To our knowledge, this is the first national study from KSA and the Gulf Cooperation Council to investigate breastfeeding practices using the most recent WHO/UNICEF indicators [23]. Our results show that the current breastfeeding practices are far from optimal, whereby they are not in line with the global targets for EBF (i.e. 50% by 2025, and 70% by 2030) [29, 30].

In agreement with other studies, our results showed that the proportions of exclusively breastfed infants decreased consistently with age [19]. The low prevalence of EBF amongst infants aged less than 6 months is similar to that reported by a recent systematic review and meta-analysis of BF practices in KSA (15.1%) [19]. However, the various studies conducted in different regions of the Kingdom have reported a wide range in EBF, varying between 1.8% and 66.7% (Table S1), although methodological differences may hinder comparison between these studies [31,32,33,34,35,36,37,38,39,40,41,42]. Based on the same standardized WHO/UNICEF indicators, the prevalence of EBF in KSA is similar to or higher than that reported from other EMR countries such as Jordan (17.8%), Tunisia (13.5%) and Yemen (9.7%), while being relatively lower than that reported from other countries of the Gulf Cooperation Council (GCC) including Qatar and Oman (29.3% and 23.2% respectively) (Table S2). Taken together, these findings place KSA amongst countries with the lowest rates of EBF worldwide.

The low prevalence of EBF in KSA may be a direct reflection of the early introduction of infant formula. A recent systematic review of breastfeeding knowledge and attitudes showed that Saudi women had a positive attitude towards infant formula feeding whereby approximately 40% agreed that it is as healthy as breast milk and 59.4% agreed that infant formula feeding is more convenient than breastfeeding [19]. Previous studies in KSA have also shown that more than 80% of women in KSA gave infant formula to the infant after the initiation of breastfeeding (i.e. resorted to MixMF) and more than two-thirds reported that ready to feed formula was given to their newborns during their hospital stay [37].

Although the prevalence of EIBF in most regions in the KSA is higher than the regional EMR average (35%), it remains lower than estimates reported by individual EMR countries such as Oman (82%) and in some regions [43,44,45,46,47,48,49,50,51,52,53] (Table S2). Of more concern is the fact that 24.5% of infants were put to the breast within days after birth, not hours. Two previous studies have in fact identified prelacteal feeding as a significant barrier to EIBF in KSA [54,55,56]. Our study findings therefore suggest the need for a wider implementation of the WHO Ten Steps to Successful Breastfeeding in KSA facilities [56]. Although the number of hospitals designated as baby-friendly has consistently increased over time in KSA (from 1% in 2004, to 7% in 2010), a recent review article reported that this increase reached only 24.1% of hospitals in 2016 [56].

Acknowledging that EIBF is key for establishing breastfeeding in the long term, and predicting future EBF, its low prevalence could account for the observed low rates of EBF and especially EBF2D [57]. As the latter is a new indicator in the WHO guidance document, previous studies in KSA have not reported on this practice [23]. When comparing with other countries, the KSA estimate is similar to that reported from Morocco (32.4%), and Egypt (37.1%) but lower than estimates reported from other Arab EMR countries, which ranged from 43.3% to 59.3% [43] (Table S2). As for CBF, its prevalence in KSA is similar to that reported from Lebanon (21.9%), while being lower than that reported from Qatar (46.7%) and most other Arab EMR countries (28.5–57.4%) [58] (Table S2).

The investigation of factors that were associated with BF practices in KSA showed that children of Saudi nationality had lower odds of meeting breastfeeding indicators. Several culture-specific factors may explain these findings, including Saudi women’s perception of low milk supply, their lack of awareness about the safety of contraceptive methods during lactation as well as returning to work, all of which were previously described as the main reasons behind breastfeeding cessation amongst Saudi women [19]. In line with findings reported from Lebanon, children who were not the first-borns had higher odds of meeting all the breastfeeding indicators [25]. This may be due to the fact that first-time mothers may have more difficulties in initiating and establishing breastfeeding and tend to be more anxious in comparison with more experienced mothers [26].

In agreement with previous studies children born via cesarean-section were less likely to meet several breastfeeding indicators [20]. Cesarean-section delivery, along with the related maternal and newborn complications, has been previously reported to impede skin-to-skin contact after birth and delay the initiation of breastfeeding. In our study sample, 37.1% of delivery were via cesarean-section, which is comparable to previous estimates from KSA [59, 60]. The rates of cesarean-section deliveries have been increasing over time in KSA, with possible reasons including the increase in the prevalence of maternal obesity and diabetes, the widespread utilization of electronic fetal monitoring, as well as heightened concern about litigations [61]. Although an initiative to decrease this rate is currently in place in KSA, it remains important to establish hospital-based protocols to support mothers after cesarean-section deliveries, such as increasing maternal awareness on the benefits of BF, allowing 24-h rooming-in, and/or bringing the infant for night feeds [20, 61]. In our study, the observation that premature children had lower likelihood of BF is worrisome given that preterm infants who are given breast milk instead of animal-based infant formula have lower risk of infections and necrotizing enterocolitis, and better neurological, cognitive, and visual development [62]. Health professionals and mothers can benefit from a better understanding of the factors that hinder mothers from transitioning their preterm infants to breastfeeding and their potential consequences. Finally, in our study, maternal employment/student status was associated with higher odds of EvBF, EIBF, and MixMF. This suggests that, despite the common perception that breastfeeding is less convenient for working mothers in KSA, employment/studying may not always be an impediment against breastfeeding [19]. In KSA, female workers are entitled to a maternity leave of 8–12 weeks (which can be extended as unpaid or partially paid leave) and an aggregate of one hour per day as a nursing break [63].

The strengths of this study include the large national sample, the adoption of the updated WHO methodology and definitions of breastfeeding indicators, and the investigation of factors that may be linked with inadequate BF practices. Our study findings should be considered in light of the following limitations. First, data collection was conducted via interviews, which can be limited by social desirability bias. In our study, data collectors were thoroughly trained on the administration of the questionnaire and on keeping a non-judgmental attitude to minimize social desirability bias. Second, children who were not born in KSA were excluded. This was deemed necessary given that certain breastfeeding indicators such as EIBF and EBF2D may be directly affected by the hospital environment. The proportion of non-Saudis (11.2%) was lower than the national estimate (23.5% based on the 2022 births registry), the reasons being potentially related to language barriers, the moving of families outside the country or the child not being born in KSA. Third, this study did not assess complementary feeding practices amongst IYC and did not collect data for the evaluation of the bottle-feeding indicator (defined as “the percentage of children 0–23 months of age who were fed from a bottle with a nipple during the previous day” [23]. Incorporating these indicators in future research would provide a more comprehensive overview of IYC feeding practices. In addition, and to provide a deeper understanding for some of the indicators such as EIBF and EBF2D, future surveys should collect more elaborate data on infant formula marketing and use within the hospitals.