Adam et al.

International Breastfeeding Journal (2021) 16:48

https://doi.org/10.1186/s13006-021-00391-3

RESEARCH Open Access

Association between breastfeeding and

preeclampsia in parous women: a case –
control study
Ishag Adam1, Duria A. Rayis2*, Nadiah A. ALhabardi1, Abdel B. A. Ahmed3, Manal E. Sharif3 and Mustafa I. Elbashir2

Abstract
Background: Preeclampsia is a global health problem and it is the main cause of maternal and perinatal morbidity
and mortality. Breastfeeding has been reported to be associated with lower postpartum blood pressure in women
with gestational hypertension. However, there is no published data on the role that breastfeeding might play in
preventing preeclampsia. The aim of the current study was to investigate if breastfeeding was associated with
preeclampsia in parous women.
Method: A case-control study was conducted in Saad Abualila Maternity Hospital in Khartoum, Sudan, from May to
December 2019. The cases (n = 116) were parous women with preeclampsia. Two consecutive healthy pregnant
women served as controls for each case (n = 232). The sociodemographic, medical, and obstetric histories were
gathered using a questionnaire. Breastfeeding practices and duration were assessed.
Results: A total of 98 (84.5%) women with preeclampsia and 216 (93.1%) women in the control group had
breastfed their previous children. The unadjusted odds ratio (OR) of preeclampsia (no breastfeeding vs
breastfeeding) was 3.55, 95% confidence interval (CI) 1.64,7.70 and p value = 0.001 based on these numbers. After
adjusting for age, parity, education level, occupation, history of preeclampsia, history of miscarriage, body mass
index groups the adjusted OR was 3.19, 95% CI 1.49, 6.82 (p value = 0.006).
Conclusion: Breastfeeding might reduce the risk for preeclampsia. Further larger studies are required.
Keywords: Preeclampsia, Breastfeeding, Risk factors, Parous women, Sudan

Background and pathophysiology of preeclampsia are not well under-

Preeclampsia is characterized by new-onset hypertension stood; however, several risk factors (parity, body mass
and proteinuria after the 20th week of gestation, and it index (BMI), chronic disease, lack of antenatal care, and
is one of the main pregnancy-related disorders [1]. It has anaemia) have been identified as risk factors and can be
been estimated that approximately 2–8% of pregnant/ used as predictors of preeclampsia [3].
parturient women worldwide have preeclampsia [2]. Pre- Breastfeeding is globally considered a vital public
eclampsia is a main cause of maternal and perinatal health issue with social, religious, and economic implica-
morbidity and mortality [2]. The function of multiple tions [4, 5]. Breastfeeding is associated with reduced
systems and organs, such as the liver, kidneys, and brain, negative cardiovascular sequelae that are attributed to
can be affected by preeclampsia [2]. The exact aetiology preeclampsia (hypertension, type II diabetes, metabolic
syndrome, and cardiovascular disease) [6]. It has recently
* Correspondence: gasimgsm1974@gmail.com
been shown that women who had normotensive preg-
2
Faculty of Medicine, University of Khartoum, P.O Box 102, Khartoum, Sudan nancies and breastfed were at a lower risk of
Full list of author information is available at the end of the article

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Adam et al. International Breastfeeding Journal (2021) 16:48 Page 2 of 6

atherosclerosis than peers who had never breastfed [7]. delivery) and blood group were recorded. Following de-
It has been shown that breastfeeding is associated with livery, the gender of the newborn was recorded.
lower blood pressure in later life [8]. Moreover, breast- To assess breastfeeding practices and duration, women
feeding was reported to be associated with lower post- were initially asked “Did you breastfeed your last baby?”
partum blood pressure in women with normal weight Women who answered “no” were categorized as never
[9] and in women with gestational hypertension [10]. To breastfed.
the best of our knowledge, there is no published data on The sample included 116 cases and 232 controls (ratio
the role that breastfeeding might play in preventing pre- of 1:2). The sample size was calculated based on the re-
eclampsia. Hence, this study was conducted in port on breastfeeding (87.2% of women initiated breast-
Khartoum, Sudan, to investigate if breastfeeding was as- feeding within the first hour) in eastern Sudan [19]. We
sociated with preeclampsia in parous women. Pre- assumed that 85% of the cases (preeclampsia) vs 95% of
eclampsia is the leading cause of poor maternal and the controls had breastfed their babies (regardless of the
perinatal outcomes in Sudan [11]. We have previously duration of breastfeeding). This sample size would result
showed that several clinical, biochemical, and genetic in 80% power with a precision of 5% to detect a differ-
factors are associated with preeclampsia [12–16]. How- ence of 10% in breastfeeding rates (95% vs 85%) between
ever, the real effects of breastfeeding in reducing the risk mothers with and without preeclampsia.
of preeclampsia remain debated.
Statistical analysis
Methods Statistical analysis was performed using Statistical Pack-
A case-control study was conducted in Saad Abualila age for the Social Sciences (SPSS) for Windows version
Maternity Hospital in Khartoum, Sudan, from May to 22.0 (SPSS Inc., Chicago, IL, USA). Proportions of the
December 2019. The cases were parous women with studied variables were expressed as the frequency (%).
preeclampsia recruited from the labour ward. The Continuous data were evaluated for normality using the
American College of Obstetricians and Gynaecologists Shapiro-Wilk test. The variables; age, parity, education
criteria [1] were used to diagnose preeclampsia as fol- level, occupation, history of preeclampsia, history of mis-
lows: pregnant women with a blood pressure equal to or carriage, and BMI were included in the multivariate lo-
greater than 140/90 mmHg on two occasions at least 6 h gistic regression adjusting for possible confounding of
apart plus proteinuria (≥ 300 mg/24 h). Women with a the relationship between previous breastfeeding and pre-
blood pressure ≥ 160/110 mmHg on two occasions, pro- eclampsia. All of these variables were included in the re-
teinuria of ≥5 g/24 h, and HELLP syndrome (haemolytic gression (i.e. no backward elimination). Some variables
anaemia, elevated liver enzymes, and low platelet count) such as IPI, blood group, antenatal care, haemoglobin
were considered to have severe preeclampsia, otherwise, level at delivery, and gender of infant were not included
preeclampsia was considered mild [1]. Women who pre- as confounding factors because these variables occurred
sented with preeclampsia before and after 34 weeks were after the previous breastfeeding. Even if these variables
classified as having early-onset and late-onset pre- are related to preeclampsia, they are not confounders of
eclampsia, respectively [17]. Two consecutive healthy the relationship between previous breastfeeding and pre-
pregnant women without any underlying diseases, such eclampsia because they are on the causal pathway. Ad-
as hypertension, renal disease, diabetes, or proteinuria, justed odds ratios (ORs) and 95% confidence intervals
served as controls for each case. Women with multiple (CIs) were computed. A P value less than 0.05 was con-
pregnancies or other comorbidities, such as diabetes sidered significant.
mellitus, renal disease, thyroid disease, major foetal
anomalies, foetal demise, and haemolytic disease, were Results
excluded from the study. There was no significant difference in the sociodemo-
After providing an informed consent, women (in the graphic and clinical variables between women who
case and control groups) were asked about their age, breastfed (n = 314) and women who did not breastfeed
parity, educational level, antenatal attendance, interpreg- (n = 34) in previous pregnancy (Table 1).
nancy interval (IPI), history of miscarriage, and history Table 2 shows comparisons of the sociodemographic
of preeclampsia/hypertension in previous pregnancies. variables between women with preeclampsia (n = 116)
Pre-pregnancy or first-trimester weight and height were and the controls (n = 232). Age and parity were signifi-
used to compute the BMI as weight/height2. The BMI cantly higher in women with preeclampsia. More women
was classified per the World Health Organization classi- with preeclampsia were employed and breastfed. There
fication for BMI [18] as follows: normal weight (18.5– were no significant differences in the educational level,
24.9 kg/m2), overweight (25.0–29.9 kg/m2), or obese antenatal care attendance, IPI, history of preeclampsia,
(30.0–34.9 kg/m2). The haemoglobin concentration (at history of miscarriage, BMI, haemoglobin level, or blood
Adam et al. International Breastfeeding Journal (2021) 16:48 Page 3 of 6

Table 1 Comparing the sociodemographic and clinical variables between women who breastfed previous children and women
who did not breastfeed previous children
Variables Women who breastfed (N = Women who did not breastfeed (N = Odds Ratio (95% Confidence
314) 34) Interval)
Age, years 30.0 (25.0–35.0) 31.0 (25.0–34.0) 1.02 (0.96,1.09)
Parity 4.0 (3.0–5.0) 3.0 (2.0–5.0) 1.09 (0.91,1.31)
Education level Numbers (proportion) Numbers (proportion)
≥ secondary 182 (58.0) 17 (50.0) Reference
< secondary 132 (42.0) 17 (50.0) 1.37 (0.67,2.80)
Occupation
Housewife 266 (84.7) 28 (82.4) Reference
Employee 48 (15.3) 6 (17.6) 1.18 (0.46,3.02)
History of preeclampsia
No 46 (14.6) 8 (23.5) Reference
Yes 268 (85.4) 26 (76.5) 0.73 (0.38,1.39)
History of miscarriage
No 235 (73.3) 20 (58.8) Reference
Yes 79 (25.2) 14 (41.2) 1.08 (0.98,1.19)
Body mass index groups
Underweight and normal 123 (39.1) 11 (32.3) Reference
weight
Overweight 126 (40.1) 13 (38.2) 0.92 (0.44,1.91)
Obese 65 (20.7) 10 (29.4) 1.59 (0.69,3.46)

group of the mother or gender of the newborn between et al. reported that women who breastfed for 0–6
the groups. The median (interquartile range) of the dur- months, 6–12 months, and > 12 months had a 13, 17,
ation of breastfeeding in those who breastfed (i.e., ex- and 21% lower risk of hypertension, respectively, com-
cluding those who did not breastfeed) was 4.0 (2.0) pared to women who did not breastfeed [21]. Schwarz
months. Among the 116 women with preeclampsia, 26 et al. showed that women who breastfed > 12 months
(22.4%) and 8 (6.8%) had severe and early-onset pre- had a lower risk (12% lower risk) of hypertension than
eclampsia, respectively. women who never breastfed [22]. Likewise, another
A total of 98 (84.5%) women with preeclampsia and study showed a lower risk of hypertension in women
216 (93.1%) women in the control group had breastfed who breastfed for > 6 months compared with parous
their previous children. The unadjusted odds ratio (OR) women who did not breastfeed [23]. Countouris et al. re-
is 3.55; 95% confidence interval (CI) 1.64, 7.70. After ported that breastfeeding was not associated with post-
adjusting for age, parity, education level, occupation, his- partum blood pressure in women with preeclampsia or
tory of preeclampsia, history of miscarriage, BMI groups in those who were normotensive during pregnancy [10].
the adjusted OR is 3.19; 95% CI 1.49, 6.82 (Table 3). The exact mechanisms of the association between
hypertension and breastfeeding remain unknown. How-
Discussion ever, it is known that lactation improves the cardiometa-
The main findings of the current study were as follows: bolic risk profile [24–26]. Breastfeeding has been
compared with women who had breastfed their previous reported to be associated with less postpartum weight
children, women who had not previously breastfed had a retention in mothers who had a normal weight before
higher risk of preeclampsia (Adjusted OR 3.19; 95% CI pregnancy [27]. Moreover, a favourable cardiometabolic
1.49, 6.82). A previous study showed that in normal- profile and decreased risk of atherosclerosis have been
weight women, breastfeeding was associated with lower reported in women with a history of normotensive preg-
blood pressure 1 month after delivery [9]. In a meta- nancies who breastfed for any duration compared with
analysis, which included 255,271 women, Rameez et al. women who did not breastfeed [7]. In a meta-analysis,
reported that breastfeeding for > 2 months was associ- Nguyen and Ding reported protective effects of breast-
ated with a relative risk reduction of 13% (pooled OR feeding on cardiovascular health (metabolic syndrome,
0.87, 95% CI 0.78, 0.97] for hypertension [20]. Zang inflammatory markers, hypertension and cardiovascular
Adam et al. International Breastfeeding Journal (2021) 16:48 Page 4 of 6

Table 2 Comparing the sociodemographic and clinical variables between women with cases (preeclampsia) and controls
Variables Cases (preeclampsia, (n = Controls (n = 232) Odds Ratio (95%CI Confidence P-
116) Interval) value
Variables occurred before the previous breastfeeding
Age, years 33.0 (28.0–38.0) 30.0 (25.0–33.0) 1.08 (1.05,1.13) < 0.001
Parity 4.0 (3.0–6.0) 3.0 (2–5.0) 1.15 (1.05,1.28) 0.004
Education level Numbers (proportion) Numbers
(proportion)
≥ secondary 70 (60.3) 129 (55.6) Reference 0.400
< secondary 46 (39.7) 103 (44.4) 0.82 (0.52,1.29)
Occupation
Housewife 86 (74.1) 208 (89.7) Reference < 0.001
Employee 30 (25.9) 24 (10.3) 3.02 (1.67,5.46)
History of preeclampsia
No 101 (87.1) 193 (83.2) Reference 0.347
Yes 15 (12.9) 39 (16.8) 0.73 (0.38,1.39)
History of miscarriage
No 86 (74.1) 169 (72.8) Reference 0.898
Yes 30 (25.9) 63 (27.2) 0.93 (0.56,1.55)
Body mass index groups
Underweight 2 (1.7) 0 (0) Undefined
Normal weight 50 (43.1) 82 (35.3) Reference
Overweight 40 (34.5) 99 (42.7) 0.77 (0.74,1.40) 0.397
Obese 24 (20.7) 51 (22.0) 0.85 (0.46,1.57) 0.623
Variables occurred after the previous breastfeeding
Interpregnancy interval, 22.0 (13.0–36.0) 22.0 (15.0–33.0) 1.01 (0.99,1.02) 0.359
months*
Antenatal care
≥ two visits 106 (91.4) 218 (94.0) Reference 0.376
< two visits 10 (8.6) 14 (6.0) 1.46 (0.63,3.41)
Hemoglobin level, g/dl 10.6.0 (9.8–11.8) 10.5 (9.9–11.4) 0.96 (0.74,1.24) 0.349
Blood groups
O 53 (45.7) 127 (54.7) Reference 0.113
Not group O 63 (54.3) 105 (45.3) 1.43 (0.91,2.24)
Infant sex
Female 58 (50.0) 109 (47.0) Reference 0.649
Male 58 (50.0) 123 (53.0) 0.88 (0.56,1.38)

disease) [28]. A previous animal study showed that at 9 influence systolic blood pressure (arterial stiffness and
months post-delivery, non-lactating mice had a signifi- compliance) [29].
cantly lower cardiac output, ejection fraction, fasting Breastfeeding affects several hormones, such as oxyto-
glucose level, and low-density lipoprotein level [26]. cin [30], prolactin [31], cortisol [32], oestrogen, and pro-
In addition, breastfeeding may affect factors that gesterone, which might impact blood pressure.

Table 3 Multivariate analysis for association of breastfeeding with preeclampsia (N = 116)

Unadjusted OR 95% CI P-value Adjusted OR 95% CI P-value
Breastfed previous child Yes Reference Reference
No 3.55 1.64, 7.70 0.001 3.19 1.49, 6.82 0.006
Adam et al. International Breastfeeding Journal (2021) 16:48 Page 5 of 6

Hormonal pathways (specifically oxytocin) may lower Consent for publication

postpartum blood pressure by decreasing inflammatory Not applicable.

markers [30]. In the central nervous system, mainly in

Competing interests
the vagal nuclei and the locus coeruleus, oxytocin might The authors declare that they have no competing interests.
interact with nitric oxide and atrial natriuretic peptide
and lower blood pressure [33]. Ghrelin, a hormone that Author details
1
Department of Obstetrics and Gynecology, Unaizah College of Medicine
affects appetite and is associated with breastfeeding, can and Medical Sciences, Qassim University, Unaizah, Saudi Arabia. 2Faculty of
reduce the risk of metabolic diseases [34, 35]. Moreover, Medicine, University of Khartoum, P.O Box 102, Khartoum, Sudan. 3College of
obesity and obesity-associated hypertension may be the Medicine, King Khalid University, Abha, Saudi Arabia.

result of insulin sensitivity [36]. Received: 14 September 2020 Accepted: 8 June 2021

Limitations
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