friendly Hospital in Riyadh with children aged 6–24 months reported
Initiative in January 2018. The MOH continues to the lowest rate (64.7%) (15), possibly because of two
activate and monitor the Baby-friendly Hospital Ini- points. First, the proportion of individuals (30.7%)
tiative among healthcare facilities in over 40 hospitals who underwent cesarean section was high. This
and primary healthcare centers, and within this initia- method of delivery has been extensively cited as a fac-
tive, the Breastfeeding Encouragement Program was tor associated with low rates of breastfeeding initiation
created (10,11). The Saudi Vision 2030 initiative has (8,16) (Table 3). Surprisingly, only 32% of the women
contributed to economic, social, and cultural advance- received postnatal breastfeeding counseling within
ments that have improved women’s standing, given the first 6 months of their pregnancy. Breastfeeding
them more authority, and increased their economic knowledge and education have been identified as fac-
engagement. As a result of these social advancements, tors of breastfeeding initiation (8,16). The WHO rec-
the manner of breastfeeding may vary in several ways. ommends a minimum of six prenatal and postpartum
Women’s engagement in the labor force has signifi- counseling sessions (17) (Table 3). Among the stud-
cantly increased recently in Saudi Arabia, thereby ies included in our review, the study conducted in the
possibly changing how women feed their infants (12). Eastern region of Saudi Arabia, particularly in two
Furthermore, the COVID-19 pandemic is anticipated prominent cities (Alkhobar and Dammam), on women
to disrupt the WHO’s 2025 global aim of raising the aged 18–55 years revealed the highest reported rate of
EBF rate in infants in the first 6 months to at least ever breastfeeding (97.5%) (18) (Table 3). This previ-
50% (13,14). ous study has two plausible justifications. First, only
18.2% of the participants underwent cesarean section.
Objectives Second, nearly 78% of the participants had received
health education regarding breastfeeding from vari-
This review aimed to update and assess the rates ous sources, with 70% receiving it in a hospital setting.
of ever breastfeeding, EIBF, and EBF that have been Women who attended the maternal and child health
reported in recent studies conducted in Saudi Arabia. clinic services at two major hospitals were included in
Acta Biomed 2024; Vol. 95, N. 6: e2024131 3

that study, and one of these hospitals is a globally rec- breastfeeding practice is influenced by many factors,
ognized baby-friendly hospital. Hence, they were pos- which have been discussed in several reports. These
sibly exposed to repeated messages that promote EBF. factors include knowledge, education, woman’s age,
In comparison with the preceding decade, Al Juaid geographical location, delivery mode, obesity, systemic
et al. published a systematic review of breastfeeding in disease, and occupational status (7,20,21) (Table 3).
Saudi Arabia in 2014, analyzing 17 studies published
between 1979 and 2011 (8). Although most of these Rate of early initiation of breastfeeding
previous studies reported ever breastfeeding rates of
more than 90% in this country, the ratings ranged from Among these included studies, a cross-sectional
76% to 98.9% (8). The average rate of breastfeeding in study conducted at the Maternal and Children’s Hospi-
the Eastern Mediterranean region was recently 84.3%. tal (MCH) in Najran City, Saudi Arabia, reported the
Thus, Saudi Arabia has a relatively higher rate than the greatest rate of EIBF (85.1%) (21). Clinics in MCH
Eastern Mediterranean region (19) (Table 1). Of note, provide immunization, pediatrics, and breastfeeding

Table 1. Studies reported rates of ever breastfed according to its geographical distribution.

Ever Ever
Sample size Breastfed Breastfed Rate
Citation Study Place Population (N) (N) (%)
(23) Azzeh et al, 2018. Mecca Mothers having children 814 658 80.8 %
aged 2 to 3 years old
(24) Raheel et al, 2018. Riyadh & Mothers having at least 614 545 88.8 %
Dammam one child
(25) Khresheh et al, Umluj Mothers aged 20 to 45 67 60 89.6 %
2018. Years old
(14) Elmougy et al, Eastern (Alkhobar Mothers aged 18 to 55 280 273 97.5 %
2018. & Dammam) Years old
(19) Alsulaimani 2019. Taif Mothers of infants aged. 202 176 87.1 %
6–12 months
(5) Ahmed & Salih, KSA Mothers with infants less 1700 1559 91.7 %
2019. than 24 months of age
(26) Hegazi et al, 2019. Rabigh Mothers of children aged 420 403 96 %
6 months to 5 years
(27) Al-Katufi et al, Al-Ahsa Mothers working in 200 182 91 %
2020. primary health care
(28) Alyousefi, 2021. Riyadh Mothers with infants 322 263 81.7 %
between 6 and 24 months
of age
(10) Albar, 2022. Jeddah Mothers of infants aged 247 229 92.7 %
4–12 months
(16) Ibrahim et al, Najran Mothers aged 18 years and 251 233 92.8 %
2023. older
(13) Hassounah et al, Riyadh Mothers of 6–24-month- 323 209 64.7 %
2023. old children
(30) Gohal et al, 2023. Jazan Mothers with infants up to 360 334 92.8 %
2 years old

This table shows that the reported rates of ever breastfeeding and its geographical regions of Saudi Arabia that ranged from 64.7% - 97.5%.
4 Acta Biomed 2024; Vol. 95, N. 6: e2024131

Table 2. Studies reported rates of early initiation of breastfeeding <1 hour (EIBF).

Citation Study Sample size (N) EIBF (N) Percentage (%)

(24) Raheel et al, 2018. 614 224 36.5 %
(23) Azzeh et al, 2018. 814 310 38.1 %
(19) Alsulaimani, 2019. 202 28 13.9 %
(26) Hegazi 2019. 420 178 42.4 %
(5) Ahmed & Salih, 2019. 1700 742 43.6 %
(10) Albar, 2022. 247 111 44.9 %
(20) Elgzar et al, 2023. 403 343 85.1 %
(13) Hassounah et al, 2023. 323 126 39.0 %

According to the included studies, the rates of EIBF (<1 hour) ranged from 13.9% to 85.1%.

support. In Najran City, MCH is the sole hospital that highest rate of EBF (45.7%) (18) (Table 3). As previ-
offers services for maternity and child health. EIBF ously demonstrated by the low percentage of women
within an hour is also supported by the MCH rules; it who underwent cesarean section (18.2%), the high
is a critical responsibility for medical professionals in exposure to breastfeeding health education and the
the delivery room and must be recorded in the patient’s frequent exposure to messages that support the con-
file. Hence, the high rate of EIBF recorded might be tinuation of EBF can explain this rate (18) (Table 3).
explained by justification (22). Conversely, a study con- In Taif City, the reported rate of EBF for the first 6
ducted in Taif in 2019 among women of infants aged months was low (16.3%), possibly impacted by the
6–12 months reported the lowest rate of EIBF (13.9%) inclusion of younger women (mean age = 23.4 years)
(23) (Table 2). This result might be explained by the (23) (Table 2).These findings also reflect Saudi Arabia’s
inclusion of younger women as participants [mean age: wide-ranging regional and temporal data heterogene-
23.4 years (SD = 4.89)]. Although authors could not ity, making the interpretation difficult (23) (Table 2).
support the results they found, their findings highlight In comparison with previous reviews, the systematic
the significant regional and historic heterogeneity in review conducted by Al Juaid et al. in 2014 revealed
Saudi Arabian data, making the interpretation chal- that the EBF rate could not be reliably estimated be-
lenging (23) (Table 2). Alzaheb reviewed breastfeeding cause the rates ranged from 0.8% to 43.9% by region
in the Middle East in 2017, analyzing studies pub- among the 17 studies conducted in Saudi Arabia. This
lished between 2001 and 2017. In terms of EIBF rates limitation may be explained by the lack of specific pa-
in the first hour of life, only two studies in Saudi Arabia rameters and the nature of study design (8).
showed rates of 11.4% and 22%, respectively. The au- According to the review of breastfeeding in the
thor found that the pooled rate of EIBF in the Mid- Middle East by Alzaheb in 2017, the rates of EBF in
dle Eastern region was 34.3% according to the results Saudi Arabia ranged from 12.2% to 31.4% in six stud-
of eight included studies (24,25) (Table 1). According ies (24) (Table 1). The author also found that across
to the current UNICEF global database (updated in the Middle East, the reported rate of EBF at 6 months
December 2022), no data were found for Saudi Arabia. of the infants’ life was 2%–56.4%. Furthermore, the
The global rate of EIBF scored 47%, and UNICEF tar- combined data of the 17 studies included in this review
gets 50% by 2025 and 70% by 2030 (5) (Table 1). reported that the pooled rate of EBF at 6 months in
the Middle Eastern region was 20.5% (24) (Table 1).
Rate of exclusive breastfeeding According to a review in 2022, the average rate of EBF
in the Eastern Mediterranean region was 30.9%. As a
Among the included studies, the study conducted result, Saudi Arabia ranks marginally above this score
in the Eastern region of Saudi Arabia reported the within the Eastern Mediterranean region (19) (Table 1).
Acta Biomed 2024; Vol. 95, N. 6: e2024131 5

Table 3. Studies reported rates of exclusive breastfeeding up to 6 months.

Citation Study Sample size (N) Exclusive Breastfeeding (N) Percentage (%)
(24) Raheel et al, 2018. 614 227 37%
(14) Elmougy et al, 2018. 280 128 45.7%
(19) Alsulaimani, 2019. 202 33 16.3%
(26) Hegazi et al, 2019. 420 116 27.6%
(27) Al-Katufi et al, 2020. 200 87 43.5%
(28) Alyousefi, 2021. 322 90 28%
(4) Abualreesh et al, 2021. 400 182 45.5 %
(17) Al-Anazi et al, 2022. 360 133 36.9%
(16) Ibrahim et al, 2023. 251 67 26.7%
(13) Hassounah et al, 2023. 323 67 20.7%
(30) Gohal et al, 2023. 360 104 28.9%
(18) Al-Thubaity et al, 2023. 1577 506 32.1%
(31) AlQurashi et al, 2023. 664 220 33.1%
(20) Elgzar et al, 2023. 403 165 40.9%

The rate of EBF for the first six months of life of the infants ranged from 16.3% to 45.7%.

As mentioned, the UNICEF’s current global data- longitudinal and cohort studies in Saudi Arabia to
base showed no data for Saudi Arabia. Only 48% of measure breastfeeding and risk factors because multi-
infants worldwide were exclusively breastfed; this rate ple variations and various sociocultural and physiolog-
is still below the targets of 50% by 2025 and 70% by ical factors would influence the results more accurately.
2030 (5) (Table 1). To meet the worldwide breastfeeding targets of 2025
and 2030, healthcare providers need to exert more ef-
forts and conduct greater interventions to encourage
Discussion breastfeeding. Interventions include those designed to
eliminate preventable causes of breastfeeding avoid-
This review revealed that the rates of breastfeed- ance. We recommend more creative initiatives to im-
ing practice reported by women in the reviewed stud- prove breastfeeding practice, nationwide follow-up
ies in different regions of Saudi Arabia are lower than studies, and establishment of a breastfeeding surveil-
the current WHO recommendations. Our findings lance system.
reflect Saudi Arabia’s broad geographical and tem-
poral data divergence in terms of breastfeeding be-
havior and practice. Recent cross-sectional surveys in Limitations
Saudi Arabia indicated that breastfeeding rates in this
country remain below the global standards, despite The cross-sectional nature of the studies con-
the Saudi MOH’s emphasis on EIBF and EBF con- ducted in Saudi Arbia. In addition to the subjective
tinuation. Presently, breastfeeding research in Saudi pattern of such studies as it depends mainly on the
Arabia has relied on cross-sectional study designs and self-reported practice by the lactating mothers so, it’s a
self-reported breastfeeding practices, raising the pos- subject to recall bias. Exploring the lack of longitudi-
sibility of recall bias or a desire for social acceptance. nal data to examine breastfeeding patterns across time
Considering the complexity and multidimensional would provide a more comprehensive understanding
nature of this surveillance, we recommend conducting of the present evidence base’s shortcomings. Other
6 Acta Biomed 2024; Vol. 95, N. 6: e2024131

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