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Table of Contents
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 141-149

Maternal mental health and infant feeding practices cohort protocol: Methodology and baseline characteristics

1 Department of Clinical Nutrition and Dietetics, College of Health Sciences, Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
2 Department of Nursing, College of Health Sciences, Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
3 Department of Health Promotion, Faculty of Health, Medicine, and Life Sciences, Maastricht University, The Netherlands
4 Department of Psychology, Al Ain, United Arab Emirates University, United Arab Emirates
5 Sharjah Child Friendly Office, Sharjah, United Arab Emirates
6 Sharjah Child Friendly Office, Sharjah, United Arab Emirates, 5Department of Neonatology, Latifa Women and Children Hospital, Dubai, United Arab Emirates
7 Obstetric and Genecology Ward, Latifa Women and Children Hospital, Dubai, United Arab Emirates
8 Department of Clinical Nutrition, Al Qassimi Hospital, Ministry of Health and Prevention, Sharjah, United Arab Emirates
9 Department of Psychiatry, University of Toronto, Toronto, Canada

Date of Submission22-Feb-2020
Date of Decision11-Apr-2020
Date of Acceptance07-May-2020
Date of Web Publication2-Sep-2020

Correspondence Address:
Hadia Radwan
Department of Clinical Nutrition and Dietetics, College of Health Sciences, Research Institute of Medical and Health Sciences, University of Sharjah, PO Box 27272, Sharjah
United Arab Emirates
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/HMJ.HMJ_13_20

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Objectives: The objectives of the current work are to describe the maternal mental health and infant feeding practices cohort design and methodology and to report the baseline sociodemographic characteristics of the participants. Materials and Methods: This 6-month prospective cohort study recruited women from post-partum wards in hospitals in the United Arab Emirates (UAE). Participants were contacted at three timelines (at delivery, at 3- and 6-month postpartum). Questionnaires with validated tools were used to collect sociodemographic characteristics, maternal and infant anthropometry, breastfeeding practices, breastfeeding self-efficacy, postnatal depression and anxiety. Results: Four hundred and fifty-seven participants with their newborns were recruited. The majority were Emiratis and Arabs (71%), multiparous (77.2%) and not working (60%). About 7.7% of the infants had low birth weight and 3.9% were macrosomic. Most women received Kangaroo care (84.5%) and rooming-in (93.0%). Only 70% of the women initiated breastfeeding and 24.3% planned to breastfeed exclusively as long as possible. The prevalence of maternal post-partum anxiety was high (70%), and 25% of the participants had major/high depressive symptomatology. Overall, participants showed a high level of breastfeeding self-efficacy and the majority perceived receiving great support from parents, spouses, in-laws, family and friends. Conclusions: This article presents the design and methodology of one of the pioneer cohorts in the Middle East and Gulf region investigating maternal mental health and its relation to breastfeeding practices and providing recent evidence for the prevalence of PPD. The results of this study will highlight the significance of maternal psychosocial factors on breastfeeding practices in the UAE.

Keywords: Anxiety, breastfeeding self-efficacy, infant feeding, post-partum depression, United Arab Emirates

How to cite this article:
Radwan H, Fakhry R, issa WB, Hanach N, Obaid RS, E. Faris MA, Al Marzooqi S, Al Ghazal H, ElHalik M, DSuza D, Al Hilali M, Rayess R, Shihadeh NN, Dennis CL. Maternal mental health and infant feeding practices cohort protocol: Methodology and baseline characteristics. Hamdan Med J 2020;13:141-9

How to cite this URL:
Radwan H, Fakhry R, issa WB, Hanach N, Obaid RS, E. Faris MA, Al Marzooqi S, Al Ghazal H, ElHalik M, DSuza D, Al Hilali M, Rayess R, Shihadeh NN, Dennis CL. Maternal mental health and infant feeding practices cohort protocol: Methodology and baseline characteristics. Hamdan Med J [serial online] 2020 [cited 2023 Feb 1];13:141-9. Available from: http://www.hamdanjournal.org/text.asp?2020/13/3/141/294172

  Introduction Top

Breastfeeding is the optimal infant feeding practice to support ideal healthy growth and development.[1] According to the World Health Organisation (WHO) and the United Nations Children's Fund (UNICEF), exclusive breastfeeding (EBF) is recommended for 6 months of infant's age followed by continued breastfeeding with appropriate complementary food for 2 years of age.[2],[3] In spite of the well-documented benefits of EBF for both women and their infants and the considerable efforts to improve breastfeeding outcomes, the early discontinuation of EBF is considered one of the major public health problems.[4],[5] The 2018 Global Nutrition Report recently illustrated very limited progress in EBF rates; internationally, we are far from the World Health Assembly goal to achieve an increase of at least 50% in EBF rates for children in the first 6 months of age by 2025.[6]

A substantial amount of research has been conducted to address the potential contributing factors that reduce EBF practices. This comprises sociodemographic, mental and social factors.[7] Of these variables, breastfeeding self-efficacy, post-partum depression (PPD) and anxiety were highlighted as important predictors of breastfeeding outcomes such as duration and exclusivity. Breastfeeding self-efficacy reflects the woman's self-confidence to breastfeed. Dennis[8] developed the Breastfeeding Self-Efficacy Scale (BSES) and subsequently the short-form (BSES-SF) to assess the mother's confidence in breastfeeding. There is consistent and robust evidence showing that BSES-SF scores are a significant predictor of breastfeeding initiation, duration and exclusivity in various cultures.[1],[9] Mothers with high breastfeeding self-efficacy had a significantly lower chance of discontinuing EBF.[10],[11]

Moreover, maternal depression and anxiety have an adverse effect on infant feeding practices, growth and development. PPD is a severe mental health condition that affects mothers in the 1st year postpartum, with symptoms frequently starting within the first 6 weeks postpartum.[12],[13] Findings of a recent systematic review of 58 studies showed a 12% (95% confidence interval [CI]: 0.04–0.20) incidence of PPD and a 17% (95% CI: 0.15–0.20) overall prevalence of depression among women without a previous history of depression.[14] The prevalence of PPD was significantly varied in different geographical locations, with Europe having the lowest prevalence (8% [95% CI: 0.05–0.11]) and the Middle Eastern countries having the highest prevalence rate (26% [95% CI: 0.13–0.39]).[14],[15] PPD has also been linked to poor breastfeeding initiation, duration and exclusivity prevalence rates.[16]

Similarly, post-partum anxiety has also been found to have a significant effect on breastfeeding outcomes. Post-partum women with anxiety were less inclined to initiate breastfeeding and more likely to discontinue breastfeeding early. They also tended to use formula during hospitalisation and have more considerable breastfeeding difficulties.[17]

In the United Arab Emirates (UAE), although the Ministry of Health and Prevention (MOHAP) has adopted the WHO and UNICEF EBF recommendations since 1992, recent data suggest that only 24% of the UAE infants were exclusively breastfed with the majority receiving complementary food before the age of 6 months.[18] Moreover, previous research investigating PPD in the UAE reported that 17.8%–22% of mothers experience depressive symptoms between 1-week and 6-months postpartum.[19],[20],[21] The 1st weeks after giving birth are important as mothers may experience breastfeeding and mental difficulties that can have a lasting impact. However, it is still uncertain how early infant feeding practices are linked to PPD and anxiety among the population residing in the UAE. There is a paucity of studies in the UAE investigating the assessment and prevalence of maternal mental health and breastfeeding self-efficacy in relation to infant feeding practices. As a public health priority in the UAE, it is important to identify women at risk for early discontinuation of breastfeeding to design tailored evidence-based breastfeeding interventions to improve breastfeeding rates.

The current cohort project aims to investigate prospectively the effects of modifiable risk factors including breastfeeding self-efficacy, PPD and anxiety on breastfeeding initiation, duration and exclusivity from the immediate perinatal period until 6 months post-partum among women in the UAE. The ultimate aim of this cohort study is to progress research on women's mental health and its influence on infant feeding and child health in the UAE. Thus, it is crucial to present an overview of the protocol of the cohort study, which will help, in generating evidence-based findings to promote a significant change at the public policy level in the UAE. Therefore, the objectives of this article are to describe the design and methodology of the UAE maternal mental health and infant feeding practices cohort study and to report the baseline sociodemographic characteristics of the participants.

  Materials and Methods Top

Study design and overview

This is a 6-month prospective cohort study that was conducted in the UAE. Data collection was completed between February 2018 and July 2019, and data analysis is currently underway. The research ethics committees at the University of Sharjah (REC/16-04-14), the Ministry of Health and Prevention (MOHAP/DXB/SUBC/No.37/2017), and Dubai Health Authority (DSREC-11/2017_01) approved the study.

Study setting and population

A convenient sample of eligible women was recruited by trained research assistants (RAs) from the maternity wards in the approved private and public hospitals across four emirates of the UAE (Sharjah, Dubai, Fujairah and Abu Dhabi). The research team approached eligible women and informed them about the study objectives, timeline and process of participant involvement. Those who were eligible and agreed to participate signed a consent form. All women were informed that they would receive a gift voucher when the study questionnaires were completed at three-time points: immediate postpartum on the ward and at 3 and 6 months thereafter. Participants were interviewed face to face by the RAs in the hospital maternity ward. During the first visit, a 30-min questionnaire was completed which included sociodemographic information, intention to breastfeed, previous breastfeeding practices and complications during pregnancy, labour, delivery, post-partum care, breastfeeding education, infant feeding method preferences, living arrangements and family and spouse support and assistance. The participants then completed a self-administered Breastfeeding Self Efficacy-Short Form (BFSE-SF) scale, Edinburgh Postnatal Depression Scale (EPDS) and the State-Trait Anxiety Inventory (STAI) (Form Y). Infant data (birth weight [g], length [cm] and Apgar score (at 1 and 5 min) were reported from the hospital medical records. At the end of the first visit, women were informed that the RAs will contact them again by telephone at 3- and 6-month postpartum to complete follow-up questionnaires.

Inclusion and exclusion criteria

The inclusion criteria of the participants were literate Emirati and expatriate women in the immediate post-partum period, aged 18–45 years with a healthy singleton pregnancy. Women were excluded if they had any condition that might prevent them from breastfeeding their infants, such as the presence of infant congenital disabilities.

Sample size and power analysis

The primary objective of this study was to explore the relationship between maternal mental health and infant feeding practices. To estimate the needed sample size, the software Power Analysis and Sample Size System version 11 (NCSS software, Utah, USA) was used to detect a correlation at 80% power and 5% type I error. This resulted in a sample size of 200 women. It was expected that about 20% of the study participants would drop out of the study during the first 6 months after birth. Hence, the target sample size was estimated to be about 400 post-partum women.

Data collection procedures

A baseline questionnaire was administered to participants in the immediate post-partum period (T1). The questionnaire included sociodemographic information about the participant, spouse and family, general information about the current pregnancy, labour and delivery and breastfeeding intentions.

At 3-month postpartum (T2), the woman was contacted by the same RA, and information was collected on the method of infant feeding, breastfeeding difficulties, support and satisfaction, mother's health data and baby's sleeping arrangements. The last follow-up visit was done at 6-month postpartum (T3) with RAs collecting information from the participants similar to what was collected in the previous visit (T2). All questionnaires were translated into Arabic and pilot tested prior to use.

Outcomes measures

The following measures and forms were administered in T1:

Breastfeeding Self Efficacy-Short Form[8]

It is a self-report instrument with 14 items to assess breastfeeding confidence. Each statement is preceded by the phrase, 'I can always' with a 5-point Likert-type scale, with 1 (not at all confident) and 5 (totally confident). Items were summed to give a total score of 14–70. Higher BFSE scores indicate higher levels of breastfeeding self-efficacy. The form was translated into Arabic to use with Arabic-speaking participants. A panel of experts was assembled and the English form was translated and back-translated into Arabic. The final approved translated version was pilot tested before it was used.

Edinburgh Postnatal Depression Scale

It is a self-report instrument with 10-item scale to identify patients at risk for PPD.[22] Each item is scored on a 4-point scale from 0–3, with the minimum score of 0 and maximum total score of 30. The following cut-off points were used: EPDS <10: normal, EPDS 10–12: any depressive symptomatology and EPDS >12: major/high depressive symptomatology. Participants in the last category needed further evaluation to rule out PPD. A validated Arabic version with adequate psychometric properties[19] was used with Arabic-speaking participants.

The State-Trait Anxiety Inventory (STAI) (Form Y)

This is 40-question self-report scale that measures two types of anxiety: state and trait with a 4-point Likert scale.[23] Cutoffs for levels of anxiety were set for both state and trait anxiety with scores 20–37: no or low anxiety, moderate anxiety: 38–44) and high anxiety: 45–80. A validated Arabic version was used with Arabic-speaking participants.[24]


Anthropometric data for the women

The participants reported maternal height, weight before pregnancy and weight gained during pregnancy. The body mass index (BMI = kg/m2) was calculated and evaluated according to the WHO classification.[25]

Anthropometric data for the infants

Anthropometric data for the infants include weight and length of the baby and Apgar score at 1 min and 5 min after birth (obtained from the medical record).

Gestational weight gain (GWG) was calculated as the difference between the maternal weight of the participant before pregnancy and the final measured weight before delivery. After that, GWG was categorised using the Institute of Medicine guidelines as insufficient, adequate or excessive weight relative to their pre-pregnancy BMI.[26]

The clinical diagnosis of gestational diabetes mellitus (GDM) of the participants was reported from the hospital medical records, who were tested during their 24–28 weeks of gestation following the National Institute for Health and Care Excellence criteria.[27]

Statistical analysis

Collected data were analysed using the Statistical Package for the Social Sciences software version 25.0 (IBM, Chicago, IL, USA). Descriptive statistics were reported. Means with standard deviations (SD) and frequencies were computed for continuous and categorical variables, respectively.

  Results Top

A group of 457 women with their newborns were recruited in the study. The maternal baseline characteristics are shown in [Table 1] and [Table 2]. Most participants (38.9%) were the UAE nationals, followed by non-UAE Arab nationals (32.8%), with only 4.6% Westerners. Religious affiliation data indicated that the vast majority were Muslims (n = 367, 80.3%) followed by Christians (n = 68, 14.9%). As for the level of education, 70.7% of the participants had a technical diploma or a university degree. More than half of the participants (n = 278, 60.8%) were not working, and amongst those working (n = 179, 39. 2%), 86.5% had a maternity leave of more than 3 months. More than a third of the participants (39.4%) had a family monthly income of >15,000 AED (equivalent to 4000 US dollars) [Table 1]. Regarding the maternal characteristics, the majority of the participants was multiparous (n = 353, 77.2%), of which 44.9% had a normal pre-pregnancy BMI, and almost half were considered either overweight or obese. The prevalence rate of GDM was 21.4% (n = 98), 36.3% (n = 166) had excessive GWG and 41.1% (n = 188) were delivered by the caesarean section [Table 2].
Table 1: Sociodemographic characteristics of the study participants (n=457)

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Table 2: Maternal characteristics of the study participants (n=457)

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[Table 3] reports the infant descriptive data. Almost half of the newborns were males (51%). Apgar scores at 1 min (mean 8.47 ± 0.89) and 5 min (mean 9.36 ± 0.59) were normal (Apgar score: 7–10). The mean birth weight and length were 3.16 ± 1.48 kg and 49.7 ± 2.5 cm, respectively. About 7.7% of the infants had low birth weight and 3.9% were macrosomic. Maternal breastfeeding practices are presented in [Table 4]. About 85% of the newborns had skin-to-skin (kangaroo care) contact within 30 min of delivery and 425 (93%) stayed with their mothers (rooming-in) at all times. Only 70% (n = 320) of the women initiated breastfeeding during the 1st h after delivery. About 42% (n = 190) stated that they planned to breastfeed for as long as possible and 37% (n = 169) for more than 12 months. As for EBF intention, 24.3% (n = 111) stated that they perceived doing that for as long as possible, with 61% (n = 277) for 4–6 months. The majority of the participants (n = 360, 78.8%) was themselves breastfed as infants. With respect to assistance after childbirth, women in the UAE generally perceived having a high support level [Table 5]. Support came from parents (n = 391, 85.6%), spouse (n = 448, 98%), in-laws (n = 402, 88%), family (n = 428, 93.7%) and friends (n = 387, 86.9%). Only 16.2% (n = 74) had a nanny to help in caring for the infant, with almost half (n = 239, 52.3%) having a housemaid to assist with housework.
Table 3: Infant characteristics (n=457)

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Table 4: Maternal breastfeeding practices

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Table 5: Maternal support

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PPD and anxiety prevalence rates are reported in [Table 6]. Overall, 56.5% (n = 258) of the women had an EPDS <10 and 18.6% (n = 85) had any depression symptomatology (EPDS = 10–12), of which 24.9% (n = 114) had an EPDS score >12, suggesting major/high depressive symptomatology. As for STAI scores, which assessed both state and trait anxiety, the results shown in [Table 6] suggest that the majority of women had moderate-to-high state anxiety (n = 348, 76.2%). Similarly, 76.1% (n = 348) of the participants had moderate-to-high trait anxiety. [Table 7] reports the BSES-SF scores of the participants. The mean score was 52.2 (SD = 11.92), ranging from 14 to 70. Overall, women in this study showed a high level of BFSE [Table 7].
Table 6: Prevalence of postpartum depression and anxiety among the study participants

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Table 7: Distribution of participants by breastfeeding self-efficacy

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  Discussion Top

This cohort study aimed to identify factors that affect maternal mental health in relation to breastfeeding. The results from our sample show that many mothers had high levels of depression and anxiety, factors that have been demonstrated in high-income countries to be related to breastfeeding outcomes.[28],[29] These mental health symptoms can have an impact on the health of the infant and the maternal-infant relationship.

Our results showed that only 70% of the women initiated breastfeeding within the 1st h postpartum, lower than the rate reported earlier (98%).[18] According to the WHO, it is recommended that women initiate breastfeeding during the 1st h postpartum; failure to do so may influence maternal milk supply, breastfeeding self-efficacy and long-term breastfeeding outcomes such as exclusivity.[11] Importantly, kangaroo care and rooming-in were two practices that were applied to the majority of the women in the present study. Many studies have shown that mothers who had early skin to skin contact and rooming-in with their infants had more confidence and reduced maternal stress and depression and led to higher rates of exclusive and overall breastfeeding.[30],[31]

With regard to maternal employment, only 39.2% of the cohort worked either full time or part-time, with 86.5% having a 3-month maternity leave. It has been shown that when women return to work, the prevalence rates of any breastfeeding and EBF decline.[32] Therefore, maternity leave is viewed as a significant factor for improving breastfeeding duration and exclusivity. Moreover, Chekol et al.[33] found that women who were employed and had maternity leave had a higher EBF rate than women who did not have maternity leave. As per the UAE Human Resources Law in Federal Government in 2019, 'Women are entitled to 3 months of fully paid maternity leave. After the female employee resumes work, she is entitled to 2 h/day as breastfeeding leave for 6 months and 1 h for another 6 months after delivery to breastfeed her child'. Previously, maternity leave was limited to 6 weeks which fell short of the International Labour Organisation recommendation of 18 weeks. The extension of maternity leave to 180 days is encouraging and helps women to breastfeed exclusively and for a prolonged duration.[34]

To elucidate the reasons/factors for suboptimal EBF rates in the UAE, this study investigated the mental health of mothers, namely anxiety and PPD in relation to breastfeeding practices.

For PPD, our results showed that about 25% of the participants had major/high depressive symptomatology with an EPDS scores >12. The lack of consensus on the EPDS cutoff points led to difficulty comparing our results across countries. In the UAE, Abou-Saleh and Ghubash[19] reported that the PPD prevalence was 18%. In another study in the UAE, Green et al.[21] using a cutoff point of more than 13 reported a prevalence rate of 22% at 3-month postpartum. Recently, Alhammadi et al.[20] reported that 16% of the post-partum women had an EPDS score of >13. This indicates that the rate of PPD is on the rise in the UAE. Our results show similar rates to Brazil (24.3%), Malaysia (22.8%) and Morocco (20.1%) using the same cutoffs.[35] In the Middle East, Haque et al.[15] reported a high prevalence of PPD (26%) and higher rates were reported in Pakistan (36.0%) and Turkey (30.5%). In the Western world, lower rates of PPD in the post-partum period were reported. Shorey et al.[14] reported in his systematic review that Europe had the lowest prevalence rate (8%), followed by the U. S. A (12%) and Australia (15%). The difference in the prevalence rates between countries might be attributed to cultural practices, demographic characteristics, under screening, underreporting, and the exact time during the post-partum period when the prevalence was measured.

Maternal post-partum anxiety can also affect maternal functioning and may interrupt the mother–infant bond establishment.[36] A systematic review reported that there was an association between maternal anxiety and breastfeeding outcomes.[37] In the current study, most of the participants had moderate-to-high state and trait anxiety, as measured by STAI. Maternal post-partum anxiety might be a potentially significant obstacle to improving breastfeeding rates in the UAE. Britton[38] observed that maternal anxiety was associated with a lower odds of EBF at 6 months and higher odds of terminating breastfeeding at 1 month.

Women who have elevated mental health symptoms may react negatively whenever they encounter breastfeeding difficulties, which would, in turn, reduce their breastfeeding self-efficacy.[39] Breastfeeding self-efficacy refers to a mother's confidence that she is able to breastfeed her infant.[40] The results showed that the mean of BSES-SF was 52.2 (SD = 11.92) and that immediately after delivery, the participants were confident and motivated to breastfeed. According to the Bandura's theory of self-efficacy, how someone interprets his/her feelings tends to influence his/her behaviour.[41] Thus, women with low self-efficacy who perceive their breastfeeding performance as inadequate are more likely to interrupt breastfeeding experience negatively and initiate formula supplementation earlier than the recommended 6-month postpartum.[42]

This augments the advantages of assessing breastfeeding self-efficacy of the women during the post-partum period to identify women with low confidence who could use additional breastfeeding support to assist them in achieving their breastfeeding goals, such as exclusivity to 6-month postpartum. Health-care professionals should also routinely assess maternal mental health during the prenatal and postnatal periods to treat depression and anxiety before they negatively impact breastfeeding outcomes and child development trajectories.

Breastfeeding support is believed to be an essential factor for sustaining breastfeeding and maternal mental health. Positive support interactions during the post-partum period have a positive influence on the mental health and health behaviours of the mothers. Existing networks of professional and breastfeeding support groups, which are in close contact with breastfeeding women, are ideal settings for educational programs to improve post-partum care.[43] Our findings showed that the participants perceived great support from parents, spouses, in-laws, family and friends. Many studies demonstrated that social support and depression were inversely related.[43],[44] Indeed, a meta-analysis suggested negative social support as one of the strongest predictors of PPD.[45] The presence of social support has been found to protect women against depression by influencing how to cope with stress.[46] Inoue et al.[47] described the association between husband support and breastfeeding outcomes where the husband's positive support and attitude increased the likelihood for a longer duration of breastfeeding. Hence, a positive support system may also have a positive impact on the initiation and duration of breastfeeding.[48] Different interventions targeting the woman's family and social network were shown to increase breastfeeding duration to prevent PPD and anxiety.[49],[50] Moreover, a better understanding of the type of support and how it influences maternal mood and infant feeding practices is warranted.

Strengths and limitations

One of the major strengths of this cohort study is the representation of the UAE population. The sample was collected from different regions in the UAE and included women from different nationalities and ethnic groups that will present clear evidence of the maternal mental health status of the mothers residing in the UAE. Moreover, the instruments used in this study were validated and culturally appropriate and allowed to identify women at risk of breastfeeding discontinuation. Another strength is the longitudinal design, which examines prospectively a range of psychosocial factors about EBF during 6-month postpartum. The benefit of longitudinal study design is that it will provide definite information about cause-and-effect relationships. Moreover, researchers can conduct several observations of the same subjects over a period of time to detect changes in the characteristics of the target population. The outcomes of this study will help in the development of a predictive model of breastfeeding exclusivity at 6-month postpartum and a predictive model of depression at 6-month postnatal.

The main limitations of the current study include selection bias and loss to follow-up typical of longitudinal studies. Participant retention was one of the main challenges of this cohort study, which might be due to loss of contact, lack of interest of some participants and some husbands' disapproval. Several initiatives were taken to increase retention, such as offering incentives (gift vouchers) and close follow-up of the participants by the RA's who were instrumental in successfully retaining a good number of the participants. Encouraging a culture of rigorous research studies in the UAE should overcome these limitations.

  Conclusions Top

The present article describes the design and methodology of one of the pioneer, lead cohorts in the Middle East and Gulf region investigating maternal mental health and its relation to breastfeeding practices and providing recent evidence for the prevalence of PPD. The results of this study will highlight the significance of maternal psychosocial factors on breastfeeding practices in the UAE. This cohort study will rigorously identify predictive factors that negatively influence EBF during the first 6 months of life. Moreover, this study will provide evidence about the importance of screening the mental health of women and its association with breastfeeding self-efficacy as a strategy to improve the national breastfeeding rates. In this regard, the application of the BSES and the EPDS scales should be implemented in the primary health-care clinics across the UAE in coordination with the multi-professional team. This will allow close monitoring of the confidence levels of the post-partum women to maintain EBF and early identification and referral of women with PPD. This cohort will help in directing policymakers to formulate national policies for perinatal mental health care aimed at reducing maternal morbidity and increasing breastfeeding rates, which will have a high impact on women, children, families and the UAE community at large.

Ethical Considerations

Ethical approvals were obtained the University of Sharjah Research Ethics Committee (REC/16-04-14), the MOHAP (MOHAP/DXB/SUBC/No.37/2017) and Dubai Health Authority (DSREC-11/2017_01) approved the study.

Declaration of patient consent

Written informed consent was obtained from all study participants.

Financial support and sponsorship

We would like to note that the research study has received funding from the Sheikh Hamdan Bin Rashid Al Maktoum Award for Medical Sciences (MRG/33/2017) and Vice-Chancellor of Research and Graduate Studies Office/University of Sharjah grant no (VCRG/R1540/2017).

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

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