It has been estimated that the lives of 1 million infants a year can be saved in the developing world by promoting breastfeeding [1]. In addition to the nutritional and psychological values of breast milk, it contains antibodies that help to protect the baby against many common childhood diseases. It is clean, always at the right temperature, inexpensive and nearly every mother has more than enough of this high quality food for her baby. For such a promotional campaign to be effective, attitudes and practices of health providers must be changed [1–3]. Health professionals need accurate, current scientific information combined with lactation and breastfeeding management skills [4–7]. In order to assure the availability of such professionals, clinical learning opportunities concerning lactation and breastfeeding must become a core unit of medical and nursing education and of postgraduate training in prenatal specialties [8–13].

It is now an established fact that breastfeeding is not a purely instinctive behaviour but it is an art transmitted from generation to generation and traditionally the skills of breastfeeding were handed down within families. Female relatives well-versed in the art of breastfeeding cared for new mothers and babies in the early weeks after childbirth. Breastfeeding has been undermined by the medicalization of pregnancy and childbirth and by commercial formula-milk popular since the l950s. In the past 50 years, mothers have given birth increasingly in hospitals, away from the help of their families and cared for by hospital personnel with at best little or no experience in breastfeeding instruction and at worst incorrect knowledge and prejudicial attitudes. Even more recently, mothers and babies are sent home from the hospital just 1 or 2 days after delivery, long before the mother’s milk has “come in” [14].

It was in this context that the present study was undertaken in Baghdad, Iraq to assess medical students’ and physicians’ knowledge, attitudes and training in relation to breastfeeding promotion. To the best of our knowledge, there are no pervious published studies on this subject in Iraq.

The study was carried out between 1 April and 31 July 2000. Three groups of health professionals completed questionnaires:

The self-administered questionnaires included questions to assess basic breastfeeding knowledge, attitudes and training experiences. The form was designed and reviewed by a panel of doctors including a breastfeeding consultant and was pretested on a random sample of 10 medical students and 5 resident doctors to check for clarity of interpretation and ease of completion.

The questionnaire contained 50 items: 30 on knowledge about breastfeeding, 10 on problem-solving techniques, 6 on attitudes to breastfeeding and 4 on training about breastfeeding techniques. Regarding questions related to attitudes and teaching methods, participants were asked to choose the most accurate answer (some were multiple choice and other were yes/no format). For questions about breastfeeding knowledge and training experiences, participants given a series of statements and asked to score T for a true statement, F for a false one and D for don’t know. Questions about problem-solving asked about suitable advice to give lactating mothers and suitable management of certain breast-feeding problems.

The pass mark for knowledge and problem-solving questions was 50% or more answers correct. To obtain a mean overall score for positive attitude, the percentages scoring positive for each question were summed and divided by 5.

The total number of respondents was 445 (265 males and 180 females). The response rates were 80.0% (320/400) for medical students, 75.0% (75/100) for resident doctors and 66.7% (50/75) for general practitioners.

Table 1 shows that general practitioners had the most positive attitudes towards breastfeeding when asked “What do you prefer for feeding your baby in the futuer?”; 86.0% thought breastfeeding was the preferred type of infant feeding compared with only 58.4% of medical students and 57.3% of resident doctors. Similarly, responses to all 5 attitude questions showed that more general practitioners had positive attitudes towards breastfeeding (Table 2).

In contrast with the low scores for preferred type of feeding, a high percentage of all respondents said that they encourage their family members and friends to breastfeed their babies (Table 2). Less than half of the medical students and residents (36.3% and 49.3%) agreed they would encourage a working mother to breastfeed her baby in her workplace compared with 60.0% of general practitioners. Only 38.7% of resident doctors and 40.9% of medical students thought it was appropriate for a mother to breastfeed her baby with modesty anywhere compared with 54.0% of general practitioners. A high proportion of all types of medic agreed that it is important to begin breastfeeding immediately after delivery. The mean percentage of general practitioners with positive attitudes was 76.8% compared with 68.8% for medical students and 70.1% for resident doctors.

The sources of information and modes of instruction about breastfeeding for medical students and resident doctors during their college years are shown in Table 4. Community medicine and paediatric courses were the most common sources of information while the obstetric course was the least frequent source. Lectures and clinical sessions were the most common modes of instruction about breastfeeding while video presentations were the least frequent mode.

There were some limitations to the study design; the difficulty in convincing the doctors to participate in the study is reflected in the low response rate from general practitioners.

General practitioners had the most positive attitudes towards breastfeeding of the 3 groups of medics, with 86.0% agreeing that breastfeeding was the preferred method of infant feeding and 76.8% having an overall positive attitude on 5 questions. This might be due to experience of breastfeeding for their own children and the fact that many had attended breastfeeding training courses. The teaching curriculum of medical students in Iraqi universities includes little on infant feeding, rarely more than 2 hours of lectures, and residency training includes limited opportunities for direct patient interaction about breastfeeding [15].

It was found that a very high percentage of respondents would encourage breastfeeding among relatives and friends. These findings are higher than those of a study by Hollen on paediatricians and obstetricians in Los Angeles, California, which found that less than 45.0% of obstetricians and paediatricians would encourage an undecided mother to breastfeed [8]. Surprisingly, the proportion of medics preferring breastfeeding is lower than that encouraging breastfeeding among family members and friends. This discrepancy might be explained if most respondents know the benefits of breastfeeding so they encourage breastfeeding, but at the same time they believe that it is difficult for mothers to breastfeed their infants when they are working outside home most of the time. This reflects gaps in their knowledge about the practice of breastfeeding, milk expression and storage.

The present study also shows that a very high percentage of respondents thought that it was important to begin breastfeeding immediately after delivery. These results are higher than those found in a study done by Hull et al. in Indonesia, where they found that only 46.0% of 167 health professionals thought that breastfeeding should be initiated immediately after delivery [6].

Although obstetricians have the most important role on the decision to breastfeed and on the initiation of breastfeeding [16], the study shows that breastfeeding and infant feeding are generally dealt with during a course in paediatrics and community medicine. Rarely are these subjects dealt with during training in obstetrics and in other fields, and when they are, the instructions are usually essentially theoretical, while audio-visual materials, which can stimulate discussion or illustrate a specific aspect of the programme, are less frequently used [17–19]. These results are similar to that found by Freed et al. on paediatric and obstetric residents and practitioners from American medical colleges [20,21].

The highest general positive attitude and success rates among general practitioners were probably due to the training courses that they had taken during their service life. This study found that 75.0% of general practitioners who were trained had adequate knowledge compared with only 27.0% who had not been trained, and this coincides with the results of Rea et al. on health professionals in Sao Paulo, Brazil [22].

Although attitudes toward breastfeeding were generally positive among medical students and physicians in Baghdad, there were many areas in which knowledge was incomplete and in which wide variation existed in advice given to breastfeeding mothers. Thus the need for improved training of doctors is clear. It is necessary, however, to learn more about what constitutes effective, high quality training, including content and methodology and necessary hours of teaching and of supervised clinical practice, instead of just the effect of “any” versus “no” training.

Great appreciation is due to all medical students and doctors for their cooperation in answering the study questionnaire.

22. Rea MF et al. Counselling on breast- feeding: assessing knowledge and skills. Bulletin of the World Health Organization, 1999, 77(6):492–8.