Al-Azhar Assiut Medical Journal

: 2019  |  Volume : 17  |  Issue : 1  |  Page : 30--34

Risk factors for cessation of breastfeeding

Hussein Koura 
 Department of Pediatrics, College of Medicine, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia

Correspondence Address:
Hussein Koura
College of Medicine, Prince Sattam Bin Abdulaziz University, PO Box 173, Al-Kharj 11942
Saudi Arabia


Introduction The Kingdom of Saudi Arabia is advancing quickly in all parts of life and health care. Nonetheless, breastfeeding is said to be on the deterioration. Patients and methods A case–control study was carried out to evaluate the risk factors that may lead to cessation of breastfeeding among infants and children less than 2 years who live in Al Kharj and Al Riyadh cities, Saudi Arabia. Cases included mothers of infants who stopped breastfeeding during first year after delivery, whereas controls were mothers of infants or children who were breastfed for 1 year or more. In total, 366 mothers were enrolled: 183 for continued breastfeeding group and the same number for stopped breastfeeding group. Each enrolled mother was interviewed by a specially designed questionnaire. Results Risk factors for cessation of breastfeeding were delivery by caesarean section, full- or part-time mother’s employment, usage of oral contraceptives, higher level of education, and absence of support for breastfeeding. Adjusted odds ratios were 2.2, 2, 1.9, 1.8, and 1.6, respectively. Conclusion As a result of the study, it was recommendation to pay attention toward pregnant women with these risk factors to support them to continue breastfeeding for 2 years.

How to cite this article:
Koura H. Risk factors for cessation of breastfeeding.Al-Azhar Assiut Med J 2019;17:30-34

How to cite this URL:
Koura H. Risk factors for cessation of breastfeeding. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 12 ];17:30-34
Available from:

Full Text


Breastfeeding has usually been the proper feeding practice for infants. The WHO recommends exclusive breastfeeding (just breast milk, excluding water, different liquids, and solid foods) for the primary 6 months of life, with supplemental breastfeeding continued for 2 years and beyond [1]. There is a sizeable evidence of short-term and long-term health advantages of breastfeeding for infants and mothers [2],[3],[4],[5],[6],[7]. Suboptimal breastfeeding practices ended in greater than 800 000 deaths among children younger than 5 years of age (11.6% of all deaths) [8]. Exclusive breastfeeding decreases mortality and morbidity from pneumonia and diarrhea, which are the main child killers [9],[10]. Breastfeeding decreases the threat of noncommunicable diseases, including childhood asthma, obesity, diabetes, and heart disease later in life [11],[12],[13],[14]. Breastfed children have shown to have better intellectual development, cognitive function, and academic performance later in life [15]. In addition to unique health advantages for infants and mothers, breastfeeding additionally benefits the society by means of reducing health care cost, parental employee absenteeism, and associated lack of family income [16],[17].

Saudi Arabia has experienced a fast general progress and socioeconomic changes, which are anticipated to have profound implications, especially in lifestyle and dietary conduct. Although breastfeeding rates are now not declining at the global level, with many countries experiencing significant increases in the past decade, only 39% of infants less than 6 months of age within the developing world are exclusively breastfed, and just 58% of 20–23-month olds gain advantage from continued breastfeeding (CBF) [18],[19]. In Saudi Arabia, breastfeeding has been customary and accepted all over the kingdom. Past research studies have mentioned breastfeeding duration exceeding 2 years [20],[21]. Introduction of solid foods was reported to be as late as the age of 12–18 months and complementary to breast milk [21]. However, several studies have stated a downward trend in breastfeeding practice and duration [19],[22],[23], as early introduction of bottle feeding was recently mentioned to replace breastfeeding [22],[23]. Additionally, solid foods have been proven to be introduced in advance than before, at among 4 and 6 months [23].

This study aims to evaluate risk factors that lead to cessation of breastfeeding among infants and children less than 2 years old.

 Patients and methods

This case–control study was carried out in Al Kharj and Al Riyadh cities, Saudi Arabia. Cases included mothers of infants who stopped breastfeeding (SBF) during first year after delivery (SBF group), whereas controls were mothers of infants or children who were breastfed for 1 year or more (CBF group). Mothers whose infants had congenital or chronic diseases, birth weight less than 2500 g, or gestational age less than 37 weeks were excluded from the study. Two out of primary health care centers located in Al Kharj and Al Riyadh cities were selected randomly through simple random sampling technique, and physicians in these services were trained on how to use the questionnaire of the study. All attending mothers in the two centers with infants or children less than 2 years of age and eligible for the study were enrolled and classified according to the previous definitions as cases or controls. Informed consent was taken from all participants. Each enrolled mother was interviewed by a specially designed questionnaire, which included demographic and socioeconomic characteristics, duration of breastfeeding, usage of contraceptive, mode of delivery, parity, sex of the baby, number of children less than 5 years old, and practice of feeding. Cessation of breastfeeding was defined as complete cessation of lactation. If the mother lactated only or breastfed together with formula feeding or solid foods, breastfeeding was considered to be continuing. Duration of contraceptive use was calculated by subtracting the infant’s age when the mother started using a contraceptive method from the infant’s age on stopping lactation. For mothers who stopped lactation, contraceptive use was only considered as a possible contributing risk factor if the intake preceded breastfeeding cessation by at least 1 month. Educated mother was considered when mother got high school or university degree. Current smoking was accepted as risk factor for SBF. If mother reported that she had not received any advice regarding breastfeeding from her family, peers, or during admission to delivery, it was considered as ‘no support for breastfeeding’. If the mother worked as either full or part time, she was considered as working mother. Sample size was calculated for odds ratio to be within 25% of true value, which is believed to be ∼2, with 95% confidence. According to a previous study, breastfeeding cessation is present in 40% among lactating mothers [24], so sample size was 183 mothers for each group. Data were entered and analyzed using the statistical package for the social sciences (SPSS, version 18.0, SPSS Inc., Chicago, Ill., USA). χ2-Test was used for difference between proportions, and 5% was considered as level of statistical significance. Multivariate logistic regression analysis was employed to determine which individual variables were independently associated with the cessation of breastfeeding. The study protocol was approved by committee consisting of Professor Maged M. Abdell-Kader and Professor Mohammed M. Shaaban. Informed consent was taken from all participants.


In total, 366 mothers were enrolled in the study: 183 for CBF group and the same number for SBF group. The two groups were comparable regarding demographic, socioeconomic, and medical history characteristics ([Table 1]). One hundred and sixty-seven mothers in each group were between the ages of 20 and 40 years. Children male/female ratio was 1.2 : 1 in CBF group, whereas it was 1.4 : 1 in SBF group. Saudi nationality was predominant among the study population, with 68.9% among breastfeeding group and 67.8% in SBF group. Risk factors for cessation of breastfeeding were delivery by caesarean section, mother’s employment, usage of oral contraceptives, higher level of education, and absence of support for breastfeeding. Adjusted odds ratios (adj ORs) were 2.2, 2, 1.9, 1.8, and 1.6, respectively ([Table 2]). Thirty-two (17.5%) mothers delivered by caesarean section in SBF group compared with 16 (8.7%) in CBF group. Ninety-eight (96.1%) working mothers in SBF group were working full time, whereas 66 (95.6%) working mothers among CBF group had the same characteristics. On contrary, 90% of educated mothers in SBF group had university degree compared with 67 (91.8%) in CBF group. According to definition mentioned before for using contraceptives, 55 (30.1%) mothers of SBF group used oral contraceptives during lactation, whereas there were only 34 (18.6%) in CBF group. Ninety-nine (54.1%) mothers in SBF group did not receive any advice regarding breastfeeding. On the contrary, 75 (40.1%) mothers of CBF group received some advice.{Table 1}{Table 2}


The findings of this study have proven that delivery by caesarean section, mothers employment, usage of oral contraceptives, higher level of education, and absence of support for breastfeeding are risk factors for cessation of breastfeeding.

According to our results, the highest risk factor that was significantly related to breastfeeding cessation was caesarean section delivery (adj OR=2.2). In Saudi Arabia, Shawky and Abalkhail [24] reported that mothers who delivered by cesarean section are at 1.9 times at more risk of SBF than those who delivered vaginally. Recent meta-analysis shows that cesarean delivery has a significant association with early cessation of breastfeeding [25]. Data of this meta-analysis were derived from greater than half a million women in 31 countries, which gives strong evidence for the effect of cesarean delivery on breastfeeding. It is believed that there are two biological mechanisms of the association between mode of delivery and breastfeeding. The primary is related to surgical treatment, as an example, long duration of separation of mother and the newborn because of complications of the surgery, such as pain, hemorrhage, and infections [26]. The second biological mechanism is associated with labor through a hormone called prolactin. Prolactin plays an essential role in the process of lactogenesis [27],[28],[29].

This study also showed that full-time or part-time job was a risk factor for cessation of breastfeeding (adj OR=2). Our results showed that full-time working mothers were the majority of samples in both groups (96.1% SBF and 95.6% CBF, respectively). Therefore, an analysis to evaluate the effect of part-time work on continuation of breastfeeding was neglected for statistical significance. Internationally, studies have constantly found that full-time employment within the first postpartum year has a powerful negative effect on breastfeeding duration [30],[31]. Cooklin et al. [32] reported that full time, part-time, or casual employment earlier than 6 postnatal months interferes with maintaining breastfeeding. American research studies have proven that mothers employed on a part-time basis have similar breastfeeding duration to those who are nonemployed mothers [30],[33], possibly as their working week is shorter, necessitating less time away from their infant.

In this study, mothers who used oral contraceptives during lactation were at 1.9 times more at risk of SBF compared with nonusers. This result coincides with previous studies that revealed the effect of oral contraceptives in reducing the length of lactation [34],[35]. In Saudi Arabia, Shawky and Abalkhail [24] and Ogbeide et al. [36] proved that using oral contraceptives is a risk factor for cessation of breastfeeding. Moreover, Alwelaie et al. [37] found that using oral contraceptives leads to SBF. Biologically, it appears reasonable that hormonal contraceptives, particularly those containing estrogen, can also inhibit lactation [38],[39]. Some women believe that oral contraceptive pills will cause harm to the infant so they discontinue breastfeeding even though it has been proved that the quantity of hormones transferred in breast milk to the infant is extremely small [40].

The surprising finding in this study was that mother’s education was a risk factor for cessation of breastfeeding (adj OR=1.8). In United Arab Emirate, Radwan reported that mothers with primary education breastfeed for longer periods than mothers of higher educational levels [41]. Education of the mother as a predictor for cessation breastfeeding differs among developing and developed countries. Educated mothers in developed countries have turned back to breastfeeding [42],[43]; however, in developing countries, mothers with higher education have more and more switched to bottle feeding or mixed feeding [44],[45]. This finding has been explained by Abada et al. [46], who demonstrated that higher education in developing countries is associated with the adoption of modern thoughts, often leading to the abandonment of traditional practices such as breastfeeding.

Many research studies on breastfeeding have shown the significance of support [47],[48],[49],[50]. Similarly, the WHO has encouraged SBF support, such as providing knowledge and information, controlling physical and psychological conditions, and enhancing the mothers’ experience of independence and security [51]. Our results demonstrated that an absence of breastfeeding support was a risk factor for breastfeeding cessation (adj OR=1.6). In Saudi Arabia, Ogbeide et al. [36] illustrated that doctors’, nurses’ and other hospital staff advice regarding breastfeeding is very strong predictor regarding mode of infant feeding. Social support from partners and family members is an essential issue associated with adequate breastfeeding [52],[53]. This includes emotional, instrumental, and informational support [54],[55],[56],[57]. Al-Jasser et al. [22] revealed that the relatives are the source of breastfeeding information for 26.8% of the mothers. Takka et al. [58] additionally reported that for the continuation of breastfeeding, the attitude of the husband toward breastfeeding is crucial, while paying close attention for the mother and the child. Several studies in Saudi Arabia have shown that there is a lack of knowledge and proper practice of breastfeeding among mothers [37],[59].


Delivery by caesarean section, employment, usage of oral contraceptives, mother’s education, and absence of support for breastfeeding are risk factors for cessation of breastfeeding. It was recommended to pay attention to pregnant women with these risk factors to encourage them to SBF for 2 years.


This project was supported by the Deanship of Scientific Research at Prince Sattam Bin Abdulaziz University under the research project 41/H/33.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1World Health Organization, UNICEF. Global strategy for infant and young child feeding. Geneva: World Health Organization 2003.
2Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008; 371:243–260.
3Horta BL, Victora CG. Long-term effects of breastfeeding: a systematic review. Geneva: World Health Organization 2013.
4Debes A, Kohli A, Walker N, Edmond K, Mullany L. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health 2013; 13(Suppl 3):S19.
5Sobhy SI, Mohamed NA. The effect of early initiation of breastfeeding on the amount of vaginal blood loss during the fourth stage of labour. J Egypt Public Health Assoc 2004; 79:1–12.
6Collaborative Group on Hormonal Factors in Breast Cancer. Collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50302 women with breast cancer and 96973 women without the disease. Lancet 2002; 360:187–195.
7Rosenblatt KA, Thomas DB. Lactation and the risk of epithelial ovarian cancer. The WHO Collaborative Study of Neoplasia and Steroid Contraceptives. Int J Epidemiol 1993; 22:192–197.
8Black RE, Victora CG, Walker SP, A Bhutta Z, Christian P, de Onis D et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013; 382:427–451.
9Lamberti LM, Zakarija-Grković I, Fischer Walker CL, Theodoratou E, Nair H, Campbell H et al. Breastfeeding for reducing the risk of pneumonia morbidity and mortality in children under two: a systematic literature review and meta-analysis. BMC Public Health 2013; 13(Suppl 3):S18.
10Lamberti LM, Fischer Walker CL, Noiman A, Victora C, Black RE. Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health 2011; 11(Suppl 3):S15.
11Gdalevich M, Mimouni D, Mimouni M. Breast-feeding and the risk of bronchial asthma in childhood: a systematic review with meta-analysis of prospective studies. J Pediatr 2001; 139:261–266.
12Grummer-Strawn LM, Mei Z. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Control and Prevention pediatric nutrition surveillance system. Pediatrics 2004; 113:e81–e86.
13Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Am J Clin Nutr 2006; 84:1043–1054.
14Rich-Edwards JW, Stampfer MJ, Manson JA, Rosner B, Hu FB, Michels KB et al. Breastfeeding during Infancy and the risk of cardiovascular disease in adulthood. Epidemiology 2004; 15:550–556.
15Heikkilä H, Kell Y, Renfrew MJ, Sacker A, Quigley MA. Breastfeeding and educational achievement at age 5. Matern Child Nutr 2014; 10:92–101.
16Ball TM, Bennett DM. The economic impact of breastfeeding. Pediatr Clin North Am 2001; 48:253–262.
17WHO/UNICEF. Advocacy strategy, breastfeeding advocacy initiative for the best start in life. WHO/UNICEF 2015. WHO/NMH/NHD/15.1.
18UNICEF. Improving child nutrition. The achievable imperative for global progress. New York: UNICEF 2013.
19Al-Jassir MS, El-Bashir BM, Moizuddin SK. Surveillance of infant feeding practices in Riyadh city. Ann Saudi Med 2004; 24:136–140.
20Abdullah MA, Sebai ZA, Swailem AR. Health and nutritional status of preschool children. In: Community Health in Saudi Arabia. Saudi Medical Journal Monograph; 1982. pp. 11–18.
21Al-Othaimeen AI, Sawaya WN, Tannous RL, Villanueva BP. A nutrition survey of infants and preschool children. Saudi Med J 1988; 9:40–48.
22Al-Jassir MS, El-Bashir BM, Moizuddin SK, Abu-Nayan AA. Infant feeding in Saudi Arabia: mothersʼ attitudes and practices. East Mediterr Health J 2006; 12:6–13.
23El Mouzan MI, Al Omar AA, Al Salloum AA, Al Herbish AS, Qurachi MM. Trends in infant nutrition in Saudi Arabia: compliance with WHO recommendations. Ann Saudi Med 2009; 29:20–23.
24Shawky S, Abalkhail BA. Maternal factors associated with the duration of breast feeding in Jeddah, Saudi Arabia. Paediatr Perinat Epidemiol 2003; 17:91–96.
25Prior E, Santhakumaran S, Gale C, Philipps LH, Modi N, Hyde MJ. Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature. Am J Clin Nutr 2012; 95:1113–1135.
26Chapman DJ, Perez-Escamilla R. Identification of risk factors for delayed onset of lactation. J Am Diet Assoc 1999; 99:450–454; [quiz 455–456].
27Tucker H. Lactation and its hormonal control. In: Knobil E, Neil JD, editors. The physiology of reproduction. New York, NY: Raven Press 1994.
28Stefos T, Sotiriadis A, Tsirkas P, Messinis I, Lolis D. Maternal prolactin secretion during labor. The role of dopamine. Acta Obstet Gynecol Scand 2001; 80:34–38.
29Wang BS, Zhou LF, Zhu LP, Gao XL, Gao ES. Prospective observational study on the effects of caesarean section on breastfeeding. Zhonghua Fu Chan Ke Za Zhi 2006; 41:246–248.
30Carlson-Gielen A, Faden RR, O’Campo P, Brown CH, Paige DM. Maternal employment during the early postpartum period: effects on initiation and continuation of breastfeeding. Pediatrics 1991; 87:298–305.
31Taveras EM, Capra AM, Braveman PA, Jensvold NC, Escobar GJ, Lieu TA. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics 2003; 112:108–115.
32Cooklin AR, Donath SM, Amir LH. Maternal employment and breastfeeding: results from the longitudinal study of Australian children. Acta Paediatr 2008; 97:620–623.
33Ryan AS, Zhou W, Arensberg MB. The effect of employment status on breastfeeding in the United States. Womens Health Issues 2006; 16:243–251.
34Rosa FW. Resolving the ‘Public Health Dilemma’ of steroid contraception and its effects on lactation. Am J Public Health 1976; 66:791–792.
35World Health Organization Task Force on Oral Contraceptives. Effects of hormonal contraceptives on breast milk composition and infant growth. Stud Fam Plann 1988; 19:361–369.
36Ogbeide DO, Siddiqui S, Al Khalifa IM, Karim A. Breastfeeding in a Saudi Arabian community: profile of parents and influencing factors. Saudi Med J 2004; 25:580–584.
37Alwelaie YA, Alsuhaibani EA, Al-Harthy AM, Radwan RH, Mohammady RG, Almutairi AM. Breastfeeding knowledge and attitude among Saudi women in Central Saudi Arabia. Saudi Med J 2010; 31:193–198.
38Hull VJ. Research on the effects of hormonal contraceptives on lactation: current findings, methodological considerations and future priorities. World Health Stat Q 1983; 36:168–200.
39Pebley A, Goldberg HI, Menken J. Contraceptive use during lactation in developing countries. Stud Fam Plann 1985; 16:40–51.
40Codaccioni X, Puech F, Leroy JL, Switala I. Breastfeeding which contraceptive method? Rev Fr Gynecol Obstet 1995; 90:302–305.
41Radwan H. Patterns and determinants of breastfeeding and complementary feeding practices of Emirati Mothers in the United Arab Emirates. BMC Public Health 2013; 13:171.
42Kassam-Lallanie D, Moynagh K, Ross H, Sellar L, Sigmundson C. Infant feeding in Halton. Halton Regional Health Department; 2002.
43Simard I, O’Brien HT, Beaudoin A, Turcotte D, Damant D, Ferland S et al. Factors influencing the initiation and duration of breastfeeding among low-income women followed by the Canada prenatal nutrition program in 4 regions of Quebec. J Hum Lact 2005; 21:327–337.
44Wilmoth TA, Elder JP. An assessment of research on breastfeeding promotion strategies in developing countries. Soc Sci Med 1995; 41:579–594.
45Morisky DE, Kar SB, Chaudhry AS, Chen KR, Shaheen M, Chickering K. Breastfeeding practices in Pakistan. Pak J Nutr 2002; 1:137–142.
46Abada TS, Trovato F, Lalu N. Determinants of breastfeeding in the Philippines: a survival analysis. Soc Sci Med 2001; 52:71–81.
47Scott JA, Landers MC, Hughes RM, Biness CW. Psychological factors associated with the abandonment of breastfeeding prior to hospital discharge. J Hum Lact 2001; 17:24–30.
48Ingram J, Rosser J, Jackson D, Dawn J. Breastfeeding peer supporters and a community support group: evaluating their effectiveness. Matern Child Nutr 2005; 1:111–118.
49Labarere J, Gelbert-Baudino N, Ayral AS, Duc C, Berchotteau M, Bouchon N et al. Efficacy of breastfeeding support provided by trained clinicians during early, routine, preventive visit: a prospective, randomized, open trial of 226 mother-infant pairs. Pediatrics 2005; 115:139–146.
50Barona-Vilar C, Escriba-Aguir V, Ferrero-Gandoa R. A qualitative approach to support and breastfeeding decisions. Midwifery 2007; 8:1–8.
51UNICEF WHO. In: Hashimoto T, editor. Breastfeeding management and promotion in Baby Friendly Hospital. Tokyo: Igakusyoin; 2003.
52Giugliani E, Caiaffa W, Vogelhut J, Witter F, Perman J. Effects of breastfeeding support from different sources on mothers’ decisions to breastfeed. J Hum Lact 1994; 10:157–161.
53Littman H, VanderBrug Medendorp S, Goldfarbb J. The decision to breastfeed. The importance of fathers’ approval. Clin Pediatr 1994; 33:214–219.
54Barron SP, Lane HW, Hannan TE, Struempler B, Williams JC. Factors influencing duration of breastfeeding among low-income women. J Am Diet Assoc 1988; 88:1557–1561.
55Scott J, Binns CW, Aroni R. The influence of reported paternal attitudes on the decision to breastfeed. J Paediatr Child Health 1997; 33:305–307.
56Binns C, Gilchrist D, Gracey M, Zhang M, Scott J, Lee A. Factors associated with the initiation of breastfeeding by Aboriginal mothers in Perth. Public Health Nutr 2004; 7:857–861.
57Scott JA, Binns CW, Graham KI, Oddy WH. Temporal changes in the determinants of breastfeeding initiation. Birth 2006; 33:1–89.
58Takka MT, Pavnonen M, Laippala P. What contributes to breastfeeding success after child birth in maternity ward in Finland? Birth 1998; 25:175–181.
59Al-Binali AM. Breastfeeding knowledge, attitude and practice among school teachers in Abha female educational district, southwestern Saudi Arabia. Int Breastfeed J 2012; 7:10.