Breastfeeding Throughout Pregnancy in Turkish Women

Abstract

Introduction:

Around the world, as well as in Turkey, women breastfeed their infants as long as possible. There is, however, a strong cultural taboo against continuing breastfeeding while having a new pregnancy. The aim of this study was to evaluate the outcome of pregnancies occurring during the lactation period and to determine whether lactation throughout the pregnancy had any adverse effects. This is the first study in Turkey to provide data on the association between the practice of lactation throughout pregnancy and outcome.

Subjects and Methods:

One hundred sixty-five multiparous women with singleton pregnancies who were ≥18 years of age, breastfeeding the previous child, and did not have systemic disease were included. Forty-five of the 165 pregnant women continued lactating, whereas 120 did not. We compared weight gain during pregnancy, hemoglobin level alterations, pregnancy complications, neonatal weight, and Apgar scores between the two groups.

Results:

Lactating pregnant women gained less weight than the nonlactating group, and the decreased level of hemoglobin during pregnancy was significant in the lactating group. Between the two groups, there was no statistically significant difference in hyperemesis gravidarum, threatened abortion, preeclampsia, premature labor and birth, neonatal weight, or Apgar scores.

Conclusions:

Breastfeeding during pregnancy is not harmful, and health professionals should not advise weaning if overlapping occurs and should observe mother, infant, and fetus closely for negative effects, and if a negative effect occurs they should take precautions.

Introduction

The health benefits of breastfeeding for both mother and infant have been well established.^1,2 Exclusive breastfeeding for 6 months followed by the introduction of complementary foods with continued breastfeeding is a global health recommendation and requires the provision of adequate social and nutritional support for lactating women.³ Breastfeeding is life-saving in developing countries; a meta-analysis reported markedly reduced mortality (especially due to infectious disease) with breastfeeding, even into the second year of life.³ Despite the clear health benefits of breastfeeding, UNICEF estimates that 1.5 million babies worldwide die each year because they are not breastfed.⁴ The United Kingdom and the United States, two developed countries, are struggling to improve breastfeeding initiation and duration rates.⁵

In addition to its health benefits, breastfeeding has significant economic and environmental benefits. Variability in breastfeeding practices is significantly influenced by cultural beliefs, ethnicity, urbanization, modernization, socioeconomic status, education, and local feeding practices.^6–8 Gender roles, social support, and attitudes of friends and relatives toward breastfeeding have also been shown to affect a mother's intended duration of breastfeeding.⁹

Around the world and also in Turkey, women breastfeed their infants as long as possible. According to the 2008 Turkey Demographic and Health Survey, breastfeeding is common in Turkey, and 97% of all children are breastfed for a certain period of time, with onset of supplements as early as 2 months. Forty-two percent of children under 6 months are exclusively breastfed. In Turkey, an interval between consecutive pregnancies of 7–23 months is 21%.¹⁰ Ovulation may be delayed for many months, but eventually pregnancy may occur in women who breastfeed, especially after the introduction of supplements. When lactation and pregnancy overlap, throughout low-income countries, most women continue lactating.^11–18 However, there is a strong cultural taboo against continuing breastfeeding in our country. The belief is widespread that when a new pregnancy occurs, the milk is not beneficial for the infant and will harm him or her.

When lactation and pregnancy overlap, the risk of depletion of nutrient stores in the mother, growth retardation of the fetus, or reduction of milk volume and composition can occur.^11,12 When a new pregnancy occurs, it is difficult for a physician to assess whether weaning or continuing lactation is preferred.

The aim of this study was to evaluate the outcome of pregnancies occuring during the lactation period and to determine whether lactation throughout the pregnancy has any adverse effect on the subsequent pregnancy. To our knowledge this is the first study in our country to provide data on the asssociation between the practice of lactation throughout pregnancy and outcomes for the mother, infant, and fetus.

Subjects and Methods

In this retrospective study, 165 women ≥18 years of age not having systemic disease and who had a subsequent singleton pregnancy within 2 years after the first infant's birth were enrolled. The study was conducted in the Fatih University Hospital between June 2004 and December 2011. The data were collected from clinical records. Women for whom obstetric history and breastfeeding experience were inadequate were excluded. Women who were pregnant while lactating formed Group A (n=45), and women who were pregnant after the cessation of lactation formed Group B (n=120). These two groups were compared in terms of prepregnancy body mass index, gestational weight gain, birth weight, and Apgar scores, obstetric complications such as anemia, missed abortion, intrauterine growth retardation, and preterm delivery.

All analyses were carried out with SPSS version 16.0 software (SPSS, Inc., Chicago, IL). Data are presented as mean±SD values, and significance for all two-tailed probability tests was set at p<0.05, unless otherwise indicated. In evaluating the quantitative variables between the two groups, the Mann–Whitney U test was used, and for categorical variables, the χ² test was used.

Results

All of the cases in the lactating group (Group A) continued breastfeeding during the pregnancy period.

There was no statistically significant difference betweeen the two groups in terms of age, prepregnancy body mass index, birth weight and gestational week at the time of birth, and Apgar scores of the babies (Table 1). The weight gain during pregnancy of the lactating group was lower compared with that of the nonlactating group, and this was statistically significant.

Table 1.

Comparison of Lactating (Group A) and Nonlactating (Group B) Pregnant Women

	Group A (n=45)	Group B (n=120)	p value
Age (years)	24.3±4.9	23.2±3.3	>0.05
Prepregnancy body mass index (kg/m²)	25.4±4.4	26.4±3.7	>0.05
Birth weight of the baby (g)	3,090±470	3,170±510	>0.05
Gestational week at the time of birth	38.2±1.3	38.7±1.1	>0.05
Apgar score
1 minute	7±0.1	7±0.4	>0.05
5 minutes	9±0.2	9±0.2	>0.05
Weight gain during pregnancy (kg)	7±3.4	13±5.6	<0.05^a

Data are mean±SD values.

Significant difference.

In the lactating group (Group A), although pregnancy complications such as hyperemesis gravidarum, threatened abortion, preterm labor, and delivery were observed to be higher than in the nonlactating group (Group B), this was not statistically significant, probably because of the limited numbers in the groups (Table 2). In both groups, intrauterine growth retardation was not observed. A decreased level of hemoglobin during pregnancy was significant in the lactating group. There was no statistically significant difference in the mean interpregnancy interval betweeen the two groups (p>0.05). The interpregnancy intervals did not statistically correlate with the pregnancy complications in the lactating women (p>0.05).

Table 2.

Comparison of Pregnancy Complications of Lactating (Group A) and Nonlactating (Group B) Pregnant Women

	Group A (n=45)	Group B (n=120)	p value
Hyperemesis gravidarum	3	3	>0.05
Threatened abortion	5	6	>0.05
Preterm labor	7	8	>0.05
Preterm delivery	1	2	>0.05
Hemoglobin at the time of delivery (g/dL)	9.7±1.7	12.3±1.5	<0.05^a

Data are number of women or mean±SD values as indicated.

Significant difference.

Discussion

Breastfeeding is beneficial for infant and mother. We know that lactation and pregnancy are both very energetic processes. A long interval between two pregnancies could permit repletion of maternal nutrient stores and lead to improved infant and fetal outcomes. When overlap occurs, maternal physiological adaptations may compensate for the extra physiological stress that this represents for the mother.¹¹ Higher energetic demands with overlap, the risk of depleting maternal nutrient stores, and poor child growth and development may be increased.¹² In many developed and developing countries, pregnant women regularly do not meet their nutritional requirements.¹¹ Requirements become very high for many nutrients during pregnancy, which are difficult to meet with dietary sources.

In low-income countries, breastfeeding during late pregnancy is very common. Data from the United States showed that 5.1% of lactating women were pregnant.¹³ In one study, 50.2% of the participants among Guatemalan women who had a child <7 years of age were breastfeeding during their current pregnancy.¹⁴ In addition, Ramachandran¹⁵ found that around 30% of pregnancies in India occurred in lactating women. Recently, the practice of breastfeeding during the last trimester of pregnancy among Peruvian women who had a child under 4 years of age was reported to be 10%.¹² Some cultures, as well as ours, mandate immediate weaning in the belief that pregnancy will harm a suckling child by spoiling the mother's milk^16,17 or deprive the fetus of nutrition.¹⁸ However, there are no data concerning the breastfeeding ratio during pregnancy in Turkey.

The association between maternal nutritional status and labor complications has been reported previously.¹⁹ For example, anemia has been linked to prolonged labor.²⁰ In this study, we experienced only a few, not statisticially significant, complications, except for a decrease in hemoglobin levels. The decrease in hemoglobin levels in lactating pregnants was statistically significant.

Birth weight is an important pregnancy outcome that reflects the intrauterine environment. This environment can be influenced by poor maternal nutritional status, representing a risk factor for small size for gestational age.^21–23 In our study, there was no significant difference in terms of birth and neonatal outcomes between the two groups. In addition, the infants born to lactating mothers were healthy and appropriate for gestational age, as reported in most studies.^11,12,24,25 In one study, there was no significant difference in full-term or non–full-term birth rates or in mean newborn birth weight in women lactating for more than 1 month during pregnancy. It is suggested that breastfeeding during a normal pregnancy does not increase the chance of untoward maternal and newborn outcomes.²⁶ In another study that examined the association between birth weight and overlap of breastfeeding and pregnancy (at any trimester), the investigators reported a nonsignificant+57 g difference in birth weight for infants who were born to mothers who did not overlap compared with those with an overlap.¹⁴ In addition, Moscone and Moore²⁴ studied this practice in 57 women who breastfed during pregnancy, with 43% overlapping until delivery, and reported that the average birth weight in this group was normal.

Muscone and Moore²⁴ reported pregnancy-related weight gain to be satisfactory in concurrently breastfeeding and pregnant women. But, in our study, the concurrently breastfeeding and pregnant women gained less weight than the nonlactating group, and this was statistically significant. Pareja de Felipa¹¹ observed a significant difference in maternal weight gain during the current pregnancy. We also observed a high weight gain in the nonlactating group.

To our knowledge, there is only one study from Turkey concerned with overlapping lactating and breastfeeding; in this study, none of the cases continued lactation after 20 weeks of gestation.²⁷ In our study, pregnant women continued lactation during the last trimester. The mean birth weight of the subsequent pregnancy was lower, but there was no difference in obstetric complications between the two groups.²⁷

According to the 2008 Turkey Demographic and Health Survey, breastfeeding is common in Turkey, and the interval between consecutive pregnancies of 7–23 months is 21%.¹⁰ Around the world and also in our country, short recuperative intervals may affect negatively the mother, infant, and fetus, but there is no consensus on weaning, continuing lactation, or the duration of continuing lactation. Recently, women have come to know the importance of breastfeeding, and the incidence of breastfeeding is as high as 96.7% in Turkey.¹⁰ Lactation and pregnancy overlap is a frequently encountered situation in our country, and the ratio of intended breastfeeding is on the increase. But, cultural taboos are still discouraging this. In the present study, except for maternal low weight gain and maternal decreasing of hemoglobin level, maternal and fetal outcomes are the same in both groups. Breastfeeding during pregnancy is not harmful, and health professionals should not advise weaning if overlapping occur and should observe mother, infant, and fetus closely for negative effects, and if a negative effect occurs they should take precautions. Of course, further extensive studies should be carried out.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Committee on Health Care for Underserved Women, Committee on Obstetric Practice. Breastfeeding: maternal and infant aspects. ACOG Clin Rev, 2007; 12(Suppl):1S–16S.

American Academy of Pediatrics; American College of Obstetrics and Gynecology. Breastfeeding Handbook for Physicians. Washington, DC: American College of Obstetrics and Gynecology, 2006.

Kramer

, Kakuma

. The Optimal Duration of Exclusive Breastfeeding. A Systematic Review. Department of Nutrition for Health and Development, World Health Organization, Geneva, 2001.

UNICEF. Nutrition—Breastfeeding: The best choice for babies. www.unicef.org/nutrition/index_27817.html (accessed May 18, 2012).

Hamlyn

, Brooker

, Oleinikova

, et al. Infant Feeding 2000. The Stationery Office, London, 2002.

Ergenekon-Özelci

, Elmacı

, Ertem

, et al. Breastfeeding beliefs and practices among migrant mothers in slums of Diyarbakır, Turkey, 2001. Eur J Public Health, 2006; 16:143–148.

Giovannini

, Banderali

, Agostoni

, et al. Epidemiology of breastfeeding in Italy. Acta Paediatr Scand, 1999; 88:19–22.

Büyükgebiz

, Cevik

, Oran

. Factors related to the duration of breastfeeding in Ankara, with special reference to sociocultural aspects. Food Nutr Bull, 1992; 4:289–293.

Paine

, Dorea

. Gender role attitudes and other determinants of breastfeeding intentions in Brazilian women. Child Care Health Dev, 2001; 27:61–72.

10.

2008 Turkey Demographic and Health Survey TDHS-2008. www.hips.hacettepe.edu.tr/eng/index.html (accessed December 18, 2012).

11.

Pareja de Felipa

. The association between breastfeeding during late pregnancy and the occurrence of small for gestational age and prolonged active phase of labor among Peruvian women [Master's thesis]. Nutritional Sciences, Iowa State University, Ames, 2007. www.books.google.com.tr/books.isbn=0549923837 (accessed December 18, 2012).

12.

Marquis

, Diaz

, Marín

. Postpartum consequences of an overlap of breastfeeding and pregnancy: Reduced breast milk intake and growth during early infancy. Pediatrics, 2002; 109:56–64.

13.

Briefel

, Bialostosky

, Kennedy-Stephenson

, et al. Zinc intake of the U.S. population: Findings from the Third National Health and Nutrition Examination Survey, 1988–1994. J Nutr, 2000; 130:1367S–1373S.

14.

Merchant

, Martorell

, Haase

. Maternal and fetal responses to the stresses of lactation concurrent with pregnancy and of short recuperative intervals. Am J Clin Nutr, 1990; 52:280–288.

15.

Ramachandran

. Maternal nutrition—Effect on fetal growth and outcome of pregnancy. Nutr Rev, 2002; 60:S26–S34.

16.

Raphael

, Davis

. Only Mothers Know: Patterns of Infant Feeding in Traditional Cultures. Greenwood Press, Westport, CT, 1985:36–85.

17.

Crean

JTG

, Ling

, Peakson

, et al. Dhavari Project 1985—Infant feeding patterns. J Trop Pediatr, 1987; 33:14–22.

18.

Ransome-Kuti

. Some cultural and social aspects of infant feding in Nigeria. In: Falkner

, Kretchmer

, Rossi

, eds. Modern Problems in Paediatrics. S. Karger, Basel, 1975:117–125.

19.

UNICEF WHO. Low birth weight: Country, regional and global estimates. 2004. www.who.int/reproductivehealth/publications/low_birthweight/ (accessed November 11, 2005).

20.

Jiang

, Christian

, Khatry

, et al. Micronutrient deficiencies in early pregnancy are common, concurrent, and vary by season among rural Nepali pregnant women. J Nutr, 2005; 135:1106–1112.

21.

Valero de Bernabe

, Soriano

, Albaladejo

, et al. Risk factors for low birth weight: A review. Eur J Obstet Gynecol Reprod Biol, 2004; 116:3–15.

22.

Lasker

, Coyle

, Li

, et al. Assessment of risk factors for low birth weight deliveries. Health Care Women Int, 2005; 26:262–280.

23.

Ramakrishnan

. Nutrition and low birth weight: From research to practice. Am J Clin Nutr, 2004; 79:17–21.

24.

Moscone

, Moore

. Breastfeeding during pregnancy. J Hum Lact, 1993; 9:83–88.

25.

Bobak

, Dejmek

, Solansky

, et al. Unfavourable birth outcomes of the Roma women in the Czech Republic and the potential explanations: A population based study. BMC Public Health, 2005; 5:10.

26.

Madarshahian

, Hassanabadi

. A comparative study of breastfeeding during pregnancy: Impact on maternal and newborn outcomes. J Nurs Res, 2012; 20:74–80.

27.

Sengul

, Sivaslıoğlu

, Kokanalı

, et al. The outcomes of the pregnancies of lactating women. Turk J Med Sci, 2013; 43:251–254.