Prevalence, safety evidence, and determinants of medicine use during breastfeeding among women in Kampala, Uganda | BMC Women’s Health

This study revealed that more than 70% of the breastfeeding mothers attending six facilities in Kampala consumed medications, and more than 50% obtained drugs without prescriptions. Women with younger infants, higher education, or current acute conditions were more likely to use medications. The most commonly used antibiotics were metronidazole, used by 46.6% of women, which has a high RID dose of 11–24%, followed by amoxicillin and ampicillin/cloxacillin, taken by 38.1%, with low exposure to the infant through breastmilk, indicating safe compatibility.

This study revealed that women with younger infants, higher education levels, or current acute conditions were more likely to use medications. The higher medication use among mothers of younger infants may be attributed to increased postpartum vulnerability and susceptibility to infections, as previously observed in maternal health studies [21, 22]. This period often includes physiological and psychological adjustments, which can lead to increased healthcare-seeking behavior and medication intake to maintain the mother’s ability to care for the newborn. Women with younger infants may prioritize their health to maintain optimal care for their infants, leading to increased medication use. Similarly, higher education levels were associated with increased medication use, which may reflect better access to healthcare information and greater awareness of the need for treatment. Likewise, the association between higher education and medication use could reflect improved health literacy and greater access to healthcare services. Educated women may be more likely to recognize symptoms requiring treatment and seek medical advice [23]. However, this association should be interpreted with caution, as other unmeasured factors such as socioeconomic status, healthcare access, or health literacy may also influence this relationship, as noted by Goldman et al. [24]. Hence, further studies are needed to explore these potential pathways.

Our study found that 57.1% of breastfeeding mothers reported exclusive breastfeeding without pumping or expressing milk. This moderate adherence to exclusive breastfeeding is consistent with prior research, particularly among women balancing caregiving and economic responsibilities. For instance, Nabunya et al. reported a 42.8% prevalence of exclusive breastfeeding among women working in the informal sector, highlighting how employment pressures can reduce time for optimal breastfeeding [3]. The absence of milk expression in our study could indicate limited awareness, cultural practices, limited awareness or access to pumping methods, which can help manage breastfeeding challenges, such as maintaining milk supply or balancing work demands. Examining exclusive breastfeeding in this study is important because it helps identify potential barriers, including employment pressures and lack of milk expression options, which may influence both breastfeeding continuity and safe medication use among breastfeeding women [25, 26]. Encouraging safe and accessible milk expression options could enhance breastfeeding continuity for mothers facing time constraints or work obligations.

A total of 64.4% of participants obtained medications without prescriptions, indicating widespread self-medication practices. These medicines were accessed from both regulated sources, such as pharmacies and drug shops, and unregulated sources, including informal vendors. While self-medication is common in Uganda due to cost and access barriers, unregulated medication use, particularly from informal vendors, poses additional risks such as counterfeit or substandard drugs. Also, widespread self-medication practices may expose infants to potentially harmful drug levels through breast milk and increase the risk of incorrect dosing, adverse effects, or drug interactions [27, 28]. Sources of obtaining drugs included: local pharmacies, drug shops, and informal vendors, where over-the-counter sales are common. Furthermore, a notable portion of women (78.9%) reported recent medication use within the past six months, as observed in Nigeria, where over 95% of women consumed medicines while breastfeeding [29]. In this study. 8.2% had never used medications while breastfeeding; however, while some breastfeeding women were comfortable using medicines when needed, 12.9% stopped breastfeeding while on antiretroviral therapy because of high viral load, which would increase the chances of HIV exposure to the infant, as recommended by the healthcare providers. Analgesics were the most frequently used medications among breastfeeding women, with paracetamol accounting for 74.5% of use. Its well-established safety profile, low relative infant dose, and compatibility with breastfeeding make it a common choice for managing pain and fever during lactation.

This is consistent with other studies showing that analgesics and antipyretics are the most commonly used medications among breastfeeding women [30,31,32], making it one of the safest analgesics for breastfeeding mothers. However, formulations containing caffeine require cautious use due to their higher exposure to breastfed infants (7–18%), which could increase infant exposure to caffeine, potentially leading to irritability or sleep disturbances in infants [33]. The extensive use of antibiotics, including amoxicillin and ampicillin/cloxacillin, also reflects a pattern of safe medication practices among breastfeeding women. These antibiotics are generally regarded as compatible with breastfeeding, and their low exposure to infants (0.5-1%) supports their safety profile, posing minimal risk of adverse effects to the infant. This is in line with studies from similar populations that show amoxicillin and cloxacillin were the most used antibiotics due to their safety profiles and effectiveness in treating maternal infections while minimizing infant exposure risks [34, 35].

This study reveals varying safety levels across drug categories for breastfeeding women. While most categories, such as antiretrovirals, antihistamines, corticosteroids, and supplements, are deemed “compatible for use” and generally safe. Caution is warranted when prescribing antibiotics (ciprofloxacin, cotrimoxazole, metronidazole, levofloxacin) and antihypertensive medications (atenolol, losartan) to breastfeeding women, as these drug classes may pose potential risks to the breastfed infant, including gastrointestinal disturbances, alterations in gut microbiota, and possible cardiovascular or renal effects. Although metronidazole has been associated with potential risks to breastfed infants, including gastrointestinal disturbances and possible mutagenic effects in high doses, it remains an essential component of treatment for postpartum infections. Given its critical role in managing maternal health conditions and the limited availability of safer, equally effective alternatives, its use during breastfeeding is often necessary, with careful consideration of dosing and timing to minimize infant exposure. The limited availability of controlled studies conducted in this population underscores the need for careful consideration. These medications should only be administered if the potential benefits to the mother outweigh the potential risks to the infant.

Antifungal drugs, such as griseofulvin, were flagged as “probably Compatible,” with limited safety data. Likewise, Yevgenia et al. evaluated the strength of the data for the most commonly administered medications in lactating women and found that 51% of medicines had no associated data, 664 (47%) had minimal-moderate data, and 30 (2%) had strong data using the LactMed database and WHO classification [36]. For medicines that are flagged for cautious use, it is generally recommended to adjust or avoid breastfeeding for 2–4 h following administration. However, for certain medications such as cotrimoxazole, it is advised to avoid breastfeeding in infants with G6PD deficiency, regardless of the standard recommendations. However, routine screening for G6PD deficiency remains uncommon in many low- and middle-income countries (LMICs), making it challenging to implement such targeted precautions in clinical practice. Nevertheless, women reported a lack of guidance from healthcare providers regarding breastfeeding adjustments while on certain medications. Furthermore, some women did not disclose their breastfeeding status to healthcare providers, highlighting a mutual gap in communication. Healthcare providers have a responsibility to inquire about breastfeeding and provide appropriate guidance before prescribing medications. Women reported receiving information mainly on dosing and timing of the drug. Despite these guidelines, breastfeeding women may be unaware of such precautions, and they may not always receive adequate information from their healthcare providers regarding the safe use of medications during lactation. Our findings are consistent with prior studies highlighting limited provider communication on medicine safety during breastfeeding. For instance, a study by Osemene and Lamikanra et al. in Nigeria reported that most breastfeeding women received insufficient guidance about medication use from health professionals and instead relied on advice from pharmacy attendants or peers [37]. In India, Bhuvaraghan et al. found that more than 60% of lactating women were unaware of whether the drugs they consumed were safe for breastfeeding, attributing this knowledge gap to a lack of proper counseling from health professionals [38]. Communication gaps between healthcare providers and breastfeeding mothers can lead to inappropriate medicine use, especially in low-resource settings. Studies from South Africa and Kenya report that conflicting advice from different healthcare providers often confuses, with some women stopping breastfeeding unnecessarily [39]. Despite global guidelines, including those from the World Health Organization recommending clear and consistent communication on medication safety during lactation, implementation at the facility level remains weak in many LMICs. Limited provider training, lack of accessible reference materials, and poor integration of breastfeeding counseling into maternal care pathways all contribute to the ongoing challenges faced by breastfeeding women.

The findings of this study highlight important public health concerns regarding medicine use among breastfeeding women in urban health settings. The high prevalence of medication use, often without prescriptions, emphasizes the need for strengthened regulation of drug access and enhanced community education to reduce risks associated with self-medication. There is a critical need to implement national policies that improve the regulation of over-the-counter drug sales, especially in informal outlets such as drug shops and unlicensed vendors.

Public health education campaigns tailored to breastfeeding women, particularly those with younger infants and lower educational attainment, should be developed to raise awareness about the risks of inappropriate medicine use and the importance of consulting healthcare providers.

Health systems must prioritize training for healthcare workers on the safety profiles of medicines during lactation, integrating this knowledge into routine maternal and child health services. Additionally, accessible, up-to-date clinical reference tools and communication strategies should be made available to support informed prescribing and improve provider-patient interactions. Strengthening pharmacovigilance systems to monitor medicine use and its impact on breastfeeding mothers and infants is essential for evidence-based policymaking. These measures, if implemented, could reduce unregulated medicine use, promote safer breastfeeding practices in Uganda and similar low-resource settings.