Medication Use in Breastfeeding Women: A National Study

Abstract

Introduction:

A wealth of evidence reveals the benefits of breastfeeding. During the breastfeeding period, nursing mothers may face many medical conditions that require medical management. The medication use among breastfeeding women in Jordan is largely unknown.

Objective:

This study assessed the beliefs and attitudes of breastfeeding women in Jordan toward medication use.

Methods:

The data were collected from breastfeeding women in hospitals and maternal and children care centers from north, middle, and south Jordan by semistructured interviews using a self-administered questionnaire from February 2015 to November 2015.

Results:

Of the 903 participants (96% response rate), 17% used over-the-counter medications and 33% took prescribed medications. Of these, 7% (n = 64) used both over-the-counter and prescribed medications. Analgesics followed by antibiotics were the most commonly used medications among breastfeeding women in Jordan. The majority of breastfeeding women consulted with their physician or pharmacist before initiating or changing any medication. Product Information was the most commonly used drug information resource utilized by breastfeeding women to inquire about safety of medication use during breastfeeding.

Conclusion:

Breastfeeding women should be educated about the reliable sources of medication information and the importance of physician consultation before initiation or modification of medication therapy. Physicians and pharmacists should be encouraged to be actively involved in detailed discussion with breastfeeding women regarding medication use.

Introduction

Awealth of evidence reveals the benefits of breastfeeding for the newborn infants and mothers. Breast milk provides complete nourishment to the infant and reduces the risk of diabetes, obesity, infection, leukemia, and asthma development.^1,2 In addition, breastfeeding mothers have reduced risk to develop type 2 diabetes,¹ breast cancer,^3,4 and ovarian cancer.¹ The current guidelines advise exclusive breastfeeding for the first 6 months after birth.^5,6 However, high-income countries have shorter duration of breastfeeding compared to middle- and low-income countries.⁷

Lactating mothers may face many medical conditions and medication use cannot be avoided. Medication use during breastfeeding may affect volume of milk and the child, if the medication transferred to milk. The transfer of medications to human milk depends on several factors, such as dose, frequency of administration, and lipid solubility of medication.^8,9 Time of feeding, milk volume, as well as the ability of infant to metabolize the medication, also play a role in the effect of medication on breastfed child.^8,10

Most medications are safe to be given during lactation, with rare contraindicated ones.^11,12 The most common medications used are vitamin and mineral supplements, antibiotics, nonsteroidal anti-inflammatory agents, and gastrointestinal drugs.^13–16 Cessation of breastfeeding is necessary if contraindicated medications are prescribed.¹⁷ Ito et al. found that despite reassurance to breastfeeding mothers by healthcare providers, some women either cease breastfeeding whenever medication is needed or deprive themselves from taking any medication.^18–20 Unfortunately, lack of proper educational programs resulted in inappropriate advice of discontinuation of breastfeeding^21,22 even for medications that are proven to be safe during this period.²³

The present study was undertaken to assess the medication use among breastfeeding women in Jordan. In addition, the study aimed to assess the beliefs and attitudes of breastfeeding women toward medication use. Assisting breastfeeding women to access evidence-based information for informed decision-making was our ultimate goal.

Materials and Methods

Study population and design

A cross-sectional study was conducted at hospitals and maternal and children care centers at Jordan Ministry of Health in the main cities of north (Irbid, Al-Ramtha, and Al-Mafraq), middle (Amman, Zarqa, and Al-Salt), and south Jordan (Al-Karak and Wadi Musa). A self-completed questionnaire was distributed to breastfeeding women at the participating sites (n = 40 sites) from February 2015 to November 2015. The questionnaire was piloted in a small number of mothers (n = 10) before the study in an attempt to improve questions' clarity. Breastfeeding women were included in the study only after they were fully informed and agreed to participate in the study. Consent to participate was taken as implied if the mothers filled and returned the questionnaire. All women who were ≥18 years old and were breastfeeding either exclusively or not at the time of the study were included. Exclusion criteria included if someone else other than the mother came to the clinic with the child. Only one questionnaire was handed to the mother if she visited the clinic more than once during the study period. The study was approved by the Institutional Review Board at Jordan University of Science and Technology (study number 23/81/2014) and Jordan Ministry of Health (study number MOHREC150008).

Data collection

Data were collected by means of semistructured interviews using a self-administered questionnaire. A trained clinical pharmacist was available to assist illiterate women. The questionnaire was developed in Arabic language and based on systematic literature review. It was composed of three sections covering different concepts. Breastfeeding women were asked to answer the 25 questions that assess their sociodemographic characteristics, beliefs and attitudes toward medication use, medication use during breastfeeding, sources of information, and the role of healthcare providers in breastfeeding women education. A medication referred to either a prescribed or over-the-counter agents. After completion of the questionnaire, a general educational material that focused on the importance of healthcare providers' consultation before initiation, modification, and cessation of medication during breastfeeding was given to each participated mother in our study.

Data analysis

Categorical variables were presented as numbers and percent. The statements were trichotomized (yes [always], no, or sometimes). The differences in responses to the 25-item questionnaire were examined using Chi-square (χ²) test or Fisher's exact test. Multinominal logistic regression test was used to determine the factors that are independently associated with beliefs and attitudes of participants toward medication use. All variables with p ≤ 0.05 in univariable analysis were included in the multinominal logistic regression test. p ≤ 0.05 was considered as statistically significant. All analyses were carried out using Statistical Package for Social Sciences (SPSS, Inc., Chicago, IL) version 20.

Results

Demographic data

A total of 940 breastfeeding women were approached in our study and 903 of them were enrolled with a response rate of 96%. Approximately, half (52%) of the women were 26–35 years old and around 13% of the participating women were older than 35 years. The majority of the participants were Jordanian with few Syrian (11%), Palestinian (4%), and other nationalities. The percentage of participating women with a college or university degree was 42% compared to 53% who finished primary and secondary education. Of interest, the majority of participated women were not in paid work (housewives) (74%). The questionnaire was distributed to all areas of Jordan almost equally (Table 1).

Table 1.

Demographics and Characteristics of Participating Breastfeeding Women

Characteristics	Number of women (%) ^a
Age (years)
18–25	319 (35.4%)
26–35	464 (51.6%)
36–45	111 (12.3%)
>45	6 (0.7%)
Nationality
Jordanian	743 (83.5%)
Palestinian	34 (3.8%)
Syrian	102 (11.5%)
Others	11 (1.2%)
Insurance
Yes	516 (57.3%)
No	385 (42.7%)
Education
Illiterate	40 (4.4%)
Primary	144 (16%)
Secondary	336 (37.2%)
College degree	113 (12.5%)
University degree	270 (29.9%)
Occupation (890)
Not in paid work (housewife)	661 (74.3%)
Not related to the medical field	139 (15.6%)
Related to the medical field	90 (10.1%)
Monthly income^b (U.S. dollar)
<420	252 (31.8%)
420–840	480 (60.6%)
>840	60 (7.6%)
Area of residence (896)
North Jordan	318 (35.5%)
Middle Jordan	294 (32.8%)
South Jordan	284 (31.7%)
Residence (812)
Countryside^c	316 (38.9%)
City	496 (61.1%)

Percentage values were calculated based on the number of women who responded to the correspondent question.

1 U.S. dollar is equivalent to 0.71 Jordanian dinar.

Countryside consists of villages and Badia. Badia is the desert area of Jordan where there is some animal and plant life.

Medication use

Approximately, 17% of breastfeeding women reported that they took over-the-counter medications such as vitamins and weight loss products and around a third of the participants had taken prescribed medications during breastfeeding period (Table 2). Of these, 7% of participants stated that they took both over-the-counter and prescribed medications during breastfeeding (Table 2). The most commonly used medication categories were analgesics (15.8%), antibiotics (11.5%), gastrointestinal medications (5.2%), cardiovascular medications (2%), and diabetes mellitus medications (2%). Only 7% of breastfeeding women stated that they have chronic diseases such as hypertension and diabetes mellitus.

Table 2.

Women's Beliefs and Attitudes About Medication Use

Attitude and beliefs	Yes n (%)^a	No n (%)^a	Sometime n (%)^a
Have you ever consulted with your physician or pharmacist before taking any medication during breastfeeding?	666 (74%)	104 (11.6%)	130 (14.4%)
Have you ever changed or stopped taking any of your medications without consulting with your physician or pharmacist during breastfeeding?	147 (16.5%)	660 (73.8%)	87 (9.7%)
Have you ever taken over-the-counter medications during breastfeeding?	152 (16.8%)^b	693 (76.8%)	58 (6.4%)
Have you ever taken any prescribed medications during breastfeeding?	294 (32.6%)^b	535 (59.4%)	72 (8%)
Have you ever checked Product Information (PI) before using it during breastfeeding?	641 (71.2%)	88 (9.8%)	171 (19%)
What medication information resources have you ever consulted during breastfeeding?
Internet	284 (31.8%)	609 (68.2%)	—
Books and medical journals	23 (2.6%)	870 (97.4%)	—
Relatives	167 (18.7%)	726 (81.3%)	—
Other (radio, midwives)	44 (4.9%)	849 (95.1%)	—
Do not search	375 (42%)	518 (58%)	—
Do you believe that medications you consume during breastfeeding may affect your baby's health?	487 (54.5%)	231 (25.8%)	Did not know 176 (19.7%)
Have you ever observed any changes in your baby while using any medication?	46 (5.2%)	391 (43.9%)	Did not use any medications 453 (50.9%)
Have you ever consumed any herbs to increase milk production?	263 (29.3%)	635 (70.7%)	—

Percentage values were calculated based on the number of women who responded to the correspondent question.

Sixty-four (7%) women took both over-the-counter and prescribed medications during breastfeeding.

Beliefs and attitudes of breastfeeding women toward medication use

Generally, most women consulted their physician or pharmacist before initiating any medication (74%) and few women changed or stopped taking any of their medications without consultation (16.5%). Half of breastfeeding women were aware about the risk of medications' on their babies. Of the 49.1% participants who used medications during breastfeeding, 5.2% of participants noticed changes in their babies' habits such as diarrhea or decrease in activity.

There are different medication information resources utilized by breastfeeding women such as Product Information (PI) and healthcare professionals. Approximately, two-thirds of participants (71%) stated that they read the PI before they took their medications. Thirty-two percent and 19% of women consulted the Internet and relatives, respectively, for further details about medications. Few women obtained extra information from radio or books and medical journals (Table 2).

Healthcare professionals' role in medication use during breastfeeding

Seventy-one percent of the participants mentioned that their physician asked them if they were breastfeeding before writing the prescription, while around 60% of the pharmacist asked whether they were breastfeeding before dispensing any medication. Less than half of the participants stated that their physicians or pharmacists took time to talk with them about their prescribed medications (Table 3).

Table 3.

Participating Women's Responses in Regards to Physicians' and Pharmacists' Role with Regards to Medication Use During Breastfeeding

Healthcare professionals' attitude	Yes n (%) ^a	No n (%) ^a	Sometime n (%) ^a
Has your physician ever asked if you are breastfeeding before prescribing any medication?	619 (70.7%)	125 (14.2%)	132 (15.1%)
Has your pharmacist ever asked if you are breastfeeding before dispensing any medication?	508 (58.6%)	178 (20.5%)	181 (20.9%)
Has your physician ever informed you of all details regarding the medication he/she prescribed?	336 (38.4%)	297 (34%)	241 (27.6%)
Has your pharmacist ever informed you of all details regarding the medication he/she dispensed?	381 (43.4%)	222 (25.3%)	274 (31.3%)

Percentage values were calculated based on the number of women who responded to the correspondent question.

Factors affecting medication use during breastfeeding

The results of the univariable analysis showed that factors affecting the use of over-the-counter medications during breastfeeding were education, age, occupation, area of residence, and insurance (p < 0.05). In contrast, the use of prescribed medications during breastfeeding was affected by age, educational level, area of residence, and occupation (p < 0.05). The results of multinominal logistic regression are shown in Table 4. The use of over-the-counter medications was higher in women who had university degree and who lived in south Jordan compared to illiterate women and those who lived in north Jordan, respectively. The use of prescribed medications was higher in women who worked in medical fields compared to housewives and women who worked in nonmedical fields. In addition, women who lived in south Jordan were more likely to use prescribed medications compared to those who lived in north and south areas.

Table 4.

Multinominal Logistic Regression Analysis for Factors Affecting Medication Use During Breastfeeding

Medication use during breastfeeding	OR	95% CI	p-Value
Over-the-counter medications
Education
University degree	Ref
Illiterate	0.162	0.033–0.791	0.024
Primary	0.497	0.239–1.030	0.060
Secondary	0.680	0.376–1.228	0.201
College degree	0.639	0.358–1.143	0.131
Area of residence
South Jordan	Ref
North Jordan	0.394	0.435–1.712	0.001
Middle Jordan	0.991	0.462–1.899	0.973
Prescription medications
Occupation
Related to the medical field	Ref
Not in paid work (housewife)	0.439	0.245–0.786	0.006
Not related to the medical field	0.457	0.249–0.839	0.011
Area of residence
South Jordan	Ref
North Jordan	0.396	0.261–0.600	<0.001
Middle Jordan	0.601	0.392–0.922	0.02

p ≤ 0.05 is statistically significant.

OR, odds ratio; CI, confidence interval.

Discussion

For many years, the research has focused on the safety of medication use during pregnancy, with little attention on breastfeeding. Previous work in Jordan focused on the perception, knowledge, and practices of breastfeeding.^24–27 In this study, we provide for the first time in Jordan, and up to the authors' knowledge in the Middle Eastern countries, beliefs and attitudes of breastfeeding women toward medication use.

In the present study, conservative use of medications during breastfeeding was noticed. This could be explained by the belief of more than half of the participating women that medication use during breastfeeding may affect their babies' health. Matheson et al. found that 50% of women thought that medication use during breastfeeding could be more or as risky as using medications during pregnancy.¹⁴ Over-the-counter medications may affect the breastfed baby if passed through milk and most women are not aware of this effect.²⁸ Breastfeeding women should be encouraged to consult healthcare professionals before taking any medication. Consistent with previous reports,^13–16 the most common medication categories that were used by breastfeeding women were analgesics, antibiotics, and gastrointestinal medications such as those to treat dyspepsia, constipation, and hemorrhoids.

Sociodemographic factors, like occupation, education, and cultural background, were found to be involved significantly in patients' beliefs and attitudes toward medication use.^29,30 Breastfeeding women who lived in south Jordan were found to consume more prescribed and over-the-counter medications compared to those who lived in north Jordan. This can be explained by limited resources and access to healthcare centers in south Jordan that forced women to keep medications at home and use them more frequently. In addition, an increased use of prescribed medications was observed among women who worked at the medical sector compared to housewives and women who worked at nonmedical-related areas.

In addition, level of education seemed to be another important background variable for over-the-counter medication use. Women who had university degree utilized significantly more over-the-counter medications compared to illiterate women. This points toward the need to adopt more educational programs at maternal and children care centers to emphasize on the importance of healthcare providers' consultation before initiating any medication during breastfeeding.

The use of herbs to increase milk production is common during breastfeeding and many breastfeeding women believe that herbs are safe and harmless,³¹ which is not always true. In our study, about third of the participants stated that they used herbs. Our result is consistent with a previous study in Western Australia where 24.3% of breastfeeding women reported that they took herbs to enhance milk supply.³¹ More studies are needed to evaluate the safety of herbs during breastfeeding.

Counseling of breastfeeding women is an essential part of the management plan. In the current study, about two-thirds of participants mentioned that their physician asked them if they were breastfeeding before writing the prescription, which is consistent with previous report.³² However, around 60% of the pharmacists asked whether they were breastfeeding before dispensing any medication. This result is inconsistent with a previous study that found only 11% of breastfeeding women were asked by their pharmacists.³² This finding reflects the increased awareness level of healthcare professionals about the importance of checking medication compatibility with breastfeeding due to continuous educational programs offered by Jordan medical and pharmaceutical associations.

Less than 50% of breastfeeding women in our study reported that either physicians or pharmacists counseled them regarding the medication they recommend or dispense. Merlob et al. found that around 60% of women stated that they were counseled by physicians and only 9% counseled by pharmacists at the time of discharge from a maternity ward few days after delivery.³³ This relatively low percentage in our study could be due to lack of appropriate knowledge about medication use during breastfeeding by physicians and pharmacists and the limited time that they have during their work. A study evaluating healthcare professionals' knowledge and attitude regarding the safety of medication use during breastfeeding at the national level of Jordan is in progress.

Medication-related information can be acquired from different resources. The majority of participants in our study acquired information before initiation, changing, or cessation of any medication from healthcare professionals. Of interest, 71% of participants stated that they regularly checked PI before initiating any medication. Contrary to the result of Merlob et al. study where only 8% of women stated that they had read the PI.³³ Breastfeeding women relied on other resources for medication information such as the Internet. However, the quality of Internet information is questionable and sometimes inaccurate.^34,35 It is noteworthy to mention that fifth of the participants asked their relatives, and hence, personal experience interfered with their medication-related decisions.

Limitations in this study include the prevalence of educated women that ∼80% of participants finished at least secondary school and this could affect their attitude and beliefs. In addition, age of babies was not collected from the participants. This study could be subject to recall bias.

Conclusion

This was the first study in Jordan and Middle Eastern countries that appraised the beliefs and attitudes of breastfeeding women toward medication use. A conservative use of medications, both prescribed and over-the-counter, was observed among breastfeeding women in Jordan. Analgesics followed by antibiotics were the most commonly used medications among breastfeeding women. The majority of participants consulted with their physician or pharmacist before initiating or changing any medication. The most commonly used drug information resource was PI. Most physicians or pharmacists did not talk with breastfeeding women about medications they prescribed or dispensed. Breastfeeding women should be educated about the reliable sources of medication information and the importance of healthcare professionals' consultation before initiation or modification of medication therapy. Physicians and pharmacists should be encouraged to be actively involved in detailed discussion with breastfeeding women on medication use.

Footnotes

Acknowledgments

The authors thank breastfeeding women who participated in the study. This study was supported by a grant from the Deanship of Research at Jordan University of Science and Technology, Irbid, Jordan.

Disclosure Statement

No competing financial interests exist.

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