PERCEPTION OF OMANI WOMEN OF EXCLUSIVE BREASTFEEDING: A GROUNDED THEORY STUDY A Thesis Submitted to The University of Manchester for the Degree of Doctor of Philosophy in the Faculty of Biology, Medicine, and Health 2020 ZALIKHA ALMARZOUQI SCHOOL OF HEALTH SCIENCES Division of Nursing, Midwifery and Social Work Table of Contents LIST OF TABLES ............................................................................................................. 7 LIST OF FIGURES ............................................................................................................ 8 LIST OF BOXES .............................................................................................................. 9 LIST OF APPENDICES .................................................................................................... 10 ABSTRACT ................................................................................................................... 12 DECLARATION STATEMENT .......................................................................................... 13 COPYRIGHT STATEMENT .............................................................................................. 13 ACKNOWLEDGEMENTS ................................................................................................. 14 DEDICATION ................................................................................................................ 15 THE AUTHOR ............................................................................................................... 16 OUTLINE OF THE THESIS .............................................................................................. 17 LIST OF ABBREVIATIONS .............................................................................................. 18 BACKGROUND TO THE STUDY ........................................... 20 1.1 OVERVIEW ......................................................................................................... 20 1.2 HISTORY OF BREASTFEEDING ............................................................................. 20 1.3 INTRODUCTION OF ARTIFICIAL MILK .................................................................. 22 1.4 WHO RECOMMENDATIONS FOR INFANT FEEDING ............................................... 23 1.5 HEALTH BENEFITS OF BREASTFEEDING ............................................................... 25 1.5.1 Health benefits of breastfeeding for infants ............................................................ 25 1.5.2 Health benefits of breastfeeding for women ........................................................... 27 1.5.3 Psychological benefits of breastfeeding ................................................................. 27 1.6 DEFINITIONS OF BREASTFEEDING ........................................................................ 28 1.6.1 Definition of breastfeeding within the Omani context ............................................. 29 1.7 BREASTFEEDING POLICIES .................................................................................. 29 1.8 EXCLUSIVE BREASTFEEDING RATE ACROSS THE WORLD ..................................... 30 1.8.1 Exclusive breastfeeding rate in high-income countries ........................................... 30 1.8.2 Exclusive breastfeeding rate in low-and middle-income countries .......................... 31 1.8.3 Exclusive breastfeeding rate in Gulf Cooperation Council Countries ..................... 31 1.8.4 Factors affecting breastfeeding.............................................................................. 32 1.9 STUDY CONTEXT: THE SULTANATE OF OMAN ..................................................... 32 1.9.1 Geography ............................................................................................................ 32 1.9.2 Demographic profile ............................................................................................. 34 1.9.3 Development in Oman ........................................................................................... 35 1.9.4 Women’s status in Oman ....................................................................................... 35 1.9.5 Family structure in Oman ...................................................................................... 38 1.9.6 Breastfeeding in Islam ........................................................................................... 39 1.9.7 Breastfeeding within the social context in Oman .................................................... 40 1.10 HEALTHCARE SYSTEM IN OMAN ....................................................................... 41 2 1.10.1 Maternal and child health services in Oman ........................................................ 43 1.10.2 Baby-Friendly Hospital Initiative ........................................................................ 44 1.11 DETERMINANTS OF BREASTFEEDING ................................................................. 46 1.12 RATIONALE FOR THE STUDY ............................................................................. 47 1.13 SUMMARY ........................................................................................................ 47 LITERATURE REVIEW ......................................................... 50 2.1 OVERVIEW ......................................................................................................... 50 2.2 POSITIONING OF THE LITERATURE REVIEW IN A GROUNDED THEORY STUDY ....... 50 2.3 RATIONALE FOR SELECTING A NARRATIVE REVIEW ............................................ 52 2.4 AIM OF THE REVIEW ........................................................................................... 53 2.5 QUESTION RELATED TO THE REVIEW .................................................................. 53 2.6 SEARCH STRATEGY ............................................................................................ 54 2.7 QUALITY ASSESSMENT OF THE SELECTED STUDIES ............................................. 57 2.8 FINDINGS FROM THE SEARCH .............................................................................. 58 2.9 DESCRIPTION OF THE SYNTHESISED QUALITATIVE STUDIES ................................. 60 2.10 ANALYSIS AND SYNTHESIS OF THE NARRATIVE REVIEW FINDINGS .................... 62 2.10.1 Breastfeeding motivators ..................................................................................... 64 2.10.2 Social support for breastfeeding .......................................................................... 67 2.10.3 Breastfeeding experiences ................................................................................... 70 2.10.4 Persistence .......................................................................................................... 75 2.11 SUMMARY OF THE LITERATURE REVIEW FINDINGS ............................................ 76 2.12 STRENGTHS AND LIMITATIONS OF THE REVIEW ................................................. 77 2.13 CONCLUSION .................................................................................................... 78 METHODOLOGY AND METHODS .................................. 81 3.1 OVERVIEW ......................................................................................................... 81 3.2 STUDY AIMS AND OBJECTIVES............................................................................ 81 3.2.1 Study aims ............................................................................................................. 81 3.2.2 Study objectives ..................................................................................................... 81 3.3 PHILOSOPHICAL UNDERPINNINGS OF RESEARCH.................................................. 81 3.4 STUDY PARADIGMS ............................................................................................ 82 3.5 UNDERPINNING ASSUMPTIONS ............................................................................ 85 3.6 THEORETICAL PERSPECTIVE: SYMBOLIC INTERACTIONISM .................................. 86 3.7 STUDY DESIGN ................................................................................................... 88 3.8 GROUNDED THEORY METHODOLOGY ................................................................. 90 3.8.1 Overview of grounded theory ................................................................................. 91 3.8.2 Selecting constructivist grounded theory ................................................................ 93 3.9 RESEARCH METHODS ......................................................................................... 95 3.9.1 Selecting the study sites ......................................................................................... 95 3.9.2 Sampling ............................................................................................................... 96 3 3.9.3 Sample size............................................................................................................ 98 3.10 DATA COLLECTION METHODS .......................................................................... 99 3.10.1 Semi-structured interviews .................................................................................. 99 3.10.2 Topic guide ....................................................................................................... 102 3.10.3 Data collection process ..................................................................................... 102 3.10.4 Transcription process .......................................................................................