High-risk pregnancy (HRP) is a significant problem in Egypt. Exclusive breastfeeding (EBF) is recommended for the first 6 months of life. This can support the lactational amenorrhea method (LAM) of contraception which depends on EBF and high frequency of breastfeeding, especially at night. This study showed lower rates of LAM and early return of menstruation among the HRP group and this may be explained by low EBF rates among them. In this study, EBF was more frequent among those with normal pregnancies (NP) (61%) than those with HRP (40%). An increase in the rate of NCDs such as diabetes and cardiovascular diseases (CVDs) is likely associated with a decrease in the practice of breastfeeding [16]. In Egypt, the national rates of EBF have been shown by the Egypt Family Health Survey in 2022 to decline progressively over the first months of life to reach 20.7% at 4–5 months [14].

Upper Egypt usually has the lowest rates of EBF due to the high offering of fluids because of the common misconception that babies need more fluids in hot weather. Despite this, EBF was lower in HRP indicating that these women were probably introducing early weaning foods and milk formula. They thought that their disease state necessitated stopping or reducing breastfeeding because of their condition. This was practiced by many HRP women irrespective of being highly educated and of urban residence. Moreover, women with HRP were less likely to have regular ANC and were more likely to end up with CSD and delivery in a tertiary-level hospital than NP, especially in cases with pre-eclampsia.

The most common conditions in the HRP were HTN (50.0%) followed by chronic anemia (22%). Hypertensive disorders of pregnancy occur in approximately 7%–10% of pregnancies and are associated with adverse maternal cardiovascular health outcomes across the lifespan. In contrast, breastfeeding has been associated with a reduction in cardiovascular risk factors in a dose-dependent manner [17].

A meta-analysis of 6 studies including more than 20,000 mothers showed that breastfeeding was associated with a relative risk reduction of 30% for diabetes and 13% for hypertension among studied participants and these findings suggest that breastfeeding is associated with long-term health benefits, including a reduction in the risk of future maternal chronic diseases [18].

A study conducted in Canada (2022) on breastfeeding women with hypertension showed that hypertensive disorders of pregnancy were associated with an increase in the odds of non-exclusive breastfeeding at 4 months postpartum. They had significantly higher odds of reporting insufficient milk supply and lower odds of breast and/or nipple pain compared with those without hypertensive disorders of pregnancy [17]. A prospective study (2023) showed that 30.6% of mothers with chronic conditions were at higher risk of early cessation of breastfeeding in the first 6 months [19]. A protocol shows that a randomized behavioral trial will be conducted among mothers with hypertensive disorders during pregnancy to assess the effect of a breastfeeding self-efficacy-based intervention which will be delivered by a trained lactation consultant in the hospital on postpartum blood pressure and breastfeeding continuation [20].

In this study, a considerable percentage of our cases of HRP were attributable to DM. Breastfeeding plays an important role in reducing blood glucose levels and preventing or at least delaying the development of type 2 diabetes among women with histories of gestational diabetes [21]. Prolactin production during breastfeeding stimulates insulin secretion from beta cells and produces serotonin. This hormone is an antioxidant and helps in the reduction of oxidative stress which makes the mother’s beta-pancreatic cells healthier [22].

A cohort study showed that gestational DM in primiparous women did not affect their duration of breastfeeding. They emphasized that the positive health effects of breastfeeding in preventing overweight and obesity are needed to minimize the risk of type 2 diabetes for themselves and their offspring [23]. Similarly, a study in Australia reported that Indigenous women with type 2 diabetes had lower odds for EBF at discharge (adjusted OR 0.4) than women with no hyperglycemia in pregnancy but at 6 weeks and 6 months there was no significant difference between the groups. They concluded that Indigenous women were more likely to predominantly breastfeed at 6 weeks across all levels of hyperglycemia [24].

Our results showed that antenatal care (ANC) visits were significantly less frequent among the HRP group. An observational trial among Scandinavian women found that antenatal breast milk expression (ABE) was feasible and increased the rates of EBF in women with DM. The researchers showed that implementing a structured ABE guideline for women with medically treated diabetes was feasible. Furthermore, the intervention was associated with a high level of satisfaction among study participants. No obvious side effects were observed, and breastfeeding rates at discharge and 6–8 weeks after delivery were higher than in comparable studies [25].

The results of the present study show that the initiation of breastfeeding within the first hour of delivery was significantly lower among women with HRP. The underlying causes of delayed initiation of breastfeeding in DM may be because maternal diabetes and obesity can delay lactogenesis. Matias et al. 2014 reported that one-third of women with GDM experienced delayed onset of lactogenesis and that maternal obesity, insulin treatment, and suboptimal in-hospital breastfeeding were the key risk factors for early breastfeeding failure [26]. A review of the beneficial effects of breastfeeding and gestational diabetes concluded that efforts should be made to support women with DM to breastfeed especially since breastfeeding was found to be protective against the development of DM in infants later in life and their mothers [27].

Moreover, we have shown that women with HRP were more at risk of breast problems, especially breast engorgement, and for dealing with these problems breastfeeding cessation was a common practice. Other researchers have shown that breastfeeding difficulties are the most common reason for breastfeeding cessation, particularly in the early postpartum and cause mothers to be less likely to breastfeed a future child [28].

Cesarean section delivery (CSD) was more common in our group of mothers with HRP compared to the NVD. Over one-half of women in Egypt are exposed to CSD. CSD was 66.4% in Upper Egypt (UE) compared to 78.5% in Lower Egypt and 75% in urban governorates. In UE it was higher in urban areas compared to rural areas (76.2% vs 63.3%) [14]. Furthermore in this study delayed breastfeeding initiation, shorter duration of breastfeeding, and higher rates of non-exclusive breastfeeding among HRP have been accentuated by the finding of higher CSD in the HRP. This has also been mentioned by other studies [29, 30]. Cesarean surgery can place high stress on both the mother and infant, and post-operative recovery is often characterized by maternal pain, limited mobility, and separation from the infant to encourage mothers to rest and heal [31]. One study in Canada showed that CSD was associated with higher odds of low milk supply and infant behavior/health difficulties than women who deliver vaginally [32]. A systemic review concluded that CSD is associated with long-term risks for mothers, babies, and subsequent pregnancies [33].

Some of the HRP cases were due to bronchial asthma or respiratory diseases. Literature shows that breastfeeding for more than 6 months was associated with a reduced risk of wheeze, bronchiolitis, and wheeze-related healthcare utilization in infants at risk due to maternal asthma. Notably, breastfeeding for shorter durations was associated with a reduced risk of healthcare utilization compared with none. The researchers suggest that larger cohorts are needed to further examine the impact of breastfeeding exposure on respiratory health in infants exposed to maternal asthma [34].

There are considerable gaps in breastfeeding outcomes in mothers with chronic diseases due to a lack of knowledge and support in the postpartum period [35]. Evidence supports a correlation between maternal chronic conditions and adverse perinatal outcomes, including increased risk for preeclampsia, cesarean section, preterm birth, and admission to the neonatal intensive care unit (NICU). However, there is a knowledge gap about the management of these women during lactation. The present study showed a higher level of knowledge about breastfeeding among those practicing exclusive breastfeeding than those who did not. It was concluded from an Egyptian study conducted by Emara et al., 2021 that mothers with good knowledge about the proper practices of breastfeeding adhered more to exclusive breastfeeding (OR 2.51) and they emphasized the importance of proper health education and sufficient practical training the mothers about proper breastfeeding practice to raise exclusive breastfeeding rate [36].

The study had some limitations as recall bias; some of the mothers were not able to recall all the details of their practices in the first 6 months. Being more informed, mothers who come to the hospital might give the desired answers even if they do not practice. Sample selection was obtained via a convenience-based non-probability technique which may result in a lack of representation of all classes and limit its generalizability.