title: Self-reported breast feeding practices and the Baby Friendly Hospital Initiative in Riyadh, Saudi Arabia: prospective cohort study.
abstract: The Baby Friendly Hospital Initiative (BFHI) is a practice guideline for healthcare providers to promote breastfeeding and increase breastfeeding rates.
  
  
  
  This study aimed to examine reported experiences and views on breastfeeding of women using prenatal and postnatal services, and opinions of staff, in the context of the BFHI programme in Riyadh, Saudi Arabia.
  
  
  
  Prospective cohort study.
  
  
  
  This prospective, longitudinal study was conducted from December 2013 to September 2015 at two healthcare facilities (BFHI and non-BFHI) in Riyadh Saudi Arabia.
  
  
  
  Women 36-40 weeks gestation receiving antenatal care at the hospitals were enrolled. Questionnaires were administered prenatally, at 1, 3 and 6 months postnatal and to the administrator and maternity staff.
  
  
  
  We recruited 277 women with an estimated 80% response rate. 156 (BFHI=78/139, non-BFHI=78/138, 56%) participants completed all questionnaires. Most BFHI-hospital participants (77.9%, n=8 for this question) acknowledged seeing the breast feeding policy compared to 23.5% (n=23) at the non-BFHI-hospital (p<0.01). Breast feeding education and encouragement was higher at the BFHI-hospital (93.3%) compared to the non-BFHI-hospital (48.2%; p<0.01). At postpartum discharge, 51% (n=53) of mothers in the BFHI-hospital were breast feeding exclusively versus 29.6% (n=29) at the non-BFHI-hospital. Where formula feed was introduced, women in the BFHI-hospital more often practiced mixed feeding rather than exclusive formula feeding with some switching from mixed feeding to exclusive breast feeding between 3 and 6 months postpartum. Exclusive breast feeding rates declined in both hospitals at 3 and 6 months postpartum with lack of community services for lactation being a major reason. Although BFHI-hospital staff (n=9) were more conversant with BFHI principles, defects in adherence to the BFHI 10 Steps were identified.
  
  
  
  This is the first study assessing the effectiveness of BFHI implementation in Saudi Arabia. Although women reported increased breast feeding rates, we identified important weaknesses that could be improved through strict compliance with BFHI practices.
authors.affiliation: College of Medicine Alfaisal University, Riyadh, Saudi Arabia.
authors.forename: Cynthia
authors.identifier: 0000-0003-1951-5277
authors.initials: C
authors.lastname: Mosher
authors.affiliation: College of Medicine Alfaisal University, Riyadh, Saudi Arabia.
authors.forename: Abdullah
authors.initials: A
authors.lastname: Sarkar
authors.affiliation: College of Medicine Alfaisal University, Riyadh, Saudi Arabia.
authors.forename: Alaa AbouBakr
authors.initials: AA
authors.lastname: Hashem
authors.affiliation: College of Medicine Alfaisal University, Riyadh, Saudi Arabia.
authors.forename: Reem E
authors.initials: RE
authors.lastname: Hamadah
authors.affiliation: College of Medicine Alfaisal University, Riyadh, Saudi Arabia.
authors.forename: Asma
authors.initials: A
authors.lastname: Alhoulan
authors.affiliation: College of Medicine Alfaisal University, Riyadh, Saudi Arabia.
authors.forename: Yosra A
authors.initials: YA
authors.lastname: AlMakadma
authors.affiliation: College of Medicine Alfaisal University, Riyadh, Saudi Arabia.
authors.forename: Tehreem A
authors.initials: TA
authors.lastname: Khan
authors.affiliation: College of Medicine Alfaisal University, Riyadh, Saudi Arabia.|Department of Emergency Medicine, King Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
authors.forename: Abdurahman K
authors.initials: AK
authors.lastname: Al-Hamdani
authors.affiliation: Department of Microbiology and Immunology, Alfaisal University, Riyadh, Saudi Arabia.|College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai United Arab Emirates.
authors.forename: Abiola
authors.initials: A
authors.lastname: Senok
mesh_terms: D000328:Adult; D001942:Breast Feeding / Q000706:statistics & numerical data*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion / Q000379:methods*; D006761:Hospitals; D006801:Humans; D007231:Infant, Newborn; D008137:Longitudinal Studies; D017410:Practice Guidelines as Topic; D015397:Program Evaluation / Q000592:standards*; D011446:Prospective Studies; D012529:Saudi Arabia; D057566:Self Report; D014944:World Health Organization; D055815:Young Adult
keywords: BFHI; Baby Friendly Hospital Initiative; Saudi Arabia; breastfeeding; exclusive breastfeeding