ResearchFactors affecting intention to breastfeed among Syrian and Jordanian mothers : a comparative cross-sectional study

Background: Breastfeeding is considered the ideal method of infant feeding for at least the first six months of life. This study aimed to compare breastfeeding intention between Syrian and Jordanian women and determine factors associated with breastfeeding intention among pregnant women in these two countries. Methods: A cross-sectional design was used to collect data from1200 pregnant women aged 18 years and above (600 participants from each country). A selfadministered questionnaire was used to collect data on socio-demographic characteristics and breastfeeding intention. Results: Intention to breastfeed was reported by 77.2% of Syrian and 76.2% of Jordanian pregnant women. There was no significant difference in intention to breastfeed between Syrian women and Jordanian women. In both countries, women with a more positive attitude to breastfeeding, women with previous breastfeeding experience and women with supportive partners were more likely to intend to breastfeed. Syrian women with a monthly family income of more than US$200, younger than 25 and primiparous or having one child were more likely to report an intention to breastfeed their infants. Jordanian women with an education level of less than high school and not living with their family-in-law were more likely to intend to breastfeed. Conclusions: In Syria and Jordan, a more positive attitude to breastfeeding, previous breastfeeding experience and presence of supportive husbands are associated with intention to breastfeed. These factors should be considered when planning programs designed to promote breastfeeding in these two countries. Background Breastfeeding is considered the ideal method of feeding and nurturing infants [1]. Infants who are not breastfed have increased rates of mortality and increased risk of several chronic childhood diseases [2]. One and a half million deaths among infants could be avoided each year if all infants were breastfed exclusively during the first six months of life [3]. Breastfeeding intention is a significant predictor of infant feeding method; Tarrant et al recently reported that breastfeeding intention is a significant predictor of breastfeeding initiation and any breastfeeding at six weeks among Irish women [4]. Studies have described many factors associated with the intention to breastfeed [5-10]. These factors include maternal age, mother's education level, family household income, number of children, mother's knowledge about the benefits of breastfeeding, previous breastfeeding experience, attitude towards breastfeeding and the mother's social support network. Understanding factors associated with intention to breastfeed will allow health care decisionmakers to plan and evaluate appropriate interventions to improve breastfeeding initiation and duration. In the current study, we examined the intention to breastfeed among pregnant women in Jordan and Syria. These two neighboring Arab countries are similar in language and religion and share many socio-demographic characteristics. Infant feeding data from UNICEF demonstrated minor differences in breastfeeding practices * Correspondence: alakour@just.edu. jo 1 Department of Maternal-Child Health Nursing, School of Nursing, Jordan University of Science and Technology (JUST), Irbid 22110, Jordan Full list of author information is available at the end of the article © 2010 Al-Akour et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Al-Akour et al. International Breastfeeding Journal 2010, 5:6 http://www.internationalbreastfeedingjournal. com/content/5/1/6 Page 2 of 8 between these two countries [11,12]. Although early initiation (39% and 32% in Jordan and Syria), and rates of exclusive breastfeeding to six months (22% and 29%, respectively) are similarly low in both countries, the proportion of children receiving breastfeeding and complementary food at 6-9 months was higher in Jordan (66%) than in Syria (37%). The 2007 Jordan population and family health survey (JPFHS), showed that only 40% of mothers exclusively breastfed their infants during the first five months of life, and about 11% were never breastfed [13]. The health systems in these two countries are similar in many aspects, as most of the general population in both Jordan and Syria receive health care through governmental agencies. Health education on breastfeeding mainly comes in the two countries through UNICEF programs including the Baby Friendly Hospital Initiative. This study aimed to compare breastfeeding intention between Syrian and Jordanian women and determine factors associated with intention to breastfeed among pregnant women in these two countries. Methods Study population This study was conducted between 1 May 2008 and 1 October 2008. A sample of 1200 Syrian and Jordanian pregnant women aged 18 years and above, who had a normal pregnancy as determined by obstetricians, was included in the current study. Participants were able to speak and read Arabic. Of the 12 main health centers in Lattakia City, Syria, six centers were randomly selected. Six hundred Syrian women were then recruited from these centers. These centers are representative of the main maternal and child health centers in the northwest of Syria and serve populations with different levels of socio-economic status. Using simple random sampling techniques, six maternal and child health (MCH) centers out of 40 MCH centers in Irbid directorates in Jordan were selected. A sample of 600 Jordanian pregnant women was selected using the "proportionate to size" method. A total of 1200 participants from all pregnant women attending targeted health centers in both countries were recruited during the study period. Six trained nurses were responsible for identifying mothers who met the eligibility criteria for participating in the study. Informed consent was obtained from all participants after providing adequate information about the purposes of the study. Data collection A self-administered questionnaire was used to collect data in both countries. The questionnaire consisted of three sections. The first section included data on participants' socio-demographic characteristics and related breastfeeding characteristics including: maternal age (years), level of education, monthly family income, number of live births, previous breastfeeding experience, breastfeeding education, occupation, whether living with a partner or not, maternal smoking during pregnancy, household composition, and breastfeeding support. The second section included one question with five items (plans) derived from a questionnaire developed by Humphreys and colleagues to assess breastfeeding intention [14]: 1) I am going to bottle-feed my baby, and I do not want to breastfeed at all. 2) I am thinking about breastfeeding, but I am not sure I want to do it. 3) I plan to try breastfeeding, but I am not sure how long I will do it. 4) I plan to breastfeed my baby for at least 1 month but probably not a full 6 months. 5) I plan to breastfeed my baby for at least 6 months. Women were defined as not having the intention to breastfeed if they reported "I am going to bottle-feed my baby, and I do not want to breastfeed at all" or "I am thinking about breastfeeding, but I am not sure I want to do it". Women were defined as having the intention to breastfeed if they reported any of the items 3, 4, 5. The third section assessed women's infant feeding attitudes using the Iowa Infant Feeding Attitude Scale (IIFAS) [15]. The IIFAS has been demonstrated to be both reliable and valid [9,15] and consists of 17 items that are scored on a 5-point Likert scale. The scale ranges from 1 (strongly disagree) to 5 (strongly agree). Eight items reflect positive attitudes to breastfeeding and nine items reflect positive attitudes to formula feeding. Items that favored formula feeding were scored reversely and a total attitude score was computed via an equally weighted sum of responses to all items. Total attitude scores range from 17 to 85, with higher scores indicating positive attitudes to breastfeeding [15]. Cronbach's alpha was 0.75 and 0.70 among Syrian and Jordanian participants respectively. Instrument translation Translation of the instruments from the English version into the Arabic version was conducted to ensure that content, semantic, and technical equivalence were retained. Back translation of the instruments was conducted to ensure the original (English) and the second language (Arabic) version of the instruments measured the same words and concepts [16,17]. Data analysis Data were analyzed using the Statistical Package for Social Sciences (SPSS) windows version 15. Chi-square was used to compare the proportion of women who intended to breastfeed according to the socio-demographic and relevant characteristics. Multivariate binary logistic regression analyses were performed to determine Al-Akour et al. International Breastfeeding Journal 2010, 5:6 http://www.internationalbreastfeedingjournal. com/content/5/1/6 Page 3 of 8 the variables related to the intention to breastfeed among participants in the two groups. A p-value of 0.05 or less was considered as statistically significant. Results Participants' characteristics One thousand two hundred Jordanian and Syrian pregnant women (600 women from each country) participated in this study. The age of participants ranged from 18 to 45 years. The mean age (SD) of participants were 27.9 (6.5) and 28.7 (5.6) years for Syrian and Jordanian women respectively. The mean (SD) IIFAS score of participants were 3.6 (0.4) and 3.3 (0.3) for Syrian and Jordanian women respectively. The characteristics of the participants are shown in Table 1. Intention to breastfeed Intention to breastfeed was reported by 77.2% o