BREASTFEEDING MEDICINE

Volume 9, Number 3, 2014

Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2013.0086

Breastfeeding Throughout Pregnancy in Turkish Women

Aylin Ayrim,1 Suzan Gunduz,2 Banu Akcal,1 and Hasan Kafali1

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

he 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 metaanalysis 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.68 Gender roles, social support, and attitudes of friends and relatives

toward breastfeeding have also been shown to affect a

mothers 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 723 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.1118 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

Departments of 1Gynecology and Obstetrics and 2Pediatrics, Faculty of Medicine, Turgut Ozal University, Ankara, Turkey.

157

158
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 infants 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 v2
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.
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).
Discussion
Breastfeeding is beneficial for infant and mother. We know
that lactation and pregnancy are both very energetic pro-

AYRIM ET AL.
Table 1. Comparison of Lactating (Group A)
and Nonlactating (Group B) Pregnant Women

Age (years)
Prepregnancy body
mass index (kg/m2)
Birth weight of the
baby (g)
Gestational week at the
time of birth
Apgar score
1 minute
5 minutes
Weight gain during
pregnancy (kg)

Group A
(n = 45)

Group B
(n = 120)

p value

24.3 4.9
25.4 4.4

23.2 3.3
26.4 3.7

> 0.05
> 0.05

3,090 470

3,170 510

> 0.05

38.2 1.3

38.7 1.1

> 0.05

7 0.1
9 0.2
7 3.4

7 0.4
9 0.2
13 5.6

> 0.05
> 0.05
< 0.05a

Data are mean SD values.

a
Significant difference.

cesses. 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 mothers milk16,17 or deprive the fetus of nutrition.18

Table 2. Comparison of Pregnancy Complications

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

Hyperemesis gravidarum
Threatened abortion
Preterm labor
Preterm delivery
Hemoglobin at the time of
delivery (g/dL)

Group A
(n = 45)

Group B
(n = 120)

p value

3
5
7
1
9.7 1.7

3
6
8
2
12.3 1.5

> 0.05
> 0.05
> 0.05
> 0.05
< 0.05a

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

a
Significant difference.

BREASTFEEDING THROUGHOUT PREGNANCY

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.2123 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 723 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,

159
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.
Disclosure Statement
No competing financial interests exist.
References
1. Committee on Health Care for Underserved Women, Committee on Obstetric Practice. Breastfeeding: maternal and
infant aspects. ACOG Clin Rev 2007;12(Suppl):1S16S.
2. American Academy of Pediatrics; American College of Obstetrics and Gynecology. Breastfeeding Handbook for Physicians. Washington, DC: American College of Obstetrics and
Gynecology, 2006.
3. Kramer MS, Kakuma R. The Optimal Duration of Exclusive
Breastfeeding. A Systematic Review. Department of Nutrition
for Health and Development, World Health Organization,
Geneva, 2001.
4. UNICEF. NutritionBreastfeeding: The best choice for
babies. www.unicef.org/nutrition/index_27817.html (accessed May 18, 2012).
5. Hamlyn B, Brooker S, Oleinikova K, et al. Infant Feeding
2000. The Stationery Office, London, 2002.
zelci P, Elmac N, Ertem M, et al. Breastfeeding
6. Ergenekon-O
beliefs and practices among migrant mothers in slums of
Diyarbakr, Turkey, 2001. Eur J Public Health 2006;16:143148.
7. Giovannini M, Banderali G, Agostoni C, et al. Epidemiology
of breastfeeding in Italy. Acta Paediatr Scand 1999;88:1922.
8. Buyukgebiz B, Cevik N, Oran O. Factors related to the duration of breastfeeding in Ankara, with special reference to
sociocultural aspects. Food Nutr Bull 1992;4:289293.
9. Paine P, Dorea JG. Gender role attitudes and other determinants of breastfeeding intentions in Brazilian women.
Child Care Health Dev 2001;27:6172.
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 R. The association between breastfeeding
during late pregnancy and the occurrence of small for gestational age and prolonged active phase of labor among
Peruvian women [Masters thesis]. Nutritional Sciences,
Iowa State University, Ames, 2007. www.books.google
.com.tr/books.isbn = 0549923837 (accessed December 18,
2012).
12. Marquis GS, Diaz JM, Marn RM. Postpartum consequences
of an overlap of breastfeeding and pregnancy: Reduced
breast milk intake and growth during early infancy. Pediatrics 2002;109:5664.
13. Briefel RR, Bialostosky K, Kennedy-Stephenson J, et al. Zinc
intake of the U.S. population: Findings from the Third National Health and Nutrition Examination Survey, 19881994.
J Nutr 2000;130:1367S1373S.
14. Merchant K, Martorell R, Haase J. Maternal and fetal responses to the stresses of lactation concurrent with pregnancy and of short recuperative intervals. Am J Clin Nutr
1990;52:280288.
15. Ramachandran P. Maternal nutritionEffect on fetal growth
and outcome of pregnancy. Nutr Rev 2002;60:S26S34.

160
16. Raphael D, Davis F. Only Mothers Know: Patterns of Infant
Feeding in Traditional Cultures. Greenwood Press, Westport,
CT, 1985:3685.
17. Crean JTG, Ling SC, Peakson DJ, et al. Dhavari Project
1985Infant feeding patterns. J Trop Pediatr 1987;33:
1422.
18. Ransome-Kuti O. Some cultural and social aspects of infant
feding in Nigeria. In: Falkner F, Kretchmer N, Rossi E, eds.
Modern Problems in Paediatrics. S. Karger, Basel, 1975:
117125.
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 T, Christian P, Khatry SK, et al. Micronutrient deficiencies in early pregnancy are common, concurrent, and
vary by season among rural Nepali pregnant women. J Nutr
2005;135:11061112.
21. Valero de Bernabe J, Soriano T, Albaladejo R, et al. Risk
factors for low birth weight: A review. Eur J Obstet Gynecol
Reprod Biol 2004;116:315.
22. Lasker JN, Coyle B, Li K, et al. Assessment of risk factors for
low birth weight deliveries. Health Care Women Int
2005;26:262280.

AYRIM ET AL.
23. Ramakrishnan U. Nutrition and low birth weight: From research to practice. Am J Clin Nutr 2004;79:1721.
24. Moscone SR, Moore MJ. Breastfeeding during pregnancy.
J Hum Lact 1993;9:8388.
25. Bobak M, Dejmek J, Solansky I, 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 F, Hassanabadi M. A comparative study of
breastfeeding during pregnancy: Impact on maternal and
newborn outcomes. J Nurs Res 2012;20:7480.
27. Sengul O, Sivaslog
lu AA, Kokanal MK, et al. The outcomes
of the pregnancies of lactating women. Turk J Med Sci 2013;
43:251254.

Address correspondence to:

Suzan Gunduz, MD
Department of Pediatrics
Turgut Ozal University
Alpaslan Turkes cad. No:57
06510 Emek, Ankara, Turkey
E-mail: akinsuzan@gmail.com