The World Health Organization (WHO) recommends that all newborns be breastfed exclusively for the first 6 months of life and given nutritionally appropriate and safe supplemental foods, with breastfeeding continuing for up to 2 years of age or beyond [1,2]. Breastfeeding provides appropriate nourishment and contributes to newborn and maternal well-being, resulting in favorable health outcomes [3]. Despite global recommendations and the massive benefits of breastfeeding, its practice is not prevalent globally.

Breastfeeding is extremely popular in Jordan, as evidenced by the fact that 92% of the children in Jordan were nursed at some point in their lives [4]. Nonetheless, the rate of exclusive breastfeeding of 6-month-old babies is less than ideal and is gradually declining in Jordan [4].

Breastfeeding mothers who have newly given birth may face several medical conditions in which there is a need for the use of medications. More than 50% of postpartum women, either breastfeeding or not, use at least one medication [5]. Since contraindicated medications are few, most medications are safe to administer during breastfeeding [6]. However, breastfeeding women may discontinue breastfeeding based on a physician’s advice [7], even for medications that are known to be safe [8]. Although there are several resources for assessing medication safety during breastfeeding, they are frequently conflicting. For example, in the case of ciprofloxacin, the patient information leaflet (PIL) for Bactall (brand name for ciprofloxacin) recommends against its use during breastfeeding and includes the statement: “Do not take ciprofloxacin during breast-feeding” [9]; however, LactMed (Drugs and Lactation Database) reports the acceptance of it use by lactating mothers with monitoring of the infant for possible effects [10]. As a result, some may believe that it is preferable to discontinue breastfeeding rather than risk exposing the newborn to potentially dangerous medicines [11].

Community pharmacists have continuous contact with breastfeeding women and are easily accessible and trusted health consultants [12]. A Gold Coast study found that 78% of pharmacists saw mothers with infants at least once each day [13]. However, pharmacists are less confident than nurses and general practitioners in providing breastfeeding-related advice [13] even though other healthcare providers consider pharmacists reliable sources of medication-related information [14,15]. A study conducted by Ronai et al. [16] in the United States to determine the resources pharmacists use to guide medication recommendations to breastfeeding mothers highlighted the importance of a consistent approach when accessing resources to guide recommendations regarding the use of medications while breastfeeding. Therefore, pharmacists must be capable of providing accurate information from reliable sources. This study aimed to explore the approaches of Jordanian community pharmacists to identifying and counseling breastfeeding mothers regarding medication usage.

The study evaluated, for the first time in Jordan, community pharmacists’ counseling practice with breastfeeding women. The results revealed three main findings. First, community pharmacists have continuously interacted with breastfeeding women, and the majority of them had a high level of confidence and comfort while giving advice regarding medication to breastfeeding women. Second, asking every woman is the Jordanian pharmacists’ preferred approach to identifying breastfeeding mothers. Third, pharmacists relied on various resources to answer women’s queries related to medication use during breastfeeding. Finally, additional significant associations were found between pharmacists’ confidence and comfort levels and key factors, such as marital status, frequency of encountering queries on medication use during breastfeeding, asking women whether the dispensed medications were for breastfeeding women, and frequency of consulting hard-copy resources.

These frequent interactions could be attributed to the fact that breastfeeding women are frequently required to take medications [5,18]. Additionally, this could be attributed to the accessibility of community pharmacists, who are seen as easily accessible and trusted health consultants [12,19]. This finding is in line with the findings reported by Ronai et al. [16] in the United States, who reported that nearly half of the pharmacists receive inquiries about medication safety from breastfeeding mothers on a weekly or daily basis.

Almost two-thirds of pharmacists reported frequently receiving prescriptions for medications that are not recommended for breastfeeding mothers. One possible explanation for this result is the low level of knowledge among healthcare providers regarding the safe use of medications during breastfeeding [14]. Inadequate knowledge of drug use during breastfeeding may also lead to insufficient medical history-taking, where essential information is not obtained from lactating mothers. Moreover, some general practitioners have been documented prescribing pregnancy medications for lactation [20], implying that their recommendations to continue or discontinue breastfeeding may be inappropriate. This raises the need to develop a reliable database of medication that are safe for lactating women.

More than two-thirds of pharmacists expressed a high level of confidence and comfort while giving advice to breastfeeding women regarding medication. These findings are similar to those of previous study that reported that most pharmacists felt comfortable advising breastfeeding women [16] and were confident in providing advice to breastfeeding mothers [21,22]. Furthermore, significant associations were revealed between pharmacists’ confidence and comfort levels and key factors such as marital status, frequency of encountering queries on medication use in breastfeeding, asking women whether the dispensed medications were for breastfeeding women, and frequency of consulting hardcopy resources. Regular involvement in queries regarding medication use during nursing is expected to improve pharmacists’ knowledge and expertise, leading to increased comfort in delivering advice. Furthermore, frequent questioning may expose pharmacists to a range of experiences, making them more comfortable and confident in providing advice on medication use during breastfeeding. Moreover, the frequent use of hardcopy resources may help to better understand breastfeeding-related medical information, enhancing confidence and comfort levels.

Because pregnant and breastfeeding women are ethically precluded from clinical trials [23], questions about the consequences of maternal medication use during breastfeeding on newborns are considered to be frequently insufficiently answered. Consequently, there is limited experience regarding the impact of these medications on breastfeeding women at the time of their introduction and marketing, which may prompt medical professionals to advise mothers against nursing [7], even though the drug is safe for use during breastfeeding. This issue is a fundamental obstacle to successful breastfeeding support.

The surveyed pharmacists reported that they relied on different resources during their course of practice to answer queries related to medicine usage in breastfeeding mothers. Both the AAP and WHO issued recommendations on the safe use of medications during breastfeeding. Less than one-third of the participating pharmacists relied on the WHO and AAP recommendations. This may be attributed to the fact that pharmacists are less familiar with these recommendations than physicians are, as reported by Al-Sawalha et al. [14]. Additionally, more than two-thirds of the pharmacists reported relying on the product label/PIL, followed by Internet search engines and websites as the main resources. Pharmacists also rely on printed materials that have a limited shelf life. However, caution should be exercised when using Internet resources, as conflicting advice may be found, and a critical review of the available data is required to derive reliable conclusions. According to Amir and Pirotta [20] in 2009, most general practitioners rely on the Internet, books, or prescription software. A previous study conducted in Australia showed that community pharmacists used a variety of resources and references to assist them, including medicine handbooks, Internet databases or websites, and product manufacturers [24]. This highlights the importance of having reliable and up-to-date data access that pharmacists can access. In addition to the recommendations offered by competent institutions, including the WHO and the AAP, which are frequently regarded as highly reliable sources because of their evidence-based content and conformity to established guidelines, LactMed is a peer-reviewed Toxicology Data Network (TOXNET) database that contains details on the safety of medicines during breastfeeding, encompassing both conventional and alternative medicines [25]. However, none of the pharmacists in our survey had reported the use of this database. This finding emphasizes the necessity of educating pharmacists regarding reliable and accessible resources, especially not just where to obtain them but also how to understand the information that is available. This could include attending workshops or programs that focus on comprehending and assessing the data provided in these resources critically and keeping up with the most recent recommendations and findings in research.

One of the most frequently mentioned challenges in the provision of pharmaceutical care throughout preconception, pregnancy, and breastfeeding is the difficulty in determining a woman’s lactation status [26]. Approximately half of the participants always asked a woman to dispense medications if she was breastfeeding. This could be attributed to the fact that the majority of pharmacists working in Jordanian pharmacies are female [17], which may make it easier for them to ask about women’s lactation status. This finding was consistent when they were asked to determine how they could identify breastfeeding women, and more than half of them could identify breastfeeding women by asking every woman. This finding is inconsistent with the findings reported by Ronai et al. [16] in the United States, who reported that over half of the surveyed pharmacists never asked women whether they were breastfeeding. Furthermore, with regards to identifying breastfeeding women, nearly half of pharmacists believed that such information could be included on a signature waiver in the form of the sentence, “Please check here if you are pregnant or breastfeeding.” [16] These differences in results may be attributed to cultural differences.

A limitation of this study is the participants’ self-selection process. All information was obtained using a self-reported method. There may be inaccurate “social desirability” responses or recall difficulties. However, it is hoped that the anonymity of the questionnaire encourages honesty. Further research is needed to boost the role of pharmacists as someone providing interventions to improve global breastfeeding rates.

In conclusion, this study showed that community pharmacists continuously interacted with breastfeeding women, and the majority had a high level of confidence and comfort while giving advice about medication to breastfeeding women. Asking every woman is the Jordanian pharmacist’s preferred approach to identifying breastfeeding mothers who are mostly concerned about the impact of medication on newborns. Pharmacists require reliable and updated data access to answer queries related to medication use while breastfeeding.