key: cord-0021948-ow28l0ob authors: Lis-Kuberka, Jolanta; Orczyk-Pawiłowicz, Magdalena title: Polish Women Have Moderate Knowledge of Gestational Diabetes Mellitus and Breastfeeding Benefits date: 2021-10-03 journal: Int J Environ Res Public Health DOI: 10.3390/ijerph181910409 sha: c41533eb53051c62f5c48962081dccc12ea12380 doc_id: 21948 cord_uid: ow28l0ob Gestational diabetes mellitus (GDM) is a multifaceted disease and is associated with complications for newborns and mothers. The aim of the study was to assess Polish women’s knowledge concerning GDM and their attitude to breastfeeding. As a research tool, an anonymous online survey that included 33 questions, grouped into three main sections—sociodemographic and obstetric variables, risk factors for GDM and neonatal adverse outcomes, and knowledge about breastfeeding—was used and administered online. A total of 410 women aged from 18 to 45 participated in this study. Based on the survey, it was demonstrated that the women had moderate knowledge concerning the maternal risk factors and adverse neonatal outcomes associated with GDM and, additionally, the short- and long-term effects of breastfeeding. Significantly deeper knowledge about GDM, including breastfeeding by GDM mothers, was observed among hyperglycemic mothers in comparison to normoglycemic mothers. However, knowledge concerning the health benefits of breastfeeding was not related to the mothers’ glycemic status. In conclusion, educational programs must include pre-pregnancy education of women and place emphasis on explaining the mechanism of development of GDM and the transformation of GDM to type 2 diabetes. This is crucial for changing the public’s perception of GDM as a temporary, reversible clinical entity. Gestational diabetes mellitus (GDM) is characterized as a disorder of glucose metabolism with the onset, or first appearance, occurring during pregnancy [1] . Normal pregnancy is diabetogenic due to the increased production of insulin (hyperinsulinemia) and insulin resistance (IR), in order to ensure adequate nutrition for the developing fetus [1] [2] [3] [4] [5] . Moreover, the increased concentration of hormones, such as estrogen, progesterone, and cortisol, as pregnancy progresses decreases the phosphorylation of insulin receptor substrate-1 (IRS-1), and may cause insulin resistance [2] ; this is compensated by a higher production of insulin by beta cells of the islets of Langerhans. However, the pancreas' capacity to produce insulin is not infinite, and finally this state leads to a gradual reduction of beta cell functioning and a decreased insulin level and may contribute to a glucose-insulin imbalance [3, [6] [7] [8] . Moreover, increased maternal adipose tissue deposition, lower physical activity, and, additionally, higher food intake facilitate the development of relative glucose intolerance [3] . The peak effect of the hormonal changes (cortisol and estrogen) in pregnant women is observed between the 26th and 33rd week of gestation and this has become the indicator to perform basic screening tests for GDM (recommended period: 24th-28th week of gestation) [1] . The main criteria for the recognition of gestational diabetes mellitus are an abnormal fasting blood glucose level and/or an abnormal oral glucose tolerance test (OGTT) [9] [10] [11] [12] [13] . Unfortunately, the glucose level imbalance during pregnancy usually does metabolic syndrome and type 2 diabetes mellitus in later life, and a lower incidence of breast and ovarian cancers [64, 65] . Over the world, only 38% of infants aged 0 to 6 months are exclusively breastfed [66, 67] . In Poland, at the end of the twentieth century, a high rate of initial breastfeeding (92%) was recorded; however, only 68% of mothers from the analyzed cohort breastfed exclusively [68] . In 2014, the breastfeeding rate for 6-week-old infants was 46% and rapidly decreased in subsequent months, reaching 17% and 11.9% at the ninth and twelfth months, respectively [60, 69, 70] . Moreover, the trend observed in the last five years in Poland is less optimistic, dropping dramatically with each subsequent month of lactation, reaching 28.9% at the fourth month and 4% in the sixth month [71] . One of the main reasons for giving up breastfeeding reported by mothers is milk deficiency, which is strictly associated with premature expansion of the infant's diet and the appealing marketing of artificial milk [60, 71] . However, according to [71, 72] , the dramatic reduction of breastfeeding is a net result of the lack of professional support and the recommendations of some experts and advisory committees, which are not fully aligned with the WHO. On the other hand, giving up breastfeeding is costly for mothers, due to the costs of formulas and accessories necessary for artificial nutrition, and, moreover, for public health, since breastfeeding prevents child and maternal diseases [73] [74] [75] . Considering the above, the aim of this study was to assess Polish women's knowledge concerning gestational diabetes mellitus and their attitude to breastfeeding. Currently, there is a lack of reliable studies characterizing women's state of knowledge about the impact of GDM on pregnant women and their children. Moreover, information regarding the level of knowledge about breastfeeding in relation to glycemic status among Polish mothers is also lacking. As a research instrument, a questionnaire (https://forms.gle/jrNG94p3dueMt8Bf9 (accessed on 10 Feburary 2021)) based on the research in the field was used. The survey was aimed at women aged 18-45 who were planning to become or who were pregnant, and women who were already mothers. Among the responders, one woman declared diabetes diagnosed before pregnancy and was excluded from the analysis (Figure 1 ). As a research tool, a 33-question anonymous, nationwide, and cross-sectional online survey assessing women's knowledge of gestational diabetes mellitus and breastfeeding was used. The final questionnaire was divided into three main sections: (i) sociodemographic and obstetric variables, (ii) risk factors for gestational diabetes mellitus and neonatal adverse outcomes, women's knowledge of gestational diabetes mellitus, and management of pregnancy, (iii) women's knowledge of breastfeeding. Before starting the study the questionnaire was initially tested and the feedback was used to modify the final version. The questions were single-or multiple-choice, with a select few allowing for open-answer responses. The reliability of the validated questionnaire was analyzed by determining Alpha Cronbach's value, which ranged from 0.570 to 0.656. However, after removing the questions that were negatively correlated, the value of Alpha Cronbach reached a level ranging from 0.668 to 0.832. This research was conducted on the basis of a questionnaire approved by the Ethics Committee at Wrocław Medical University (No. KB-64/2021). The women were recruited from February 2021 to March 2021 using the survey, which was administered online using Google Forms, and potential participants gained access through local parenting groups that communicated via Facebook. Based on the total number of births in 2020, and the prevalence of GDM in Poland, the estimated sample size was calculated using TIBCO STATISTICA ver. 13.3 (StatSoft, Inc., Tulsa, OK, USA) as 384 participants, with a level of confidence of 95% (alpha = 0.05) and a confidence interval of 5% (absolute ± %). about the impact of GDM on pregnant women and their children. Moreover, information regarding the level of knowledge about breastfeeding in relation to glycemic status among Polish mothers is also lacking. As a research instrument, a questionnaire based on the research in the field was used. The survey was aimed at women aged 18-45 who were planning to become or who were pregnant, and women who were already mothers. Among the responders, one woman declared diabetes diagnosed before pregnancy and was excluded from the analysis (Figure 1 ). The independent sociodemographic variables (continuous variables) were age and pre-pregnancy body mass index (BMI). The ages of the respondents were reported by the women participating in the study were subsequently categorized as follows: 18-25, 26-30, 31-35, 36-40, and 41-45 years. The pre-pregnancy body mass index (BMI) was calculated after completing the survey, based on the body weight and height provided by respondents and classified according to the WHO guidelines [76] . The following categories were used: underweight (BMI below 18.5 kg/m 2 ), normal weight (BMI ranging from 18.50 to 24.9 kg/m 2 ), overweight (BMI ranging from 25.0 to 29.9 kg/m 2 ), class-1 obesity (BMI ranging from 30 to 34.9 kg/m 2 ), class 2 obesity (BMI ranging from 35 to 39.9 kg/m 2 ) and class 3 obesity (BMI above 40 kg/m 2 ). Moreover, the place of the respondents' residence (>100,000 inhabitants, 10,000-100,000 inhabitants, <10,000 inhabitants and rural area), education level (primary, vocational, high school, and university), marital status (married, separated/divorced, cohabiting, single), monthly income per 1 person (PLN 4500), and the social status of the respondents were recorded. The social status, as independent data, was assigned according to the categories recommended by the Polish Economic Institute [77] , namely class I-Higher grade professionals (doctors, professionals normally qualified with university degrees, teachers, directors and managers of companies), Class II-Lower grade professionals (medium-sized business owners, senior technicians, mid-level government administration, mid-level managerial staff), Class III-Routine nonmanual employers and higher grade of administration and commerce, Class IV-business owners with employees, Class V-Business owners with employees, Class VI-Farm owners and self-employed in primary production, Class VII-Lower grade/level technicians (masters, foremen), Class VIII-Skilled workers, Class IX-Unskilled workers, and Class X-Agricultural workers. The obstetric data included: current obstetric state/condition (pregnancy planning, first pregnancy, breastfeeding mother, and non-breastfeeding mother), parity, the gestational age of the last pregnancy (extremely preterm: 24-27 weeks, preterm 28-35 weeks, near term: 36-37 weeks, and term: 38-41 weeks), difficulty becoming pregnant (yes, no), and miscarriage in the past (yes, no). The questions in this section of the survey included: the women's glycemic status (normoglycemic or hyperglycemic), the presence of gestational diabetes mellitus (hyperglycemia compensated by diet (GDM G1), hyperglycemia compensated by diet and insulin treatment (GDM G2)), screening time for GDM (≤12 weeks of gestation, 13-23 weeks of gestation, recommended period (between 24 and 28 weeks of gestation), and after 28 week of gestation). Fasting glucose concentration (normal, abnormal) and glucose concentration (oral glucose tolerance test-OGTT) following the ingestion of 75 g of glucose after 1 h and 2 h (normal, abnormal) were determined according to declarations by the pregnant women during routine periodic visits, and the results were recorded in the patients' pregnancy charts. Finally, the women were asked to assess their state of knowledge concerning gestational diabetes mellitus (using the scale: detailed, moderate, poor, and none) and sources of awareness of GDM (doctor, midwife, television/internet, books/parenting magazine, family members/friends, and education). The data obtained from the survey in the area of maternal risk factors of GDM included: age above 35 years (yes, no), whether the mother was overweight or obese (yes, no), the presence of hypertension before pregnancy (yes, no), the occurrence of type 2 diabetes in a parent or sibling (yes, no), and polycystic ovary syndrome (yes, no). The questions concerning the risk factors for newborns delivered by mothers with GDM included: higher risk of preterm delivery (yes, no), higher risk of fetal macrosomia (yes, no), higher risk of occurrence of postpartum hypoglycemia in the newborn (yes, no), higher risk of having a fetus or neonate affected by congenital anomalies (yes, no), higher risk of being overweight or obese in adulthood (yes, no), and higher risk of developing glucose intolerance and type 2 diabetes mellitus in adulthood (yes, no). The questions addressed to the respondents in the field of pregnancy management included: physical activity (yes, moderate, no), childbirth education (yes, no), consumption of supplements, folic acid, vitamin D and medication to treat allergies, upper respiratory tract infections, urinary and genital tract infections, thyroid disease, high blood pressure, and venous thromboembolism (yes, no) during pregnancy. The other pregnancy-related variables in the study were: consumption of alcohol (yes, occasionally, no), and smoking (yes, occasionally, no). The questions in this section of the survey included: declaration of breastfeeding by mothers (yes, no, I do not know), breastfeeding period (1 month, 3 months, 6 months, 7-12 months, >1 year, >2 years, not applicable). Moreover, the respondents were asked about the health benefits of breastfeeding for the baby and mother and the effects of early infant nutrition on growth and metabolism (metabolic programming). The details concerning the assessment of knowledge levels were adapted from a study reported by Ramli et al. [78] . The following evaluation scale of grading, namely detailed (80-100%), moderate (60-79%), and poor (<60%) was used. The statistical analysis was performed with TIBCO STATISTICA ver. 13.3 (StatSoft, Inc., Tulsa, OK, USA). The manuscript contains a mixed data set (continuous and categorical variables). The continuous variables of the analyzed parameters (age, BMI) are given as the mean ± SD (standard deviation), whereas the categorical variables are presented as numbers and percentages (% (n/N)). The normality of the distribution in relation to the variables was checked with the Shapiro-Wilk test. Due to the abnormal distribution of the data, the chi-squared test was used to evaluate the differences between the groups in terms of categorical variables. Additionally, the Mann-Whitney U and Kruskal-Wallis tests were used for the continuous variables. A two-tailed p-value lower than 0.05 was regarded as significant. Univariate logistic regression was used to determine the predictors of the GDM knowledge levels, which showed p values lower than 0.05, using odd ratio (OR). The level of confidence was set at 95% with a probability level of p < 0.05 considered as statistically significant. The mean age of the respondents was 30.8 ± 5.1 years and ranged from 18 to 45. More than half of the women (233/407; 57.2%) had a normal pre-pregnancy BMI and underweight, overweight and obese women constituted 6.4%, 22.4% and 14.0% of the total, respectively. The most numerous group consisted of mothers living in cities with a population of >100,000 (178/410; 43.4%), while 23.2%, 6.8% and 26.6% of the women stated that they lived in cities with a population 10,000-100,000, below 10,000, and in a rural area, respectively. Women who had graduated from university constituted the largest percentage of the study group (303/410; 73.9%). Most of the women were married (318/410; 77.6%), and single parenthood was reported by 2.9% of the respondents only (10/410) ( Table 1) . In the study sample, more than a third of the women stated that they belonged to class III (152/400; 38.0%), the second most frequently mentioned social status was class VIII (79/400; 19.5%), and the third was class I (61/400; 15.3%). The most common monthly income per person reported by the women was 1500-2999 PLN (177/406; 43.6%). The analysis of sociodemographic variables in relation to women's knowledge level about GDM (detailed, moderate, poor, none) showed significant differences for: prepregnancy BMI (p = 0.02) ( Table 2) , place of residence (p = 0.03), marital status (p = 0.02), and monthly income per person (p = 0.02) (Tables 2 and 3 ). The detailed characteristics of the participants are shown in Tables 1-3 . The values shown in the table are given as the percentage of respondents in the given subgroup (n) in relation to all the respondents (N) for whom the specific information was available. Table 2 . GDM knowledge level in relation to age and BMI of respondents. The values shown in the table are given as the percentage of respondents in the given subgroup (n) in relation to all the respondents (N) for whom the specific information was available. Among all the respondents who took part in the survey, the largest group (123/410; 30%) constituted women who were in their first pregnancy. This was followed by women who already had children but were not breastfeeding (104/410; 24.4%) or breastfeeding mothers (101/410; 24.6%). Women in a pregnancy that was not their first constituted 18.5% (76/410), while the respondents who were planning a pregnancy represented 1.5% (6/410) only. Primiparous mothers accounted for nearly half of the study group (170/395; 43.0%) and the mean gestational age in the studied population was 39.2 ± 1.5 weeks, ranging from 35 to 42 weeks of gestation. The majority of the respondents (300/407; 73.7%) reported having no difficulties in conceiving a child, although 18.1% (74/409) of the respondents had a miscarriage in the past (Supplementary Materials Table S1 ). In the study sample, more than two-thirds of the women reported performing moderate physical activity during pregnancy (276/404; 68.3%), while no physical activity was reported by 10.9% (44/404 Table S2 ). The analysis of the management of pregnancy in relation to maternal glycemic status showed significant differences for physical activity (p = 0.01) and the use of drugs to treat high blood pressure (p = 0.000008) and venous thromboembolism (p = 0.02) between the hyperglycemic and normoglycemic groups, but no differences for childbirth education, alcohol consumption and smoking were recorded (Table 4 ). In the analyzed cohort of mothers, the women with abnormal glycemic status during pregnancy constituted 35.7% (143/401) of the respondents and gestational diabetes mellitus compensated by diet was reported by 63.1% (89/141) of the women from the GDM group. The timing of the diagnosis of gestational diabetes, as reported by the women, was in the recommended period, i.e., between 24 and 28 weeks of gestation (53/140; 37.9%); however, 30.7% (43/140) of the respondents reported early GDM, which was diagnosed ≤12 weeks of gestation (Table 5) . The mean fasting glucose concentration in the GDM group was abnormal for 58.5% (64/109) of the pregnant women. On the other hand, 31% and 32% of the respondents demonstrated abnormal results on the oral glucose tolerance test (OGTT) following the ingestion of 75 g of glucose after 1 h and 2 h. The overall level of knowledge concerning gestational diabetes mellitus was evaluated as moderate and poor for 47.5% and 35.0% of the respondents, respectively, and as the main source of knowledge about hyperglycemia during pregnancy, the women indicated: television/internet (216/398; 54.3%), doctors (205/398; 51.5%) and books/parenting magazines (108/398; 27.1%) ( Table 5 ). The data obtained from the survey in the area of maternal risk factors for GDM showed that the respondents were familiar with the fact that the risk of the occurrence of GDM increased above 35 years old (210/396; 53.3%) as well as in the case of the mother being overweight or obese (319/402; 79.4%) (Supplementary Materials Table S3 ). Knowledge concerning the impact of the mother's hypertension before pregnancy and type 2 diabetes in a parent or sibling on the occurrence of GDM was stated by 51 The data in the table show categorical values, which are given as the percentage of respondents in the given subgroup (n) in relation to all the respondents (N) for whom the specific information was available. The analysis of women's knowledge concerning maternal risk factors in relation to maternal glycemic status showed a significantly higher level in the hyperglycemic than the normoglycemic group concerning the risk associated with the mother's age being above 35 years (p = 0.01) and the prevalence of type 2 diabetes in a parent or sibling (p = 0.001) (Supplementary Materials Table S5, Figure 2 ). The women's knowledge concerning the adverse neonatal outcomes of GDM was significantly higher for the hyperglycemic group in comparison to the normoglycemic group with regards to the higher risk of occurrence of preterm delivery (p = 0.003), fetal macrosomia (p = 0.0000001), postpartum hypoglycemia (p = 0.0000004), congenital anomalies (p = 0.00001), becoming overweight or obese in adulthood (p = 0.02), and developing glucose intolerance and type 2 diabetes mellitus in adulthood (p = 0.0001) (Supplementary Materials Table S5, Figure 3 ). In the present study, 92.4% (376/407) of the women declared their willingness to breastfeed. Among the women who had children, only 13.7% (55/402) and 15.7% (63/402) reported breastfeeding for over 1 and 2 years, respectively (Supplementary Materials Table S6 ). The vast majority of (372/406; 91.6%) participants of the on-line study reported that they had been informed about the health benefits of breastfeeding for newborns/infants, i.e., strengthening emotional bonds (383/407; 94.1%), intellectual development (338/406; 83.3%); reduction of the risk of respiratory diseases (302/403; 74.9%), diabetes (243/403; 60.3%), and childhood obesity (264/401; 65.8%); and for the mother, i.e., reduction of the risk of breast (278/401; 69.3%) and ovarian (241/400; 60.3%) cancer (Supplementary Materials Table S6 ). In total, 85% (347/408) of the respondents were familiar with metabolic programming in early life, and demonstrated a high level of knowledge concerning the possibility of breastfeeding by gestational diabetic mothers (351/407; 86.2%) (Supplementary Materials Table S6 ). The analysis of breastfeeding knowledge levels in relation to maternal glycemic status showed a significantly higher level in the hyperglycemic group concerning the possibility of breastfeeding by a mother with diagnosed diabetes during pregnancy (p = 0.0001) ( Table 6 ). The values shown in the table are given as the percentage of respondents in the given subgroup (n) in relation to all the respondents (N) for whom the specific information was available. No statistically significant differences were found between breastfeeding knowledge levels in relation to age, BMI, education level, and monthly income per person of the women who participated in the study. However, the breastfeeding knowledge levels for specific types of information were related to the place of residence and the marital and social status of the respondents ( Table 7 ). The place of residence was significant for only one out of the seven analyzed questions concerning breastfeeding (p = 0.02) (Have you been informed that breastfeeding reduces the risk of your baby developing diabetes?). By contrast, marital and social status were significant for four (p ranged from 0.0004 to 0.03) and two (p ranged from 0.001 to 0.01) out of seven analyzed questions, respectively. The univariate analysis identified that BMI (OR = 1.09; 95% CI = 1.05-1.14) significantly predicted a good level of GDM knowledge, while residing in an urban area with 10,000-100,000 residents (OR = 0.61; 95% CI = 0.35-1.07) and having a non-breastfeeding mother (OR = 0.59; 95% CI = 0.33-1.05) were significant predictors of a low level of GDM knowledge. By contrast, marital status and monthly income per person were not useful as predictors of the level of GDM knowledge (Table 8 ). According to scientific databases such as Web of Science, Scopus and PubMed, there are no reports characterizing in detail Polish women's levels of knowledge concerning gestational diabetes mellitus and their attitudes towards breastfeeding. Moreover, these data are also not collected by the relevant government institutions dedicated to public health in the country. The present study attempted to deliver missing data essential for the promotion of and support for this important area of public health. The influence of socio-demographic data, obstetric variables, the management of pregnancy, the risk factors for gestational diabetes mellitus (including adverse maternal and neonatal outcomes), and women's knowledge of gestational diabetes mellitus and breastfeeding were studied. Currently, the percentage of pregnancies affected by gestational diabetes mellitus is approximately 3-8% and the number of cases is systematically increasing [14, 15] . The factors favoring the rapid development of diabetes include socio-cultural changes, aging societies, urbanization and modern lifestyles, i.e., the increased consumption of processed foods and carbohydrates, a significant reduction of the proportion of vegetables and fruit in the diet, and, finally, decreased physical activity [79] [80] [81] [82] [83] [84] . To the best of our knowledge, the present survey-based study is the only such detailed analysis evaluating the level of knowledge concerning GDM among Polish women. However, Bień et al. [85] studied factors affecting the quality of life and acceptance of illness among pregnant women with diabetes, and Ługowska and Kolanowski [86] analyzed the nutritional behavior of pregnant women in Poland. In the present study, a significant difference in the scores for knowledge about the adverse neonatal outcomes of GDM was found among participants with different glycemic statuses (Figure 3) , with particular physical activity levels during pregnancy (p = 0.01), who used certain medications during pregnancy (p = 0.000008 for drugs to treat high blood pressure and p = 0.02 for drugs to treat venous thromboembolism), and with diabetes, who demonstrated particular levels of breastfeeding awareness (p = 0.0001). GDM knowledge levels (detailed, moderate, poor, none) were significantly different in relation to sociodemographic characteristics, such as pre-pregnancy BMI (p = 0.01), area of residence (p = 0.03), marital (p = 0.02), and economic status (p = 0.02), but not in relation to the age (p = 0.41), social status (p = 0.16), or educational level (p = 0.36) of respondents. On the basis of the completed questionnaires, 47.5% of the participants declared that they had moderate and 10.5% detailed knowledge of the development of gestational diabetes. Among all the questions addressed to the respondents, the lowest knowledge level was observed for the maternal risk factors and adverse neonatal outcomes of GDM. In total, 51.6% of the normoglycemic participants and 38.8% (p = 0.01) of the hyperglycemic participants were not familiar with the fact that advanced maternal age is one of the risk factors of GDM. Additionally, more than 70% of the participants in the normoglycemic and more than 60% of the participants in the hyperglycemic group were unaware that polycystic ovary syndrome is also considered as a risk factor of GDM development ( Figure 2 ). Significantly lower knowledge levels about the adverse neonatal outcomes of GDM was found among normoglycemic mothers in comparison to hyperglycemic mothers, due to the greater education about diabetes among pregnant women with diagnosed GDM. The former were also much more aware that pregnancy affected by GDM leads to a higher risk of preterm delivery (84.1%), fetal macrosomia (94.4%), postpartum hypoglycemia in the newborn (78.1%), congenital anomalies (73.0%), overweight or obesity in adulthood (69.8%), and developing glucose intolerance and type 2 diabetes mellitus in adulthood (67.4%) (Supplementary Materials Table S5, Figure 3 ). Based on the results collected from the section concerning women's knowledge in the field of gestational diabetes mellitus, using the scale recommended by Ramli et al, [78] , the overall data clearly indicate that Polish women have moderate knowledge levels (63.3%) concerning the risk factors for GDM (mean percentage of women in the normoglycemic (56.02%) and hyperglycemic (70.63%) group who answered 'yes' to the questions asked) (Supplementary Materials Table S5 ). In our opinion, the observed difference in knowledge levels concerning GDM between women with hyperglycemia and normoglycemia was related to the tendency among hyperglycemic women to search for additional information about disease, which allows them to understand and manage their condition. Our results are in line with the results presented by Park et al. The authors [87] , who based their study on a questionnaire concerning knowledge and health beliefs about gestational diabetes and breastfeeding intention among Korean women with healthy pregnancies, concluded that education on breastfeeding for hyperglycemic women is extremely important and should focus on the benefits of breastfeeding and strengthening mothers self-efficacy. Our findings indicate that more than 65% of our respondents performed moderate physical activity regardless of their glycemic status; however, a lack of physical activity during pregnancy was significantly more frequent among hyperglycemic Polish mothers (16.8%) in comparison to those who were normoglycemic (7.8%), which is in line with the latest research by Szatko et al. [88] . Pregnant women's knowledge concerning physical activity seems satisfactory, but details concerning its health benefits, as well as the optimal frequency and duration, could be improved. It is interesting that almost one fifth of the study group of hyperglycemic women reported no physical activity during pregnancy, which suggests that the current status of the women (gestational diabetes) is not a sufficient incentive to take up physical activity. In the survey, the respondents named television/internet (54.3%) as their main source of knowledge about gestational diabetes, as well as their obstetrician (51.5%), books/parenting magazines (27.1%), and family members/friends (24.9%). Unexpectedly, the midwife as a source of awareness of GDM was indicated by 14.3% of respondents only (Table 5 ). Midwives are responsible for preparing a mother for childbirth, and during visits they could make hyperglycemic mothers aware of the possible short-and long-term effects of gestational diabetes. Unfortunately, in many cases, gestational diabetes is considered a temporary disease, although research clearly shows that the conversion rate from gestational diabetes to diabetes is increasing [34, 89] . Moreover, it should be noted that pregnant women with an impaired glucose level, which, according to the current criteria, is not considered as gestational diabetes, require dedicated glycemic monitoring as well as diabetic education. The results presented in our study indicate that the encouragement of pregnant women to undertake dedicated physical activity by medical professionals is insufficient, despite the fact that it affects the well-being of the mother and the fetus. In light of the above, there is a need to reinforce the role of obstetricians and midwives as sources of reliable knowledge, which should be reflected in lowering the incidence of some complications during pregnancy. Additionally, as stated by Kwiendacz et al. [90] , there is still a need to educate potential doctors in the field of gestational diabetes mellitus more thoroughly, since there are gaps in students' knowledge related to diabetes. This indicates a need for persistent improvement in spreading diabetology knowledge during medical education in order to more efficiently combat the diabetes epidemic [90] . It should also be remembered that lowering a woman's emotional anxiety may [91, 92] result in better compliance and a better attitude towards changes of lifestyle, including diet and physical activity during and after completing pregnancy. The reported frequency of maternal milk feeding in both the analyzed groups was very high, above 90%. However, the difficulties of the perinatal period and problems with stabilizing and sustaining lactation resulted in the abandonment of breastfeeding by 21.8% of normoglycemic mothers and 32.2% of hyperglycemic mothers within the first sixth months of lactation. Our results clearly show that there are still areas that could be improved relatively easily by the effectiveness of puerperium care as well as further prevention campaigns against the development of diabetes in the next generations. In the analyzed cohort of Polish women, the breastfeeding knowledge level was related to some sociodemographic variables, namely marital and social status and place of residence. The identified differences are most likely related to limited breastfeeding education, especially in smaller localities (Supplementary Materials Figures S1 and S2) . Unfortunately, access to qualified medical staff (e.g., lactation consultants) is limited and moreover often involves some additional costs that not all women can afford. The obtained data are in line with the results presented by Heck et al. [93] , who demonstrated that socioeconomic status is a key predictor of a wide range of health behaviors and health outcomes among mothers. For this reason, the education of midwives and, potentially, neonatologists and pediatricians, who are all in direct contact with mothers, supporting and helping them through the difficult period of puerperium and the difficulties related to breastfeeding (e.g., mastitis, inflammatory breast diseases during lactation), play an extremely important role in this field. The breastfeeding knowledge levels did not vary overall in relation to maternal glycemic status. According to the survey results, only one significant difference was found concerning breastfeeding by mothers with diagnosed gestational diabetes mellitus (p = 0.0001) ( Table 6 ). In the group of normoglycemic mothers, almost 20% were not sure if mothers with diagnosed GDM could breastfeed their child, in contrast to less than 4% of hyperglycemic mothers. Based on the responses of the Polish women in both groups (normoglycemic and hyperglycemic), their breastfeeding knowledge levels according to the adopted knowledge scale were assessed as moderate independently of maternal glycemic status (69.51% and 79.14%, respectively). The results of our study clearly show that the hyperglycemic mothers were had more breastfeeding knowledge than normoglycemic respondents, and this might be explained by the fact that with the onset of gestational diabetes, they were inclined to seek information on the origins and management of this pathology. Independently of their glycemic status, the mothers were familiar with nutritional programming. A child's early-life metabolic programming can be considered a continuation of prenatal programming. Feeding mother's milk as an exclusive form of nutrition up to 6 months is recommended for newborns by the WHO and is an important element of early-life metabolic programming, due to the associated long-term health benefits, such as protection against obesity and diabetes in later life [94, 95] . In line with the above, breastfeeding is additionally important, because the occurrence of a glucose imbalance diagnosed for the first time during pregnancy (GDM) predisposes both the mother and the child to an increased risk of obesity and diabetes in later life. Early diagnosis of GDM, as well as efficient management, including correction by diet, physical activity, and dedicated education for diabetic mothers, may play an important role in decreasing the prevalence of diabetes and obesity. Hence, it has become a priority issue in public health [33] . In a global context, weak knowledge about the management of GDM was seen in Malaysian [96] , Indian [97] , Bangladeshi [98] , and Nigerian [99] studies. These studies reported that most respondents were unfamiliar with the risk factors, screening time, and adverse maternal and neonatal outcomes of GDM. On the other hand, the findings of our study are in line with the results reported by Kaptein et al. [100] , who demonstrated that healthcare providers should capitalize on hyperglycemic women's motivation to make lifestyle changes during pregnancy to reduce their future risk of diabetes. Likewise, the meta-analyses published by Xu et al. [101] pointed out that among Chinese women, the benefits of GDM treatment/control are known, which reduces the possible consequences of GDM on the mother or the baby, while healthcare interventions aimed at GDM prevention are absent or extremely limited. A similar situation is observed in Poland. In contrast to the data presented by Ogu et al. [99] , our study revealed that place of residence and marital status did not predict levels of GDM knowledge. This was probably closely connected with the fact that, currently, the majority of women have access to information from different media. Among the analyzed variables, it was revealed that having a mother who did not breastfeed was a significant predictor of low levels of GDM knowledge. On the other hand, having been pregnant before or currently breastfeeding both related to the possibility of greater exposure to GDM information through attendance at antenatal and childbirth school, as well as to a greater likelihood of searching information about the wellbeing of mother and child in the perinatal and later periods. However, it should be pointed out that only conscious women or mothers are able to participate in some dedicated parental programs. Our findings showed that the provision of health education about GDM, especially for young women, even before the planned pregnancy, is extremally important. Our conclusions are in line with an observational study on a Finnish cohort by Laine et al. [102] , who showed that information about the positive impact of breastfeeding, namely reducing the risk of the development of glucose intolerance and type 2 diabetes mellitus, on the later life of mothers and their children should be provided for young, poorly-educated, overweight women. An unquestionable strength of the present study is that it included only women of a reproductive age, namely 18-45 years, which makes the studied cohort representative. Moreover, the data were derived from a national survey and obtained using a well-established, dedicated methodology, including a designed survey form and the calculation of a minimal sample size, all of which highlighted the problem of GDM in today's society. Some limitations should be considered when interpreting the findings of our study. Firstly, causal relationships between sociodemographic and obstetric variables, the management of pregnancy, and women's knowledge concerning gestational diabetes mellitus and breastfeeding, could not be established due to the cross-sectional study design. Secondly, self-reported data such as the knowledge score concerning gestational diabetes mellitus and breastfeeding, were not validated using objective measures and may have been different between different participants' responses. Additionally, the presented results did not take into account the emotional and psychological context of the women who participated in the study. Finally, it should also be noted that the use of an online survey may have an impact on the cohort analysis, due to variations in the cohort's familiarity with the technology involved. Our study revealed that the women whose responses we studied had a moderate level of knowledge about the maternal risk factors and adverse neonatal outcomes associated with GDM and, additionally, the short-and long-term effects of breastfeeding. Women's understanding of abnormal glucose levels during and after pregnancy is extremely important as it allows the provision of modern diabetes therapy, which includes early prevention, identification and monitoring of risk factors. A conscious mother who understands her participation in the therapeutic process becomes an active partner in the control and supervision of GDM. The results presented showed that the knowledge score for gestational diabetes mellitus and breastfeeding was moderate; thus, government agencies should increase efforts to educate society in the field of diabetes, childbirth education and the short-and long-term health benefits of breastfeeding, for both mothers and infants. The increasing prevalence of GDM prevalence and the high conversion rate from GDM to type 2 diabetes should prompt the government and public institutions to significantly contribute to controlling and slowing the progression of the diabetes epidemic, especially through early education. The treatment of diabetes and its complications is expensive for both patients (due to the cost of anti-diabetic medication) and national economies (through the indirect costs incurred through loss of work, productivity or earnings) [81] . As reported by Wierzba et al. [103] , in Poland spending on diabetes treatment is increasing steadily, and approximately 80% of diabetics in Poland state that they cannot afford optimal, modern diabetes therapy [104] . Therefore, the Polish diabetes policy should be specially aimed at a multidimensional approach and take into account a wide range of activities, including integrated programs at different levels, which is crucial for promoting healthy diets and daily physical activity. Supplementary Materials: The following are available online at https://www.mdpi.com/article/10 .3390/ijerph181910409/s1, Table S1. Obstetric variables, Table S2 . Management of pregnancy, Table S3 . Knowledge concerning maternal risk factors for gestational diabetes mellitus in analyzed cohort assessed based on questionnaire, Table S4 . Knowledge concerning neonatal adverse outcomes of gestational diabetic mothers in analyzed cohort assessed based on questionnaire, Table S5 . Women's knowledge concerning maternal risk factors for GDM and neonatal adverse outcomes of GDM and in relation to maternal glycemic status, Table S6 . Women's attitude and knowledge concerning breastfeeding and short-and long-effects, Figure S1 . Women's knowledge concerning breastfeeding and in relation to sociodemographic variable: marital status (A-D), Figure S2 . Women's knowledge concerning breastfeeding and in relation to sociodemographic variables: place of residence (A) and social status (B and C). Gestational diabetes mellitus Etiology and pathogenesis of gestational diabetes Gestational diabetes mellitus Expressions of VEGF-A and VEGFR-2 in placentae from GDM pregnancies Gestational retinal microvasculature and the risk of 5 year postpartum abnormal glucose metabolism Insulin and IR Cellular mechanisms for insulin resistance in normal pregnancy and gestational diabetes Normal pregnancy-a state of insulin resistance Report of the expert committee on the diagnosis and classification of diabetes mellitus Diabetes in pregnancy outcomes: A systematic review and proposed codification of definitions The World Health Organization (WHO) versus The International Association of Diabetes and Pregnancy Study Group (IADPSG) diagnostic criteria of gestational diabetes mellitus (GDM) and their associated maternal and neonatal outcomes Standards of Polish society of gynecologists and obstetricians in management of women with diabetes Guidelines on the management of diabetic patients. A position of Diabetes Poland A new diagnostic perspec-tive-Hyperglycemia in pregnancy-As of the year Prevalence of gestational diabetes mellitus in Europe: A meta-analysis on behalf of the DALI Core Investigator Group. Gestational diabetes mellitus in Europe: Prevalence, current screening practice and barriers to screening. A review Epidemiology of gestational diabetes mellitus according to IADPSG/WHO 2013 criteria among obese pregnant women in Europe Quality of life, wishes, and needs in women with gestational diabetes: Italian DAWN pregnancy study Australian women's experiences of living with gestational diabetes Gestational diabetes mellitus and quality of life during the third trimester of pregnancy Factors affecting the quality of life in women with gestational diabetes mellitus: A path analysis model. Health Qual Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes Prevalence of gestational diabetes mellitus and its risk factors in chinese pregnant women: A prospective population-based study in Tianjin, China Maternal age and the risk of gestational diabetes mellitus: A systematic review and meta-analysis of over 120 million participants Pregestational body mass index, gestational weight gain, and risks for adverse pregnancy outcomes among Taiwanese women: A retrospective cohort study Independent and combined effects of age, body mass index and gestational weight gain on the risk of gestational diabetes mellitus Association between gestational diabetes and pregnancy-induced hypertension Hypertension complicating diabetic pregnancies: Pathophysiology, management, and controversies Prevalence and risk factors of gestational diabetes mellitus in Asia: A systematic review and meta-analysis Effect of gestational diabetes and hypertensive disorders of pregnancy on postpartum cardiometabolic risk Family history of diabetes and the risk of gestational diabetes mellitus in Iran: A systematic review and meta-analysis Polycystic ovary syndrome as an independent risk factor for gestational diabetes and hypertensive disorders of pregnancy: A population-based study on 9.1 million pregnancies Gestational diabetes: The public health relevance and approach Diabetes atlas committee. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas Screening in high-risk group of gestational diabetes mellitus with its maternal and fetal outcomes Gestational diabetes mellitus: Risks and management during and after pregnancy gestational diabetes and later risk of cardio-vascular disease: Women's experiences and motivation for lifestyle changes explored in focus group interviews Trends in obstetric intervention and pregnancy outcomes of Canadian women with diabetes in pregnancy from 2004 to 2015 Type 2 diabetes mellitus after gestational diabetes: A systematic review and meta-analysis Gestational diabetes mellitus and risk of type 2 diabetes 10 years after the index pregnancy in Sri Lankan women-A community based retrospective cohort study Associations of maternal hyperglycemia in the second and third trimesters of pregnancy with prematurity Introduction of metformin for gestational diabetes mellitus in clinical practice: Has it had an impact? Neonatal hypoglycemia screening in newborns from diabetic mothers-arguments and contro-versies Glycaemic control during early pregnancy and fetal malformations in women with Type I diabetes mellitus Use of maternal Ghb concentration to estimate the risk of congenital anomalies in the offspring of women with prepregnancy diabetes Morbidity and mortality amongst infants of diabetic mothers admitted into a special care baby unit in Port Harcourt Major congenital malformations in women with gestational diabetes mellitus: A systematic review and meta-analysis Maternal gestational diabetes, birth weight, and adolescent obesity Metabolic syndrome in childhood: Association with birth weight, maternal obesity, and gestational diabetes mellitus Gestational diabetes and the incidence of type 2 diabetes: A systematic review Maternal obesity, gestational diabetes, breastfeeding and childhood overweight at age years. Pediatr. Obes Association between maternal diabetes, being large for gestational age and breast-feeding on being overweight or obese in childhood Integrating GDM management in public health: Pakistan perspective Gestational diabetes and childhood obesity: What is the link? Sytuacja Demograficzna Polski do 2020 roku. Urodzenia i dzietność Fetal programming and gestational diabetes mellitus Adverse maternal metabolic intrauterine environment and placental epigenetics: Implications for fetal metabolic programming Gestational diabetes mellitus and developmental programming Exclusive Breastfeeding for Six Months Best for Babies Everywhere The importance of early bonding on the long-term mental health and resilience of children Breastfeeding for diabetes prevention Breastfeeding, childhood asthma, and allergic disease Impact of breastfeeding on maternal metabolism: Implications for women with gestational diabetes Breastfeeding and maternal health outcomes: A systematic review and meta-analysis The Lancet Breastfeeding Series Group. Why invest, and what it will take to improve breastfeeding practices? Lancet Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect Infants' nutrition in Poland in 1997. Ped Pol Karmienie naturalne wżywieniu niemowląt z wybranych miast Polski Centralnej i Wschodniej Udział pokarmu kobiecego wżywieniu dzieci do drugiego rokużycia w Polsce na przykładzie województwa kujawsko-pomorskiego Promotion of breastfeeding in Poland: The current situation Ued Fda, V. Support of breastfeeding by health professionals: Integrative review of the literature Role of breast feeding in primary prevention of asthma and allergic diseases in a traditional society Protective effect of breastfeeding on diarrhea among children in a rapidly growing newly developed society Association between breastfeeding and breast cancer risk: Evidence from a meta-analysis Knowledge, attitude, and practice regarding osteoporosis among allied health sciences students in a public University in Malaysia Environmental/lifestyle factors in the pathogenesis and prevention of type 2 diabetes Cost-of-illness of type 2 diabetes mellitus in low and lower-middle income countries: A systematic review Costs and its drivers for diabetes mellitus type 2 patients in France and Germany: A systematic review of economic studies Managing gestational diabetes mellitus using a smartphone application with artificial intelligence (SineDie) during the COVID-19 pandemic: Much more than just telemedicine Testing for gestational diabetes during the COVID-19 pandemic. An evaluation of proposed protocols for the United Kingdom, Canada and Australia Recommendations and management of hyperglycaemia in pregnancy during COVID-19 pandemic in Italy Iwanowicz-Palus, G. Factors affecting the quality of life and the illness acceptance of pregnant women with diabetes The nutritional behaviour of pregnant women in Poland Knowledge and health beliefs about gestational diabetes and healthy pregnancy's breastfeeding intention Physical activity during pregnancy-the state of Polish women's knowledge Postpartum alterations blood glucose homeostasis Knowledge about diabetes mellitus among Polish medical students The psychological impact of living with diabetes: Women's day-to-day experiences Lifestyle and stress management in women during COVID-19 pandemic: Impact on cardiovascular risk burden Socioeconomic status and breastfeeding initiation among California mothers Impact of metabolic hormones secreted in human breast milk on nutritional programming in childhood obesity World Health Organization (WHO) Evaluation of knowledge regarding gestational diabetes mellitus and its association with glycaemic level: A Malaysian study Knowledge about gestational diabetes mellitus amongst pregnant women in South Tamil Nadu Evaluation of knowledge regarding gestational diabetes mellitus: A Bangladeshi study Gestational diabetes mellitus knowledge among women of reproductive age in southern Nigeria: Implications for diabetes education The subjective impact of a diagnosis of gestational diabetes among ethnically diverse pregnant women: A qualitative study Healthcare interventions for the prevention and control of gestational diabetes mellitus in China: A scoping review Impact of gestational diabetes mellitus on the duration of breastfeeding in primiparous women: An observational cohort study Innovative diabetes treatment in Poland-Mmethods and costs Improving pregnancy outcomes in women with diabetes mellitus: Modern man-agement We would like to thank Anna Kopszak from Department of Statistical Analysis Center, Wroclaw Medical University for statistical consultation. The data presented in this study are available on request from the corresponding author. The authors declare no conflict of interest.