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Islam and Breastfeeding

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Islam and Breastfeeding:

Evidence Based Practice in Saudi Arabia

Lani Wittmann, MSN, RN, Midwifery Diploma, IBCLC*

Nursing Clinical Teaching Unit Coordinator,

King Abdulaziz Medical City,

Riyadh, Saudi Arabia

Islam and Breastfeeding:

Evidence Based Practice in Saudi Arabia


The concepts of evidence based practice and transcultural nursing theory come together in this paper, which explores the relationship between Islam and breastfeeding. The scientific evidence to support the benefits of breastfeeding are well documented. However, in a devote Islamic culture such as Saudi Arabia, the teachings of the Holy Qur'an are of ultimate significance to a Muslim believer. Thus, an understanding of how the Qur'an addresses breastfeeding is essential for any program, that is expected to result in major changes in policy and practice. An extensive review of Qur'anic references revealed an unequivocal support of breastfeeding. These findings are in keeping with current scientific research, and must be considered as evidence in itself, in the planning and implementation of breastfeeding programs.

Breastfeeding is an important immediate and long-term preventative health care and health promotion measure for infants and mothers. The general decline in breastfeeding over the past half century has led to a global health crisis of epic proportions. Every year over one million babies die, and millions others are impaired, because they are not adequately breastfed (UNICEF, u.d.). Nurses play a pivotal role in implementing strategies and programs directed to the promotion, protection, and support of breastfeeding. These strategies must be based on the most current and accurate knowledge on breastfeeding practice.

In the past few years there has been a strong movement in the nursing profession to encourage 'Best Practice' based on evidence (Sarah Cole Hirsh Institute, 2001; Walker & Redman, 1999). The definition of evidence is "information that gives a strong reason for believing something" (Crowther, 1995). Evidence based practice (EBP) has been defined as "The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients" (Enkin et al., 2000, p. 4). McMaster University (1998) defines evidenced based clinical practice as "an approach to healthcare practice in which the clinician is aware of the evidence that bears on his or her clinical practice and the strength of that evidence". The strength of various types of evidence can be ranked into a hierarchy, ranging from large multicenter randomized controlled trials and systematic reviews, or metanalyses; down to judgment or beliefs based on personal experience or the experience of others. Beliefs are very powerful, but because they can be haphazard, and sometimes misleading, this form of evidence must be backed up by the results of formal research studies.

Certainly, the evidence supporting the individual health and population wide benefits of breastfeeding, as well as the significant morbidity and mortality attributed to the use of infant formula, are now well documented (UK BFHI, 2001). This research has been conducted in both developing and developed countries, including the UK, USA, and Canada. Following an expert scientific committee's systematic review of the world scientific research, the World Health Organization (WHO) now recommends exclusive breastfeeding for the first six months of life, followed by the continuation of breastfeeding, along with other appropriate complementary foods, for up to two years and beyond (WHO, 2001). This global recommendation, applicable to all populations, was ratified by the Fifty-fourth World Health Assembly in May 2001.

In Saudi Arabia, like in many other countries, breastfeeding prevalence and duration rates have steadily decreased over the last few decades. In addition to inappropriate hospital practices, this decline was associated with the mass marketing and extensive availability of breastmilk substitutes. It was further facilitated by the process of rapid urbanization, a high disposable income, and many culture specific influences, which negatively impacted on breastfeeding. Statistics vary between populations, with urbanized, higher income, educated and employed women displaying the lowest breastfeeding initiation and duration rates, and older, rural and illiterate women the highest prevalence, although even this group may be experiencing a decline (Al-Ayed & Qureshi, 1998; Al-Nasser, Bamgboye & Alburno, 1991; Al-Shehri, Farag, Baldo, Al-Mazrou, & Aziz, 1995). In 1997, the Ministry of Health conducted a national survey, which found that 60 per cent of infants had been breastfed "until weaned", up from 41 per cent in 1981 (Hassan, 2001). While any increase is encouraging, this report specifies neither the duration, nor exclusivity of the breastfeeding. A typical pattern, particularly for the growing urban population, is one of mixed breast and formula feeding, initiated from birth, with an early introduction of weaning foods between three and 6 months, and a concomitant decline in breastfeeding. The most recent publication by Al-Ayed and Qureshi (1998) confirms this observation. They documented exclusive breastfeeding rates in a well-to-do urban sample as 32.4 per cent at 3 months and 22.1 per cent at six months. At one month, 61.8 per cent of infants were receiving mixed bottle and breastfeeds, with no breastfeeding after one year. The Ministry of Health is actively addressing this problem, with the formation of a National Breastfeeding Committee, which will spearhead the implementation of the WHO/UNICEF BFHI in the Kingdom (personal communication, September 2001)

In every country, breastfeeding occurs within a cultural context, which has a strong influence on a mother's attitude towards infant feeding. Culture is defined by Leininger as "the learned, shared, and transmitted knowledge of values, beliefs, norms and lifeways of a particular group that guides an individual or group in their thinking, decisions, and actions in patterned ways" (1995, p. 60). She specifically emphasizes the importance of foreign expatriate nurses working in Saudi Arabia to acquire a transcultural "holding knowledge" in order to provide culturally congruent



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