Background
The feeding practices from birth to 24 months are of utmost importance to meet the evolving nutritional requirements of infants and young children. Breastfeeding has been proven to reduce the risk of childhood diseases and malnutrition [
1]. Moreover, breastfeeding is also a contributing factor in preventing non-communicable diseases such as obesity, diabetes, and cardiovascular diseases in the later stages of life [
2‐
4]. There is also evidence that breastfeeding decreases the incidence and/or severity of a wide range of infectious diseases [
5] and is known to have a positive impact on the immune system, cognitive, emotional and social development [
6].
Appropriate nutrition during infancy and childhood is a prerequisite for optimal child health and development [
7]. Consequently, the global strategy for infant and young child feeding recommends that breastfeeding should be initiated within the first hour after birth, and breast milk exclusively, should be used to feed infants during the first 6 months of life [
8]. From 6 months of age, breastmilk does not adequately supply the infants’ daily requirements of certain nutrients like iron and vitamin D, and therefore complementary feeding is needed [
9]. Hence, in addition to the recommendation of exclusive breastfeeding from birth to 6 months of age, the WHO also recommends timely initiation of safe, nutritionally-adequate and age-appropriate complementary feeding at 6 months with continued breastfeeding up to 2 years of age or above [
10]. It has been shown that nutritional adequacy and proper timing of complementary feeding are crucial to the prevention of infant morbidity and mortality, including malnutrition and overweightness [
11,
12]. Based on the recommendations, the WHO has designed a tool where a set of indicators related to infant feeding practices are helping users, like governments, to determine strengths and weaknesses and potential need for improvements related to exististing practices, policies and procedures [
13] .
Although the UAE has adopted the WHO and United Nations Children’s Fund (UNICEF) recommendations for feeding infants and young children, results of the United Arab Emirates (UAE) Family Health Survey from 2000, the only national survey that has been conducted since the country adopted the WHO recommendations, show that only 34% of infants were exclusively breastfed for up to 4 months of age [
14]. More recent studies have looked at children from parts of the UAE, used smaller sample sizes compared to the Family Health Survey, and have mainly investigated practices of UAE nationals [
15‐
17].
Traditionally, as a Muslim country, breastfeeding was the normal means of feeding infants and young children in the UAE [
18]. Following the rapid economic transition of the UAE, it has grown into a modern, multinational and urbanized society, with several societial changes that may influence mothers willingness, ability and desire to breastfeed their babies. More females are now getting tertiary education, and consequent to the economic transition, female employment has increased from 29.2% in 1990 to 40.9% in 2017, a change that may have impacted the feeding practices of infants and young children by their mothers [
19]. Investments in healthcare facilities and improved living conditions have resulted in a steep decline in infectious diseases whereas the nutrition transition and a sedentary lifestyle has lead to an increase in non-communicable diseases [
20‐
22]. A high prevalence of overweightness and obesity is noticeable among children but also underweightness and micronutrient deficiencies have been documented in children [
23,
24]. According to the Ministry of Health, nutrition-related chronic diseases are now major causes of morbidity and mortality in the UAE [
25]. The Emirates of Abu Dhabi recently released a report on how to combat childhood obesity in the Emirates, and one of the main objective is to increase the breastfeeding prevalence [
26,
27]. Presently, there is very little documentation on the current feeding practices among infants and young children in Abu Dhabi. It is therefore critical to determine if the current nutritional practices among infants in Abu Dhabi are optimal, or require more effective guidelines and interventions in order to achieve the goals of the UAE vision 2021 [
28]. The aim of this study was to evaluate breastfeeding practices among mothers in Abu Dhabi, UAE, and to compare them to the recommendations of the WHO. Comparative analysis was not part of the objective, but are planned to be reported in future papers.
Discussion
In this cross-sectional study, most of the children (95.6%) were introduced to breastfeeding and as recommended, the majority initiated breastfeeding within an hour after delivery earning a rating of “good” according to the WHO indicators. Additionally the WHO indicator of exclusive breastreeding rate was considered “fair” and the duration of breastfeeding was considered “poor”. Most mothers whose babies were 6 months or older (89%) reported giving complementary food to their babies. However, early initiation of complementary feeding among infant being 6 months of older was reported among 21.7%.
In other countries breastfeeding initiation varies between 17.7 to 98.4% [
30]. The initiation rate of breastfeeding in this study of 95.6% is high, and is on par with other studies conducted in the UAE, indicating that hospitals, regardless of being governmental or private and regardless of whether they have implemented the WHO and UNICEF Baby Friendly Initiative or not, are encouraging and supporting mothers to start breastfeeding [
16,
17]. The finding of Emirati mothers initiating breastfeeding to a lower extent than the other nationality groups is somewhat surprising as the UAE is a Muslim country and Islam emphasizes the importance of breastfeeding. This indicates that there is a need to understand what socio-cultural factors and barriers are impacting mothers’ decisions on whether or not to initiate and continue breastfeeding to better support all women, regardless of nationality [
18].
An early initiation of breastfeeding promotes exclusive breastfeeding by bonding between mother and child. This helps the mother breastfeed her child for a longer duration which increases the chances of successful breastfeeding, and generally lengthens the duration of breastfeeding [
31,
32]. Early initiation of breastfeeding occurred in 59.8% of the infants, which, according to the WHO rating is considered “good” (range 50–89%) [
13]. The results are lower than those reported by other researchers in the UAE (75–80%) [
16,
17,
33]. In this study almost a third of the children were delivered through cesarean section, a practice that is becoming more and more common in the UAE [
34]. This may delay the initiation of breastfeeding beyond an hour and could potentially explain why the current results are slightly lower than in previous studies. Other reasons may be due to variations in hospital practices and support to mothers immediately after delivery.
The exclusive breastfeeding during the last 24 h among children below 6 months of age at the time of the interview was 44.3%, which is rated “fair” according to the WHO tool, indicates that there is a need for improvements. The survival analysis, showing the cumulative exclusive breastfeeding experience among all children who initiated breastfeeding, showed that only 7% of all children who initiated breastfeeding in this study were exclusively breastfeeding at 6 months. Although the results in this study is not at the desired level, the overall rates of exclusive breastfeeding are slightly better than those reported in previous studies conducted in Abu Dhabi, Dubai and Al Ain where the rate of exclusive breastfeeding at 6 months varied between 0.0–1.9% [
16,
17]. One of the other Emirates, Sharjah, has managed to improve the breastfeeding rates over the past years as a result of a targeted multisectorial and multidirectional breastfeeding campaign that has been ongoing since 2011. This campaign has provided professional support to get all healthcare facilities accredited as baby friendly, offering breastfeeding rooms at workplaces and in public places, and forbidding promotion of baby formula in nurseries and healthcare facilities as some of the main activities [
15]. While it is not always easy to incorporate international campaigns in local settings, an exchange of experiences within the UAE would likely be beneficial as stakeholders could support each other to reach the goals set by the WHO of having 50% of infants being exclusively breastfed at 6 months of age in 2025 [
35]. The WHO further recommends continued breastfeeding until 2 years of age, which was a common practice in the 1970’s in the UAE [
36]. However, in the current study continued breastfeeding up to the age of two was very uncommon, again revealing the need to understand what factors are impacting infant feeding practices [
12,
37].
In the study, most mothers who did not exclusively breastfeed their children for 6 months used formula feeding instead, a practice that is discouraged according to the recommendations. However, if mothers do not breastfeed, an age appropriate formula that meets the infants’ nutritional needs is still the preferred option over the early introduction of complementary feeding. Although there are slight variations in the recommendations of initiation of complementary feeding between countries there seem to be a common understanding that complementary feeding should not to be introduced before 4 months at the earliest, due to an immature gastrointestinal system [
38]. Early introduction of complementary feeding results in an increased risk of the child having allergies and interferes with successful breastfeeding [
39]. According to the WHO, timely complementary feeding means introducing semisolid food by 6 months of age whereas some countries like the United Kingdom means that complementary feeding can be initiated from 4 to 6 months of age if the child seems to be ready [
40]. Previous studies in the Middle East have shown that complementary feeding is often introduced earlier than recommended [
16,
41,
42]. In this study 21.7% of the children of 6 months or older had been introduced to complementary feeding before they were 6 months, a practice that has been associated with suboptimal health and growth in infants in other studies [
43,
44]. In a recent study conducted by Radwan in the UAE, 83.5% of the children had received complementary feeding before 6 months of age [
17]. The differences in findings may be related to study methodology or differences in the sample characteristics. The current study presents the result of a heterogeneous sample with around half of the mothers being non-UAE nationals whereas the study by Radwan only included Emirati mothers [
17]. Furthermore, studies have shown that introducing complementary feeding later than 10 months has been associated with a higher risk of micronutrient deficiencies [
41,
45]. In this study most children were receiving complementary feeding before 10 months of age which is good as breastmilk doesn’t offer sufficient vitamins and minerals at that age [
9]. Among the few children who were introduced to complementary feeding later than 10 months, it would be of importance to investigate their health status.
The WHO rating tool is primarily designed for national needs assessments and hence the ratings in this study should be applied and interpreted with caution. Nevertheless, the ratings of “poor”, “fair”, “good” and borderline “fair to good” were obtained. These findings indicate that there is a need to design and implement effective strategies to improve the duration of exclusive breastfeeding, as the current practices and policies are not conducive to the successful meeting of the national and local goals to improve infant health and reduce childhood obesity [
28,
46].
Since it is a cross-sectional study that included mothers of infants and young children up to 2 years of age, there may be some problems of recall on breastfeeding practices particularly among mothers with older children in the study and this can be seen as a limitation. Using the WHO indicator for exclusive breastfeeding rates among children being below 6 months of age in this study may have its limitations as many children were 0–3 months old, which may lead to an overestimation. The UAE is a multinational country where around 80% of the population in Abu Dhabi are expatriates [
29]. Although the results in this study can not be seen as representative for all of the UAE, a major strength of the study is that infants, both UAE nationals and expatriates were recruited from the majority of the centers rendering maternal and health services located in various geographical areas in Abu Dhabi capital district as well as the community making the sample likely to be representative of Abu Dhabi.
Acknowledgements
The authors are indebted to the Abu Dhabi Health Services Company (SEHA) for granting access and approval to seven public ambulatory healthcare centers across the Emirate of Abu Dhabi. We would like to express our gratitude to the study participants for their sincere cooperation and the provision of valuable information. We appreciate the work done by Ms. Sharon Kelly on improving the English language. Furthermore, we would like to thank Dr. Ludmilla Scott, Amira, Razan, Nahed, Nour, Dhuha, Ayesha, Jawaher, and Edward for their time and commitment.