Public Health Nutrition, 2019;22(5), 848-861. doi:10.1017/S1368980018002999

Comparison of national cross-sectional breast-feeding surveys by maternal education in Europe (2006–2016)

Mahesh Sarki, Alexandr Parlesak and Aileen Robertson

From Department of Global Nutrition and Health, University College Copenhagen, Sigurdsgade 26, 2200 København N, Denmark

Correspondence should be addressed to Dr Aileen Robertson, Department of Global Nutrition and Health,  University College Copenhagen, Sigurdsgade 26, 2200 Copenhagen  E.mail:



Objective: Breast-feeding is an important determinant of health of mothers and their offspring. The present study aimed to compare breast-feeding rates across Europe disaggregated by maternal education and establish what proportion achieves at least 50% exclusive breast-feeding (EBF) at 6 months. Design/Setting: Secondary analysis of national or sub-national studies’ breast- feeding data for EU Member States plus Norway and Iceland, published in 2006– 2016. Nineteen EU Member States plus Norway reported rates of EBF and any breast-feeding disaggregated by maternal education, of which only thirteen could be matched to the International Standard Classification of Education. Participants: Mothers and their infants aged 0–12 months. Results: Data on EBF rates at 6 and 4 months disaggregated by level of maternal education were found in only four and six countries, respectively. At 6 months, population average EBF rates of 49% in Slovakia and 44% in Hungary were closest to WHO’s target of at least 50% EBF. At 4 months, mothers with high education level in Denmark, the Netherlands and Germany had the highest EBF rates (71, 52 and 50 %, respectively). Mothers with low education level were less likely to initiate breast-feeding and cessation occurred early. The inequality gap ranged from 63 % in Irish mothers to no gap or very low levels of inequality in Poland, Sweden and Norway. Conclusions: More mothers with high, compared with low, education initiate breast-feeding and practise EBF for longer. More European policies should be targeted to protect, support and promote breast-feeding, especially among mothers with only mandatory education.

Keywords: Exclusive breast-feeding; Maternal education;  Social gradient; Health Inequality in Europe



A healthy start in life, including exclusive breastfeeding for 6 months, is the key to reducing health inequalities and chronic diseases, such as diabetes type2. across Europe. Health inequalities, assessed using level of maternal education, starts before the first 1000 days of life. For example EU women of reproductive age, with lower levels of education, have increased risk of obesity which results in increased risk of excessive weight gain during pregnancy and increased risk of failure to exclusively breastfeed (1).


Excessive weight gain during gestation increases the offspring´s risk of being either small for gestational age (SGA) or large for gestational age (LGA) and their ability to breastfeed is often impaired. Inability to exclusively breastfeed for 6 months can lead to post-partum weight retention in the mother along with poor infant feeding practices which increase the risk of excessive weight gain and diabetes in childhood especially in infants born into families with low socioeconomic status (SES) (1). During the first 1000 days the risk factors, associated with health inequalities and non-exclusive breastfeeding for 6 months, accumulate, compound and perpetuate the risk of early childhood obesity and subsequent adult chronic disease, such as diabetes mellitus type2 (figure 1).



Figure 1 Life-course framework for understanding inequalities in childhood obesity and risk of diabetes

Source: adapted from Pérez-Escamilla R . The 2010 Dietary Guidelines: Lessons learned for 2015; Focus: Childhood obesity. 6th Biennial Childhood Obesity Conference, San Diego, June 29, 2011


The prevalence of obesity in women in Europe with a high level of education is less than ten percent (7.7%) and significantly lower (p<0.05) than women with secondary and primary education. In 2014, one out of every seven (14.3%) women of reproductive age (18-44 years) with a low level of education were obese. This is almost double that of women with high education levels and around one quarter higher than those with mid-level education (11.2%) (1).


It is important that the authorities in individual EU countries monitor the prevalence of overweight (BMI>25) in women of reproductive age in order to prevent obesity in women before they become pregnant. Figure 2 shows EU data on the proportion of women who were overweight in 2014, according to their educational attainment level. As the education level rises, the proportion of women being overweight falls so that the proportion of overweight was much lower among those with high levels of education. This pattern is seen in all EU Member States with the exception of Malta where the lowest share was among the women within the intermediate level of education. The proportion of women with a low level of education who were overweight was at least 30% above those with a high level of education in Slovenia, Cyprus, Slovakia, Croatia, Portugal, Spain, Luxembourg and Austria, as well as Turkey.



Figure 2 Percentage of European women who were overweight (BMI >25) by educational level in 2014



If overweight women are prevented from becoming obese before pregnancy they are less likely to: gain excessive weight during gestation; have a lower risk of giving birth to either a SGA or LGA infant; and be better able to breastfeed. An obese pregnant woman with a low level of education is more likely to give birth to a SGA infant, who is less able to feed exclusively at their mother´s breast for 6 months. A SGA infant  has increased risk of childhood obesity and chronic disease, such as diabetes type 2. The increased risk of a SGA birth in mothers with a low level of education is 55% greater than those with a high education level and the risk of not initiating exclusive breastfeeding increases (2). Similarly antenatal risk factors associated with LGA infants are prevalent in women with a low level of education. They tend to take less physical activity, also during pregnancy, and it is recognised that physical activity levels, in girls with low SES, fall significantly when they move into their child bearing age (1). International investigators found that, among term pregnancies where mothers took no regular physical activity at 20 weeks gestation, the prevalence of LGA infants was high, almost ten percent (9.3%). The increased risks, including high blood glucose levels, were not evident in women who took regular physical activity nor in women who were not obese.  The authors concluded that regular physical activity in mid-pregnancy helps lower the risk of LGA infants and can protect against high maternal glucose levels and gestational diabetes. LGA infants may have difficulty in exclusively breastfeeding for 6 months especially if their mothers are obese (3).


Unfortunately data on exclusive breastfeeding (EBF) rates at 6 months are not monitored regularly in EU countries by socioeconomic status (SES).  These data were found only for four countries (Latvia, Luxembourg, Poland and Romania) where rates of EBF in mothers with low levels of education were well under WHO recommendations (12,6,6,14% respectively). Population average EBF rates of 49% in Slovakia and 44% in Hungary were closest to WHO’s target of at least 50 % EBF at 6 months, but these data were not disaggregated by SES. At 4 months, mothers with high education levels in Denmark, the Netherlands and Germany had the best EBF rates (71, 52 and 50 %, respectively). Mothers in Europe with a low education level were less likely to initiate breast-feeding and cessation occurred early in all countries where data were available.


When EBF rates are low, there is increased risk of too early introduction of complementary foods, i.e. the introduction of non-(breast) milk foods or nutritive liquids when milk alone is no longer sufficient to meet nutritional requirements. Too early introduction of complementary feeding may contribute to an increased risk  of childhood obesity (1). Data on complementary feeding rates by SES were found for only 3 European countries:  “Growing up in Ireland” infant cohort showed that on average 14% of Irish mothers introduced foods between 3 to 4 months and almost twice as many mothers with low and middle levels of education, compared with those with high levels, had introduced foods before 4 months;  almost two-thirds of Dutch mothers (62%) on average introduced foods before 6 months but more mothers with low levels of education, compared with high, introduced foods before 6 months and before 3 months, (73% and 56%) and (10%and 4%) respectively; In the UK too early introduction of foods was also associated with mothers’ SES and only one fifth (20%) of mothers in professional occupations, compared with nearly double (38%) in manual occupations, introduced foods before 4 months. In general the risk factors associated with too early introduction of complementary foods are: smoking mothers of young age; low socio-economic status; and not breastfeeding. In an attempt to reduce levels of childhood obesity and diabetes, EU countries should be encouraged to collect data by SES on complementary feeding using a common methodology.


In summary a more joined-up and coordinated approach around increasing exclusive breastfeeding levels for 6 months is needed within maternal and young child health and care services. Improved coordination could decrease risk of childhood obesity and diabetes, improve maternal health and reduce health inequalities. A coordinated approach is conceptualised in figure 1 where the sequence of events set infants, especially girls, to become obese before they become pregnant and increase their inability to exclusively breast feed and so transfer the risk of obesity and diabetes to the next generation. Obese women, in order to lose their excess weight retained  during gestation, need skilled support to enable them to breastfeed exclusively for 6 months.


Central governments can initiate joined-up approaches through creating joint priorities and building social safety-nets for the most disadvantaged. This includes honouring pledges concerning the Convention of Rights of Child and other UN Resolutions, including the length of paid maternity leave and halting the aggressive marketing of breastmilk substitutes, to protect exclusive breast feeding for 6 months. Without the correct start in life, infants are set on a trajectory where unhealthy exposures accumulate, compound and perpetuate their risk of childhood obesity and diabetes.



  1. Sarki, M, & Robertson, A, “A report on literature reviews and scientific evidence relating to the impact of interventions and policies on the socio-economic gradient in maternal and infant nutrition in the first 1000 days,” Available at: (accessed 19 August 2019).
  2. Vieira, MC, McCown, LME, North, RA, Myers, JE, Walker, JJ, Baker, PN, et al. “Antenatal risk factors associated with neonatal morbidity in large-for-gestational-age infants: an international prospective cohort,” Acta Obstet Gynecol Scand, vol. 97, pp. 1015-1034, 2018
  3. Cordero, L, Oza-Frank, R, Landon, MB, Nankervis, CA, “Breastfeeding initiation among macrosomic infants born to obese nondiabetic mothers,” Breastfeed Med. 10, no. 5, pp. 239–245, 2015