Exclusive breastfeeding during the 40-day rest period and at six months in Lebanon: a cross-sectional study

Many societies in the Middle East observe a 40-day postpartum period of rest, seclusion, and ritual that helps establish and maintain breastfeeding [1, 2] and protects the mother and newborn from illnesses [3]. During this 40-day rest period, the mother often stays at home and receives help with household chores and congratulatory visits from related women and neighbors [3]. She is encouraged to eat a special diet rich in meat, poultry, soups, and other foods thought to be good for milk production [3]. Other than the cultural aspect, the 40-day rest period has religious underpinnings. For both Muslims and Christians, the 40 days following birth coincide with the period of vaginal discharge resulting from involution of the uterus [4‐6]. Despite being closely linked to infant feeding practices, few studies have examined the 40-day rest period in relation to total and exclusive breastfeeding [1, 2].

The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for the first 6 months of life [7]. Despite these recommendations and the well-established benefits of breastfeeding, the proportion of mothers who EBF for 6 months in the Middle East is estimated at 20.5% (95% CI 14.5, 28.2) [8]. The prevalence of EBF for 6 months in specific countries of the Middle East ranges from 2% in Kuwait [9] to 56.4% in Iran [10]. In Lebanon, a small Middle Eastern country on the Mediterranean sea, the prevalence of EBF for 6 months was 10.1% in a national sample of mother-child dyads recruited from primary healthcare centers in 2004 [11]. More recently in 2016, the prevalence of EBF for 4–6 months was estimated at 16.5% among mothers of toddlers attending daycare centers [12].

None of the previous studies conducted in Lebanon focused on the 40-day rest period as a cultural practice for breastfeeding. Understanding the context-specific patterns and determinants of breastfeeding practices is essential to ensure successful promotion strategies [13]. Therefore, it is timely to place a lens on the 40-day rest period and to examine the factors associated with EBF in Lebanon. The objectives of this paper are to estimate the prevalence of EBF at 40 days and at 6 months, and to examine the sociodemographic, maternal, and child factors associated with EBF in a nationally representative sample of mother-child dyads in Lebanon in 2011–2012.

The study was designed as a cross-sectional survey as part of the “Early Life Nutrition and Health in Lebanon (ELNAHL)” project [14].

Of the 1194 eligible mother-child dyads that were contacted, 1029 participated in the survey (response rate 86%). Twenty-four surveys with missing data were excluded, leaving 1005 mother-child dyads in the analysis. At the time of the interview, 947 children were 40 days or older and had complete information about feeding practices at 40 days, while 893 children were 6 months or older and had complete information about feeding practices at 6 months and thereby included in the analysis at 40 days and at 6 months, respectively.

To our knowledge, this study is the first in the Middle East to examine the prevalence and predictors of EBF during the 40-day rest period. From a nationally representative survey in Lebanon, we report a prevalence of EBF of 41.5% at 40 days and 12. 3% at 6 months.

While belonging to a family with more children was positively associated with EBF at 40 days, belonging to a family owning more cars or being born via C-section was associated with lower odds of EBF at 40 days and at 6 months. In addition, the odds of EBF for 6 months were lower among children whose mothers were overweight or obese.

The 40-day rest period is practiced in several cultures worldwide including the Amazon [16], Greece [4], China [17], Malaysia [18], Nepal [6], India [5], Burma [19], Turkey [20], Negev Bedouins [1, 3], and Egypt [2]. However, few studies have examined the prevalence of total and exclusive breastfeeding during this period [1, 2]. In a study of Negev Bedouin Arab women [1], 24% of the women exclusively breastfed their infants for the first 2 months regardless of whether women received help during the first 40 days. In a qualitative study of maternal beliefs about breastfeeding in a poor urban neighborhood in Egypt [2], women reported exclusively breastfeeding their infants for the first 40 days, after which they supplemented the breastmilk with fluids and foods to promote growth and fatness and to decrease the time spent breastfeeding. In Lebanon, the prevalence of EBF for 8–12 weeks was 27.4% among a sample of first-time mothers residing in the capital, Beirut, as part of a randomized trial of postpartum depression [21]. The lower rate of EBF in that study compared to ours (41.5%) might be due to the longer duration at which EBF was assessed (56–84 days), the sample of women representing an urban population in which EBF rates have been suggested to be lower [22, 23], and the selective nature of participating in a postpartum depression study.

The prevalence of EBF for 6 months in our study was estimated at 12.3% in 2012. The figure is slightly higher than that estimated by Batal et al. in 2004 (10.1%) among a national sample of women recruited from health centers operated by the Ministry of Social Affairs [11]. A more recent study by Mattar et al. in 2016 estimated the prevalence of EBF for 4–6 months at 16.5% among mothers with 12–36-month-old toddlers recruited from a representative sample of licensed daycare centers by the Lebanese Ministry of Public Health [12]. Compared to other countries in the Middle East, our prevalence estimate of EBF for 6 months is closest to that of 12.2% in Saudi Arabia [24]. Despite the fact that the Levant countries are in geographic proximity and share similar traditions and population characteristics, the rates of EBF for 6 months in Lebanon were only similar to those in Syria at 12.9% [25], but lower than those in the Gaza Strip in Palestine (24.4%) [26] and higher than those in Jordan (1%) [27].

A higher number of cars owned in a household, an indicator of higher socio-economic status, was associated with lower odds of EBF at 40 days and at 6 months. Indeed, the number of cars was correlated with other socio-economic variables including mother’s and father’s educational level, family monthly income, house ownership, and crowding index (data not shown). Unlike in high-income countries where breastfeeding rates are higher among wealthier and more educated women, breastfeeding rates are lower and the duration is shorter among wealthier women in low- and middle-income countries [28]. According to two cross-sectional studies conducted in middle-income countries, the first in Nigeria in 2012 [29] and the second in Morocco in 2016 [30], mothers of higher socio-economic status had a lower likelihood of EBF for 6 months. Lebanon, a middle-income country, followed a similar trend.

Compared to vaginal delivery, C-section delivery was consistently associated with lower odds of EBF at 40 days and at 6 months. Other studies from Lebanon yielded mixed results on the association between mode of delivery and exclusive breastfeeding. While Mattar et al. [12] found that C-section delivery was associated with shorter duration of exclusive breastfeeding, Batal et al. [11] did not. However, the latter found differences in hospital practices that support or hinder breastfeeding initiation, which in turn affect breastfeeding exclusivity and duration [31]. For example, a smaller proportion of women who delivered via C-section reported that the hospitals discussed the benefits of breastfeeding with them, allowed 24-h rooming-in, and brought the baby for night feeds compared to women who delivered vaginally. Indeed, 24-h rooming-in and bringing the baby often to the mother for feeding were associated with higher odds of breastfeeding initiation within few hours after birth. Rates of C-section delivery are high in Lebanon with an estimated prevalence of 49% among a sample of women who delivered between 2000 and 2015 [32]. This prevalence greatly exceeds the rate for C-section deliveries of 10–15% suggested by the WHO [33]. Caesarian section delivery along with the associated maternal and newborn complications have been reported to hinder skin-to-skin contact after birth and delay breastfeeding initiation which in turn reduce breastfeeding duration [34, 35].

The number of children in the family was associated with EBF for 40 days, where mothers with a larger number of children were more likely to EBF. In a prospective cohort study conducted in six low- and middle-income countries in 2010 [36], nulliparity was associated with lower odds of EBF for the first 42 days postpartum in two of the included countries, Guatemala and Pakistan.

Overweight and obese mothers were less likely to EBF for 6 months. Given the cross-sectional nature of the study, we cannot determine the direction of the association, notably whether mothers who were presumably overweight or obese in pregnancy were less likely to EBF or whether mothers who did not EBF were more likely to be overweight or obese at the time of the interview. Evidence from the literature supports both directions of association between maternal BMI and duration of EBF. In a cross-sectional study in Germany [37], EBF duration was shorter among obese mothers than among normal-weight mothers. In an analysis of CDC Pregnancy Risk Assessment Monitoring System of 19,145 mothers from 2004 to 2008 [38], overweight and obese mothers, compared to the normal weight, had higher odds of discontinuing breastfeeding before 6 months due to insufficient milk and breastfeeding difficulties. On the other hand, shorter breastfeeding duration has been implicated in maternal overweight and obesity. In a study of 212 women in Finland in 2007 who were surveyed 16–20 years postpartum [39], mothers who breastfed for less than 6 months had higher total body fat mass and fat mass percentage than mothers who breastfed for more than 6 months.

This study has a number of limitations. First, it is a cross-sectional study with unclear chronology of the factors associated with exclusive breastfeeding. Second, mothers reported infant feeding practices of their children, with potential for more recall bias among mothers of older children due to a longer time since delivery; however, almost half of the children were younger than 2 years of age.

The study offers a unique lens into infant feeding practices related to the 40-day rest period and first 6 months of life in Lebanon. The prevalence of EBF at 40 days and at 6 months was 41.5 and 12.3%, respectively. The inverse association of higher socio-economic status, as reflected by the number of cars owned, and C-section delivery with lower odds of EBF persisted across the first 6 months. Future research should investigate the factors associated with EBF in prospective cohort studies and help to better understand the cultural practice of the 40-day rest period in relation to breastfeeding. Such research can guide effective planning for interventions to improve breastfeeding practices and ultimately children’s health status.