Epilepsy is a chronic neurological disease that affects around 1%–2% of people in the world1 of all age groups. Treatment of woman with epilepsy (WWE) during their childbearing years is a medical challenge. WWE are required to take antiseizure medications (ASMs) during pregnancy, which poses a risk of adverse effects to the fetus. The risk of teratogenicity is estimated to be around 3%–9.3% with older ASM formulations.2 However, next-generation ASMs such as lamotrigine and levetiracetam have a lower risk of around 1.9%–4.6%.2 In general, it is recommended that women are continued on their ASMs, with dose adjustment during pregnancy. Folic acid supplementation is recommended for all WWE of childbearing age to reduce the risk of teratogenicity.2 Breastfeeding is another major challenge for WWE. Patients are often afraid to breastfeed their children because of the risk of drug excretion in the milk. The International League Against Epilepsy encourages breastfeeding among WWE, as the concentration of medication excreted in milk is low.2,3 A prospective study assessing the concentration of ASMs in breast milk found substantially lower levels than those in maternal serum.3–5 Although WWE are recommended to breastfeed, there are limited data on the frequency of breastfeeding among these individuals.

In Saudi Arabia, a prior study estimating the rate of breastfeeding among the general population found that around 94% of women started off breastfeeding their children.6 Mothers who delivered by cesarean section or used oral contraceptive pills were less likely to continue breastfeeding 12 months after delivery.6 There have been no studies conducted in Saudi Arabia to estimate the rate of breastfeeding among WWE. The aim of this study was to assess the rate of breastfeeding initiation and continuation among WWE treated in a tertiary care center in the Makkah region.

This cross-sectional descriptive study was conducted in King Abdullah Medical City in the Makkah region of Saudi Arabia. The institution provides a referral center for epilepsy patients, as it has an epilepsy clinic and epilepsy monitoring unit. All female patients with a diagnosis of epilepsy were identified from 2019 to June 2023. Inclusion criteria were women who1 had given birth after a diagnosis of epilepsy and2 gave birth within the last 5 years. We excluded patients who gave birth before the onset of epilepsy and who gave birth more than 5 years previously. For patients with multiple deliveries during the last 5 years, the data included were related to the last pregnancy. Patients who agreed to participate were interviewed by phone call or during their follow up visits to epilepsy clinic. Incomplete data were excluded from the analysis. As the study was conducted at King Abdullah Medical city ethical approval was obtained from their Institutional Review Board (22–1012). The study complies with the Declaration of Helsinki.

An electronic questionnaire was filled in by a trained bilingual data collector after consent was received from the participants. All participants were informed about the study purpose, Consent was sent electronically to participants. Participants who returned the signed consent were interviewed by phone call or by direct contact during their clinic follow up. The questionnaire was adapted from a study by Nanya Haoa.7 Data collected included patients’ demographic features, information about the patients’ disease and treatments used, number of pregnancies while on ASMs, type of infant feeding, duration of breastfeeding, and attitude toward breastfeeding.

The data were collected, reviewed, and then fed into the Statistical Package for Social Sciences version 21 (SPSS: IBM). All statistical methods used were two-tailed with an alpha level of 0.05, and results were considered significant if the P value was less than or equal to 0.05. Descriptive analysis was done by prescribing frequency distribution and percentage for study variables, including patient personal data, residence, work, and epilepsy data. Delivery data and ASM regime, pregnancy and ASM regime, breastfeeding data during different pregnancies, and medical counseling were tabulated. Reasons for not breastfeeding were graphed. Cross tabulation to show the significance of factors associated with breastfeeding among patients was carried out with Pearson’s chi-square test, or exact probability test if there were small frequency distributions.

Out of the 159 WWE of childbearing age followed up in the epilepsy clinic, 48 fulfilled our inclusion criteria and agreed to participate. Table 1 shows the demographic data for the study population. A total of 32 WWE (66.7%) were over 30 years old, and 41 (85.4%) were from urban areas. Generalized epilepsy was the diagnosis for 26 (54.2%) patients. A total of 22 (45.8%) women were prescribed only one antiepileptic drug, 18 (37.5%) were on two drugs, and 8 (16.7%) were on three or more drugs (Table 1).

Table 1 Bio-Demographic Data of Female Child-Bearing Patients with Epilepsy in Makkah, Saudi Arabia

Table 2. Delivery data and ASMs among child-bearing female patients with epilepsy in Makkah, Saudi Arabia

Table 2 Delivery Data Among Child-Bearing Female Patients with Epilepsy in Makkah, Saudi Arabia

A total of 39 (81.3%) of the patients had had more than one delivery. As for the number of ASMs, only one drug was used to treat 20 (41.7%) participants, two drugs for 7 (14.6%), three drugs for 10 (20.8%), and more than three for 11 (23%). Table 3 shows the pregnancy and delivery features of WWE. A total of 54.2% of the mothers experienced seizures during their pregnancy.

Table 3 Pregnancy and ASMs Among Child-Bearing Female Patients with Epilepsy in Makkah, Saudi Arabia

Table 4 shows the rate of breastfeeding among WWE in Makkah, Saudi Arabia. Exactly 68.6% of patients practiced breastfeeding. Breastfeeding since childbirth was common among 74.3% of patients, and 12.1% of mothers breastfed for six months. Bottle feeding was needed with 72.9% of patients.

Table 4 Breastfeeding Patterns Among Mothers with Epilepsy in Makkah, Saudi Arabia

Figure 1 shows the reasons given by the WWE for not breastfeeding their children or weaning before six months. The most commonly reported reasons included a fear of the harmful effects of medications on the child (38.9%), insufficient breast milk (30.6%), health problems in the child or mother (8.3%), and frequent seizures (8.3%).

Figure 1 Reasons of not practicing breastfeed for child or weaning him before 6 months among study patients with epilepsy.

Table 5 shows medical counseling on breastfeeding among patients with epilepsy. A total of 35 (72.9%) WWE consulted their doctor before their first experience of breastfeeding, 25 (52.1%) reported that lactation specialists spoke to them before or at the time of delivery, and 21 (43.8%) said that neurologists talked to them about breastfeeding.

Table 5 Medical Counseling on Breastfeeding Among Patients with Epilepsy After Childbirth

Table 6 shows the factors associated with breastfeeding among patients with epilepsy on ASMs in Makkah, Saudi Arabia. Breastfeeding was reported among 73.2% of patients from urban areas versus 42.9% of those from rural areas, and the difference was statistically significant (P = 0.043). In addition, 81.8% of patients on one ASM reported breastfeeding compared to 62.5% on more than two medications (P = 0.048). Other significant factors related to breastfeeding were not having a seizure during pregnancy (81.8%–57.7%, P = 0.049) and a normal vaginal delivery (NVD) (81.3%–43.8%, P = 0.008). The other factors tested were not significant.

Table 6 Factors Associated with Breastfeeding Among Patients with Epilepsy on ASMs in Makkah, Saudi Arabia

The benefits of breastfeeding are well established for both mothers and infants. Infants who have been breastfed have lower rates of respiratory tract infection, gastroenteritis, asthma, allergic dermatitis, celiac disease, inflammatory bowel disease, diabetes, and obesity development.8 Breastfeeding also has a significant impact on the neurodevelopment of infants.8 For mothers, breastfeeding has both short- and long-term effects. In the short-term, breastfeeding is associated with a reduction in postpartum depression and postpartum blood loss. In the long-term, mothers who breastfeed their infants are at a lower risk of developing rheumatoid arthritis, cardiovascular diseases, and breast and ovarian cancers.8

Despite all these documented benefits, the rate of breastfeeding in our study was low. We found that 68.5% of WWE breastfed their babies. The rate of breastfeeding among WWE tends to vary according to country. Lower breastfeeding initiation rates were observed in the United States (50.9%)9 and China (59.4%),7 and a higher rate was observed in Poland (77%).10 The rate of breastfeeding in our series was within the range of previously reported results. However, when we directly compared the rates of breastfeeding between WWE and healthy adults, the rate was lower among WWE than the general population. Alfaraj et al reported a rate of 50.9% among WWE versus 87.6% in a healthy control group.9 In our study, we did not include a control group. However, the rate of breastfeeding was much lower than that previously reported for the general population in Saudi Arabia (87.1% vs 97.3%).6,11,12

Although the American Academy of Pediatrics recommends exclusively breastfeeding infants until they are 6 months old,8 most of our patients (74.3%) used bottle feeding at the same time as breastfeeding. Exclusive breastfeeding was only reported by 27.1% of patients. A low rate of exclusive breastfeeding has also been reported for the general population in Saudi Arabia.12 The rate of exclusive breastfeeding among the Saudi population varied according to the region of the kingdom: 16.3% in Taif12 and 31.4% in Tabuk.13 The low rate of exclusive breastfeeding is a major problem, not only for WWE but for the general population as well. A low rate of exclusive breastfeeding was found in working mothers, low-birth-weight infants, those with cesarean section births, and Saudi nationals. Knowledge of the benefits and being given a recommendation for exclusive breastfeeding were positively related to exclusive breastfeeding.13 Other factors associated with exclusive breastfeeding among the general population included having three to six children and a 1-year interpregnancy interval.12

There were several factors reported by the WWE as reasons for not practicing breastfeeding, with the major one being the fear of the effect of medications on the baby (38.9%), followed by insufficient milk (30.6%). Frequent seizures were reported in 8.3% of participants as a reason for not practicing breastfeeding. Our results are comparable to previous reports on breastfeeding among WWE in other nations. A recent systemic review of all studies of ASM concentrations in breast milk found the relative infant doses (RIDs) to be variable. The RIDs of carbamazepine, lamotrigine, primidone, phenobarbital, gabapentin, valproic acid, ethosuximide, levetiracetam, and topiramate were 3.70%, 36.33%, 4.96%, 3.15%, 4.37%, 1.90%, 31.49%, 12.50%, and 12.18%, respectively.14 Although the drugs were detected in infant serum, they did not produce clinically significant side effects in the infants.14 Despite these significant results, fear is one of the major limitations of breastfeeding in WWE. Efforts to improve knowledge among WWE of the benefits and safety of breastfeeding should be implemented.

In this study population, the most significant factors affecting breastfeeding among WWEs were the number of prescribed ASMs, not having a seizure during pregnancy, NVD, and living in an urban area. Patients on a single medication were more likely to breastfeed than patients on multiple medications. This could be related to the fear experienced by patients on multiple ASMs. Patients on multiple medications are probably have poorer seizure control, which could contribute to lower breastfeeding rates. This was confirmed by the significant impact of having a seizure during pregnancy on breastfeeding. Patients who experienced seizures during pregnancy were less likely to breastfeed their infants. Patients on multiple medications and with poorly controlled seizures are less likely to breastfeed, a potential cause of which is the fear of having a seizure during breastfeeding and potentially harming the infant. The effect of poor seizure control on breastfeeding was also seen in a Chinese study, in which patients on no or one medication were more likely to breastfeed their infants than those on multiple ASMs. The study also revealed that poor seizure control during pregnancy was associated with a lower likelihood of breastfeeding.7 Another obstetric variable that had a positive impact on breastfeeding was NVD, as 81.3% of patients who had NVD breastfed their infants compared to 43.8% who had cesarean sections. This relationship was not seen in previous studies of breastfeeding among WWE.7 Woman who had an NVD were more likely to recover from delivery earlier than woman who had cesarean sections. This observation was also seen in healthy Saudi mothers, for whom cesarean section was one of the variables associated with exclusive breastfeeding.13,15 Patients from urban areas were more likely to breastfeed their infants than those from rural areas, which may have been related to a greater understanding of the benefits of breastfeeding among urban communities. Interestingly, the breastfeeding rate was not significantly related to whether the patients received education about the safety and benefits of breastfeeding by a neurologist or lactation specialist. This differs from prior studies, which found that WWE who were educated about breastfeeding by their neurologist or an educational consultant were more likely to initiate breastfeeding.9 We did not explore the types of education on the benefits of breastfeeding given by the neurologist or educational consultant. The type of intervention and number of visits to educational consultants may play a role in improving breastfeeding behavior in WWE.

The study was carried out at a tertiary care center, where most of the patients were referred with drug-resistant epilepsy. This reality is clearly illustrated by the fact that only 45.8% were on a single ASM. The data collated do not clearly represent the situation in patients with well-controlled epilepsy, who would be referred to primary or secondary care facilities. Another limitation was the small sample size. Although we had a total of 159 WWE, only 48 patients fulfilled the criteria of inclusion and agreed to participate. Most of our patients were never married, which highlights the difficulties faced by WWE in communities and the impact of the disease on their lives.

The rate of breastfeeding among WWE was lower than that within the general population. Factors associated with the initiation of breastfeeding were being on a single ASM, better seizure control during pregnancy, an SVD, and living in an urban area. The most common reason given for not breastfeeding was a fear of the effect of the medication on the baby. Educational programs about the benefits of breastfeeding targeting all WWE of childbearing age are recommended to help reduce their fears and improve the rate of breastfeeding.

The author(s) report no conflicts of interest in this work.

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