Breastfeeding and breast milk represent the standard of nutrition for babies that improves the health of mothers and children throughout life (1, 2). While breastfeeding is vital for early childhood development, mothers also enjoy significant health benefits of breastfeeding in terms of establishing an emotional relationship with the child, reducing the risk of postpartum depression, postpartum bleeding and anemia, and long-term effects such as the risk reduction for osteoporosis, malignant breast and ovaries diseases and type 2 diabetes (1–3).

The Global Strategy on Infant and Young Child Feeding clearly defines the optimal nutritional parameters for infants and young children. The strategy recommends breastfeeding to be initiated during the first hour after birth and that the infant should be exclusively breastfed during the first 6 months of life—which means there are no other foods or liquids, including water (1, 2).

Globally, only 40% of children under the age of 6 months are exclusively breastfed (4). Therefore, one of six major global nutritional goals in World Health Organization (WHO) Comprehensive Nutrition, Mothers and Infants Plan is the increase of exclusive breastfeeding practice during the first 6 months to at least 50% (5).

The health system and the analysis of its simulative and dissimulative practices play a significant role in the promotion of breastfeeding. These practices refer to the initiation of breastfeeding in the first hour after delivery or feeding with some non-breast milk in the maternity ward. Whether a child is born in a hospital or outside a hospital, in a rural or urban area, placing newborns on the breast in the first hour after birth gives them the best chance of surviving, establishing long-term breastfeeding, growing and developing to full potential (1, 2, 6). Skin contact immediately after birth increases the likelihood that babies will be breastfed during the first months of life and also prolongs the duration of breastfeeding (6).

WHO and The United Nations Children's Fund (UNICEF) launched the Baby-Friendly Hospital Initiative (BFHI) to improve the breastfeeding practices and support breastfeeding in maternity wards worldwide. Ten Steps to Successful Breastfeeding are the guideline of the initiative, and it emphasizes the importance of early breastfeeding and achieving optimal breastfeeding practices (7, 8). A systematic review of the Baby-friendly Hospital Initiative in 19 countries has shown that adherence to the Ten Steps to Successful Breastfeeding can increase breastfeeding rates (9).

Initiation and length of breastfeeding depend on demographics, biological and socioeconomic factors, the impact of the community, and public health policy (10). Demographic and socioeconomic factors can cause breastfeeding cessation before 6 months of the infant's life. Some studies confirmed a significant association between the low level of mothers' education and breastfeeding cessation before the 6 months of an infant's life (11–14). Mother's attitude toward the breastfeeding practice can be shaped by area of living, type of settlement, aesthetic reasons that are becoming more and more frequent in the population of future mothers (15).

Ethnicity can influence the practice of exclusive breastfeeding, especially belonging to the Roma population. The Roma population is the second-largest ethnic minority in Serbia, and according to official data, there are almost 150,000 Roma, which is 2.05% of the total population in the Republic of Serbia (16). The Roma population is among the most vulnerable population group in Europe, especially in the Republic of Serbia, quite often exposed to discrimination, social marginalization and poverty, but also with less access to health services, especially mother and child to preventive health services and practice (17–20).

According to the last available data, the infant mortality rate in the Republic of Serbia is 5 per 1,000 live births in the non-Roma population (inter agency groups) while in Roma population it accounts for 12.8 per 1,000 live births (21). When it comes to the under-five mortality rate, in non-Roma population it is 6 in the non-Roma population (22) and 14.4 in Roma population (21). Although under-five mortality in Serbia has reduced in recent years for both populations is below the Sustainable Development Goal target of 25 deaths per 1,000 live births (23), it is still important to highlight the importance of breastfeeding for the improvement of children outcomes (1, 2).

Data from Multiple Indicators Cluster Surveys (MICS) that have been periodically conducted in Serbia (21, 24) showed that the prevalence of child undernutrition (under the age of 5) in recent year was higher than earlier in Roma children while there was a slight decrease in undernutrition rate in non-Roma children (13 vs. 12% for non-Roma children and 31 vs. 32.8% for Roma children) (21, 24). Still, it is important to make an effort to prevent childhood malnutrition and the prevention of breastfeeding as one of the crucial activities in this field.

Numerous studies around the world examined the factors influencing the breastfeeding practice, but studies of this type are not frequent among vulnerable populations, such as Roma community. Therefore, our analysis aimed to assess the prevalence of exclusive breastfeeding practice and identify the potential factors associated with the practice of exclusive breastfeeding of infants up to 6 months on representative samples of the Roma and non-Roma population.

The study included mothers of 467 infants under 6 months of age. The percentage of exclusively breastfed babies is 13.3%, with no significant difference for ethnicity (Roma population 13%, non-Roma population 13.4%, p = 0.910).

This analysis is the first study in the Republic of Serbia conducted on a national sample of non-Roma and Roma populations that examined potential predictors of exclusive breastfeeding. A tiny percentage (13.3%) of exclusively breastfed infants under 6 months, with almost no difference between the populations, indicates to the neglected importance of breast milk as a food during the first months of life. A series of social changes during the 20th and 21st centuries such as greater mobility of families, the popularization of infant milk formulas, a passive attitude of the community and health care professionals toward natural nutrition, led to the rapid takeover of adapted milk formula over breastfeeding (3, 26).

Compared to the neighboring countries, the lowest percentage of exclusively breastfed infants has been observed in the Republic of Serbia. Only in the Republic of Serbia, the percentage of exclusively breastfed infants does not differ between the Roma and non-Roma population, while in other neighboring countries, Roma population has a higher frequency of exclusive breastfeeding practice than non-Roma population (Bosnia and Herzegovina: 22.3% vs. 18.3 %; Northern Macedonia 32.1% and 23.0%) (27, 28). These findings of significantly low rates of exclusive breastfeeding in the Republic of Serbia serve as an alarm that prevention work needs an urgent intervention to educate both healthcare professionals and mothers who are at risk of not breastfeeding or stopping breastfeeding before the recommended times, regardless the ethnicity.

According to the results of our study, infants from the capital, Belgrade, had the best chance to be exclusively breastfed for the first 6 months of age in both populations. Data from the Statistical Office of the Republic of Serbia on income in money and kind and individual consumption of households show that the highest revenues are in Belgrade, while the lowest are in Southern and Eastern Serbia. The following pattern has appeared: the better income indicators were observed, the higher the percentage of exclusively breastfed infants was. Hence, places where living and working conditions are better and the incomes are higher create a supportive environment for women to breastfeed (29).

Furthermore, the highest percentage of the exclusively breastfed infant in the capital partly could be a result of the existence and the activities of the Hallo Baby phone counseling center launched in Belgrade in 2001 within the Health Promotion Center, City Institute of Public Health. This counseling center contributes to the promotion of the mothers' and child health by counseling and encouraging decision-making related to health, proper nutrition, care, growth and development of children, based on adequate and timely information and advice under professional evidence. This service is available 24/7 and provides support to all parents from the capital who mostly calls when the child is sick, but also when the breastfeeding is about (30). Moreover, the biggest efforts to organize childbirth preparation programs within health institutions have been made in Belgrade during the last several years, so it is not surprising that mothers from Belgrade are strengthened by knowledge in this field.

The practice of exclusive breastfeeding in urban areas was more common than in rural areas. Rural areas are characterized by low population rates, low birth rates, so significant investments are needed to support mothers to breastfeed. Equal access and accessibility issues are of crucial importance when it comes to the broader picture of breastfeeding support in any region, especially in rural areas. Study on factors associated with the beginning and duration of breastfeeding in rural areas in the United States has shown that economic factors in rural areas, such as the woman need to return to work and limited resources to support the continuation of breastfeeding, represent significant barriers to the practice of exclusive breastfeeding (31–33). The results of our study are in accordance with the studies done worldwide (31–33) and there is no doubt that mothers living in urban areas benefit from the density and variety of support services and breastfeeding expertise (34).

Women living in rural areas are often unemployed due to lack of qualifications and low level of education, they do not have social interaction with other women because they stay at home while partner makes a living, which altogether leads to a lack of knowledge about breastfeeding and its importance especially during the first months of infant's life. Women's rights are less respected in such environments where women stay home and care for children, and men earn money (35). Therefore, special attention should be paid to raising the awareness of parents who are geographically or culturally isolated in rural areas regarding breastfeeding.

While the age of the father was not associated with the practice of exclusive breastfeeding in the Roma population, in the non-Roma population, the likelihood that the mother will exclusively breastfeed the infant for the first 6 months of life increases with the age of the partner. The assumption is that older men are more mature, aware of the benefits for their child and as such an essential support for women during the first months of the infant's life. Wambach showed that women who exclusively breastfeed, succeeded because their partners supported the decision, believing that breastfeeding was best for the baby (36). Partner contributes to the practical and emotional support for breastfeeding and several studies have found that greater father involvement during the prenatal period increases the likelihood of breastfeeding initiation and duration (37, 38). The support of fathers maybe even more influential especially in a rural area where women may be geographically isolated from their mothers or other family members (37, 38).

Although studies conducted worldwide have shown that the Baby-Friendly Program has significantly increased the rate of exclusive breastfeeding in the world (39, 40), the practice of infant staying in the same room with the mother in the maternity ward showed, in contrast, quite opposite results. In the Roma population, mothers who did not stay in the same room with their baby had a seven-fold higher chance of breastfeeding exclusively during the first 6 months, whereas in the Roma population staying in the same room did not affect the practice of breastfeeding. The assumption is that a larger sample of Roma population would give a similar result since the values of logistic regression were going in the same direction. One of the explanations for these findings is found in the evaluation of the Baby-Friendly Program in the Republic of Serbia, showing that the Baby-Friendly Program was not implemented properly (41). On the other hand, mothers were frustrated by the fact that they were alone with their newborn for a considerable part of the time, did not cope with breastfeeding, especially the primipara and there was insufficient help regarding breastfeeding. While babies were crying, mothers did not know how to behave; they waited for a long time for someone to show up and help them. During this time, those mothers not included in Baby-Friendly Program are at the regular regime of sleep, rest, they do not hear crying, babies are fed and those mothers later leave the hospital more relaxed and rested (41). Thus, much greater support is needed for mothers, especially encouraging them to start breastfeeding in the first hour after birth and to stay together with the baby 24 h a day (7, 8). In 2012, the Republican Expert Commission (REC) on Health Protection of Women, Children and Youth adopted “National standards of health care tailored to the needs of mothers and children” which provides the same standard of service and the right of infants to be fed by breast milk in all health care institutions. However, in 2014 the REC Perinatal Health Task Force surveyed maternity wards and found that the implementation of the National Standards was incomplete in almost all health care facilities. One example is the application of adapted milk formula in maternity wards without medical records (42).

Studies worldwide have shown that attending antenatal breastfeeding educations is one of the crucial steps for breastfeeding success (43–46). Pregnant women with knowledge about breastfeeding are more likely to plan breastfeeding, which is key to following breastfeeding recommendations later (47–49). Regarding this, attending a childbirth preparation program (unique educational program on pregnancy, nutrition, physical activity, childbirth, breastfeeding, mother care and newborn child within health care institutions) can significantly improve maternal knowledge on pregnancy health, breastfeeding, newborn care and parenting skills. In our study, non-Roma mothers attending the childbirth preparation program were 18 times more likely to exclusively breastfeed their baby. However, the problem here is an extremely low number of mothers attending the birth preparation program. One of the reasons for the low attendance rate is that this form of counseling work is available in 40 out of 160 existing health centers established by the Regulation on the Network of Health Care Facilities Network Plan (50). Also, women from the Roma population are significantly less likely to undergo regular checkups during pregnancy. Very often their first visit is for childbirth so their absence can be associated with the lack of knowledge about the existence of these types of support (51).

Although in Roma population no correlation was observed between the number of children and the practice of exclusive breastfeeding, in the non-Roma population, the likelihood for mothers to exclusively breastfeed was higher with each subsequent child. A positive association between the practice of exclusive breastfeeding and the number of children has been confirmed in studies by Radwan, as well as by Yilmaz where mothers of two or more children were found to be more likely to exclusively breastfeed compared to those with only one child (52, 53). Failure to start breastfeeding with the first child is associated with failure to start and continue breastfeeding with the second and/or subsequent child (54, 55). Jessri confirmed that mothers multipara were more than twice as likely to exclusively breastfeed their babies for the first 6 months than primipara (56). Women who gave birth at least twice had more knowledge, confidence and experience, and were more likely to exclusively breastfeed their infant for 6 months (57). In this regard, the importance of counseling and developing breastfeeding skills for first-borns should be emphasized in order to overcome barriers and to establish, promote and support breastfeeding.

What characterizes women in both populations is the association between the practice of exclusive breastfeeding and the return of the menstrual cycle. If a menstrual cycle has not returned after childbirth, that woman is more likely to breastfeed longer. A study in Nigeria has shown that breastfeeding duration is the most significant predictor of the duration of lactational amenorrhea (58). Although lactational amenorrhea is used as a method of contraception, it is important to emphasize that it does not provide protection again pregnancy by itself. According to The Bellagio Consensus, the necessary conditions under which breastfeeding can be safely and effectively used as a contraceptive method are lactational amenorrhea, exclusive breastfeeding, and a period shorter than 6 months after birth (59).

The prevalence of exclusive breastfeeding of infants younger than 6 months was 13.3%, with no difference between Roma and non-Roma population, which is far below the WHO recommendations. While in Roma population the choice of a woman to exclusively breastfeed is associated with the duration of lactational amenorrhea, in general population the decision of a woman to exclusively breastfeed is strongly associated with the region where she lives, the type of settlement, the age of the partner, the fact whether the baby drank anything other than breast milk days in the maternity ward, staying in the same room with the mother at the hospital, parity, and attending the birth preparation program during pregnancy.

Preventive work should focus on improving the knowledge (education) of healthcare professionals and mothers who are at risk of stopping breastfeeding before the recommended time. Also, it is necessary to urgently start with the implementation of all 10 steps BFHI in maternity wards, mobilizing resources, and providing support to mothers who have breastfeeding problems regardless of the region and type of settlement.

The datasets generated for this study are available on request to the corresponding author.

The studies involving human participants were reviewed and approved by UNICEF (Multiple Claster Indicator Study). Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

ZS contributed to concept and design, acquisition of data, analysis and interpretation of data, drafting the article, and final approval of the manuscript. BM contributed to concept and design, analysis of data, revising the article draft critically for important intellectual content, and final approval of the manuscript. BD contributed to concept and design, revising the article draft critically for important intellectual content, and final approval of the manuscript. VB-M contributed to concept and design, revising the article draft critically for important intellectual content, and final approval of the manuscript. All authors agree to take responsibilities for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved, accept responsibility for the paper as published, and took part in this research from the very early beginning until the final approval of the manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.