Mothers' Knowledge and Adherence to Who Breastfeeding Recommendations: A Cross-Sectional Study in Greece

Breastfeeding is the biological norm for feeding infants. When used properly, it offers a multitude of health benefits for both mother and child. [1,2,3]. The World Health Organization (WHO) advises that infants should start breastfeeding within the first hour of life and continue exclusively for the first six months. After six months, breastfeeding should be complemented by appropriate and safe complementary foods, continuing until the child is at least two years old or older [3]. It has been observed that breastfeeding expedites the mother's process of returning to her prepregnancy weight and the uterus's shrinkage to its prepregnancy size. Moreover, breastfeeding has been demonstrated to lower the risk of breast cancer (particularly in cases when a woman has been breastfeeding for > 12 months) [4,5,6], ovarian cancer, dyslipidemia, and type 1 and type 2 diabetes mellitus. In addition, breastfeeding offers the infant numerous advantages because it supplies all the nutrients it needs in the right amounts and qualities depending on its developmental stage. It also shields the infant from infections like ear, gastrointestinal, and respiratory infections and helps prevent food allergies from developing in the future [7].

According to WHO and UNICEF, many infants and children do not receive optimal nutrition [8]. Several studies confirm that breastfeeding rates worldwide remain below the levels needed to protect maternal and child health [8,9,10,11,12]. For example, Victora et al. (2016) found that only 36% of infants aged 0–6 months were exclusively breastfed between 2007 and 2014 [9], while WHO data from 2017 show that just 41% of infants under six months were exclusively breastfed [11-12]. The WHO collective targets for global rates in 2030 are 70% of women to breastfeed their newborn in the first hour, 70% to breastfeed exclusively for six months of which 80% of women to continue breastfeeding for one year, and 60% for two years [13,14].

The present study aims to investigate the rates of breastfeeding in Greece according to WHO and UNICEF guidelines.

This is a cross-sectional study that was carried out in four day care centers of South Athens, Greece, from February 22, 2018, to June 30, 2019. The sample of study consisted of 674 mother-child couples. The mothers were informed about the purpose of the study by the researcher. Also, they were informed about the confidentiality of the data and the anonymity of the study. The mothers also filled out the consent form for participation in the research. The questionnaires were completed by the mothers, who, after one week, returned them to the researcher.

The average age of mothers was 36.91 years (SD = 4.51), with the youngest mother being 24 years old and the oldest 56 years old. The average age at pregnancy was 33.93 years (SD = 4.52), with the youngest mother at pregnancy being 20 years old and the oldest 52 years old.

Regarding health and lifestyle during pregnancy, 80 women (11.9%) reported developing gestational diabetes, while 591 women (87.7%) did not. Furthermore, 71 women (10.5%) reported smoking during pregnancy, while 602 women (89.4%) did not. Additionally, 46 women (6.8%) reported drinking alcohol during pregnancy, with 627 women (93.1%) abstaining from alcohol. In terms of maternal weight, 486 women (72.1%) had a normal weight, 85 women (12.6%) were overweight, 50 women (7.4%) were underweight, and 47 women (7%) were obese (Table 1). These findings highlight a relatively high average maternal age, which reflects a trend in delayed pregnancies. While most women appeared to be in good health, with high percentages not engaging in smoking, drinking alcohol, or developing gestational diabetes, a significant proportion of women were either overweight or obese, with around 20% of the participants falling into these categories.

The type of delivery was reported by the 674 women: 244 (36.2%) women gave birth by normal delivery, 26 (3.86%) women gave birth by vacuum extraction delivery, and 404 (59.94%) women by cesarean section. Epidural anaesthesia was performed in 561 (83.2%) women, of which 291 (51.9%) women reported that epidural anaesthesia was their personal choice. Breastfeeding was also reported by the women: 650 (96.54%) women reported that they breastfed the newborn, while 24 (3.56%) women reported that they did not breastfeed; 629 (93.3%) women reported breastfeeding the first hour after birth of the newborn, while 44 (6.5%) women did not breastfeed (Table 1).

The length of breastfeeding was also recorded: 236 (35.01%) women breastfed exclusively for at least six months; 27 (4, 01 %) women breastfed > 5 months and < 6 months; and 50 (7.42%) women breastfed < 5 months. Of the 236 women who breastfed at least 6 months, 106 (44.91%) continued breastfeeding for one year, and 22 women (9.32%) continued for two years (Fig. 1, Table 1).

A total of 246 women (36.5%) reported that their newborn was immediately removed after birth, while 387 women (57.4%) did not experience this, and 40 women (5.9%) did not provide a response. The average time taken to transfer the neonate to the room for women whose babies were removed after delivery was 6.28 hours (SD = 8.77), with the shortest time being 1 hour and the longest 48 hours. Regarding infant feeding in the first few days, 330 women (49%) reported that their newborns were given formula milk, while 332 women (49.3%) did not use formula milk. Among the 330 women who indicated their infants received formula milk, 234 (70.9%) said they were aware of it, 37 (11.21%) were not aware, and 59 (17.87%) did not respond. Of the 27 women who answered why formula milk was given, the reasons provided included jaundice, the baby being underweight, insufficient milk supply, the baby being in an incubator, a health problem, or the baby needing to stay in the hospital.

Figure 1.

Duration of exclusive breastfeeding.

Figure 2.

Questions about breastfeeding.

The women recorded the reasons for not breastfeeding: 135 (20.03%) women reported that they were told they did not have enough milk, 91 (13.5%) women that their nipples were not good, and 62 (9.2%) women that their milk was thin (Table 1).

They also reported on the information they were given about breastfeeding: 592 (87.3%) women were informed about breastfeeding, while 66 (9.79%) women were not informed, and 16 (2.37%) women did not respond. Regarding the percentage of 592 women who were informed about breastfeeding, 245 (41.4%) women said they were informed by the midwife, 252 (42.6%) women by staff, 100 (16.9%) women by the doctor, 6 (1%) women by the Internet, and 47 (7.9%) women by other sources (books, friends, seminars, relatives, first child, etc.).

The ease of breastfeeding was elicited from the woman: 441 (65.43%) women reported that the breastfeeding process was easy enough and very pleasant; 100 (14.84%) women had a neutral attitude; 438 (64.99%) women reported that they were enough and very informed about breastfeeding; 74 (10.98%) women had a neutral attitude; 219 (32.49%) women reported that they had a lot of help during breastfeeding; 120 (17.80%) women had a neutral attitude; and 131 (19.44%) of the women did not report on the availability of help at all (Fig. 2).

The women expressed their feelings about breastfeeding: 129 (19.14%) women reported that they would like to change something during breastfeeding, while 356 (52.82%) women did not want any change. Of the women who wished to change something, 20 (15.50%) women would like to be calmer, 19 (14.73%) women would like to be better informed, 11 (8.53%) women would like to breastfeed normally and not with the use of a breast pump, 11 (8.53%) women would like to breastfeed more, and the remaining 58 (44.96%) women reported 26 different reasons.

Based on the multiple linear model, the dependent variable was the breastfeeding interval in months while the independent variables were normal delivery, giving foreign milk in the first few days, exclusive breastfeeding, third-party report of not having enough milk or having thin milk, third-party report of not having good nipples, information about breastfeeding, degree of enjoyment of breastfeeding, degree of information about breastfeeding, assistance during breastfeeding, and removal of the newborn after delivery. The stepwise method was used to find the optimal model (this method starts by introducing variables into the model until there is no improvement, at which point it stops). The final model was found to be statistically significant, F (6. 345) = 21.996, p < .01, R square = .275. The model had no problems with multilinearity (VIF < 10) and autocorrelation (Durbin Watson = 1.966, acceptable values 1–3).

Statistically significant predictor variables for the duration of exclusive breastfeeding include exclusive breastfeeding itself (b = 7.004, p < .01), the degree of pleasure from breastfeeding (b = 1.898, p < .01), gestational diabetes (b = 2.644, p < .05), being overweight (b = 4.355, p < .01), and having a normal weight (b = 1.951, p < .01). Women who exclusively breastfeed are able to breastfeed 7.004 months longer than those who do not. Women without gestational diabetes breastfeed 2.644 months longer than those with gestational diabetes. Additionally, for every one-unit increase in the degree of pleasure from breastfeeding, the duration of breastfeeding increases by 1.898 months. Overweight women (BMI > 25) breastfeed 4.355 months longer compared to underweight women (BMI < 20), while women with a normal weight (BMI between 20 and 25) breastfeed 1.951 months longer than underweight women (Table 2).

Breastfeeding rates in Greece remain below WHO and UNICEF targets, although recent data suggest improvement. Exclusive breastfeeding and maternal satisfaction were identified as key factors influencing its duration. Promoting and supporting breastfeeding should be a public health priority, and further research is needed to better understand and enhance exclusive breastfeeding practices during the first six months of life.