Factors Associated with Breastfeeding Duration in Tunisia: A Cross-Sectional Analysis Highlighting the Role of Early Initiation

1. Introduction

In the last decade, breastfeeding remains one of the most powerful, yet underutilized interventions for improving global maternal and child health. Despite overwhelming evidence of its benefits, exclusive breastfeeding rates continue to fall short of targets, with only 48% of infants worldwide being exclusively breastfed for the recommended six months.¹ This gap between scientific evidence and real-world practice is even more pronounced in the Middle East and North Africa (MENA), where only ~35% of infants aged 0–5 months are exclusively breastfed according to regional UNICEF strategic data.² Systemic barriers including inadequate healthcare support, workplace challenges, and persistent societal misconceptions further contribute to low breastfeeding rates.

Recent studies from 2023-2025 have further strengthened the case for breastfeeding, demonstrating its protective effects against childhood leukemia,^3,4 food allergies,⁵ and maternal diabetes.¹ However, in Tunisia, while breastfeeding initiation rates remain strong at 85%, exclusive breastfeeding at six months has plateaued at just 38%, reflecting regional trends and underscoring the need for targeted interventions.⁶

The post-pandemic era has introduced new challenges, including healthcare workforce shortages and increased economic pressures that force mothers to return to work prematurely. At the same time, digital misinformation about infant feeding continues to proliferate, further complicating breastfeeding promotion efforts.

Beyond structural and cultural barriers, behavioral determinants play a critical role in shaping breastfeeding outcomes. The observed discrepancy between a mother’s intention to breastfeed and her actual practice—the so-called intention–practice gap—can be theoretically understood through the Theory of Planned Behavior (TPB) and the Health Belief Model (HBM). According to Ajzen’s TPB, behavioral intention depends on attitudes, subjective norms, and perceived control, which may be constrained by social or institutional barriers.⁷ Likewise, Rosenstock’s HBM emphasizes that perceived benefits, barriers, and cues to action influence whether health-promoting behaviors such as sustained breastfeeding are adopted.⁸ Applying these models offers a conceptual framework for understanding why, despite strong maternal intentions, breastfeeding continuation remains suboptimal.

In addition to behavioral support, structural interventions are essential. Human milk banks—which provide screened donor milk for infants unable to receive their mother’s milk, especially preterm or low-birth-weight newborns—have been successfully implemented in several low- and middle-income countries.^9,10 Although milk banking initiatives are still emerging in North Africa, integrating them into maternal and neonatal health systems could complement breastfeeding promotion and improve neonatal outcomes.¹¹

The study included women who delivered between November 2023 and February 2024. Breastfeeding continuation was assessed up to 12 months postpartum, with data collection extending into early 2025, focusing on factors influencing breastfeeding continuation, particularly the timing of initiation. It addresses persistent barriers and highlights promising solutions, including Tunisia’s updated Labor Code for workplace lactation support and AI-powered lactation assistants. By reviewing successful interventions in similar contexts, this work offers actionable recommendations to close the implementation gap and accelerate progress toward global breastfeeding targets, vital for maternal and child health.

2. Methods

2.2 Study population

The study included women who delivered during the study period meeting the following criteria:

Inclusion criteria

• • Age 18 years or older

• • Delivery at 34 weeks of gestation or later, regardless of delivery mode

• • Informed and voluntary consent to participate

Exclusion criteria

• • Maternal age < 18 years

• • Newborns transferred to specialized units (e.g., pediatric surgery or pediatric cardiology)

• • Complicated deliveries requiring maternal admission to intensive care unit

• • Intrauterine fetal death

• • Neonatal death

• • Medical contraindications to breastfeeding

• • Refusal to participate

• • Incomplete questionnaire data

A study flowchart detailing case selection and exclusions has been developed ( Figure 1).

Figure 1. Flowchart for the study.

3. Results

In total, 400 women were included.

4. Analytical study

4.1 Univariate analysis

1. Demographic and socioeconomic factors

Table 6 represents the univariate analysis of demographic and socioeconomic factors across postpartum breastfeeding duration groups (1–3 months, 3–6 months, and >6 months).

Table 6. Univariate analysis of demographic and socioeconomic factors across postpartum breastfeeding duration groups (1–3 months, 3–6 months, and >6 months).

Demographic & Socioeconomic factors	Category	1–3 months N (%)	3–6 months N (%)	>6 months N (%)	p -value
Ethnicity	Tunisian	53 (100%)	104 (96.3%)	239 (100%)	0.064
	Sub-Saharan African	0 (0%)	4 (3.7%)	0 (0%)
Residence	Rural	4 (7.5%)	11 (10.2%)	19 (7.9%)	0.740
	Urban	49 (92.5%)	97 (89.8%)	220 (92.1%)
Higher Education	No	38 (71.7%)	69 (63.9%)	154 (64.4%)	0.525
	Yes	15 (28.3%)	39 (36.1%)	85 (35.6%)
Low Socioeconomic Level	No	44 (83.0%)	80 (74.1%)	213 (89.1%)	0.005
	Yes	9 (17.0%)	28 (25.9%)	26 (10.9%)

All participants in the 1–3 month and >6 month postpartum groups were Tunisian (100%), whereas in the 3–6 month group, 104 women (96.3%) were Tunisian and 4 women (3.7%) were Sub-Saharan African. This difference in ethnicity was not statistically significant (p = 0.064).

Concerning residence, most women lived in urban areas across all groups: 92.5% in the 1–3 month group, 89.8% in the 3–6 month group, and 92.1% in the >6 month group. Rural residence was reported by 7.5%, 10.2%, and 7.9% of women respectively. These differences were not significant (p = 0.740).

Regarding education, women without higher education represented 71.7% in the 1–3 month group, 63.9% in the 3–6 month group, and 64.4% in the >6 month group. These variations were not statistically significant (p = 0.525).

However, socioeconomic status showed a significant difference between the groups (p = 0.005). A low socioeconomic level was reported in 17.0% of women in the 1–3 month group, 25.9% in the 3–6 month group, and only 10.9% in the >6 month group.

2. Health and lifestyle factors

Table 7 represents the univariate analysis of healthand lifestyle factors across the postpartum breastfeeding duration groups.

Table 7. Univariate analysis of health and lifestyle factors across the postpartum breastfeeding duration groups (1–3 months, 3–6 months, and >6 months).

Health & Lifestyle factors	Category	1–3 months	3–6 months	>6 months	p -value
Active Smoking	No	51 (96.2%)	107 (99.1%)	236 (98.7%)	0.420
	Yes	2 (3.8%)	1 (0.9%)	3 (1.3%)
Passive Smoking	No	35 (66.0%)	78 (72.2%)	178 (74.5%)	0.266
	Yes	18 (34.0%)	30 (27.8%)	61 (25.5%)
Obesity	No	39 (73.6%)	80 (74.1%)	199 (83.3%)	0.026
	Yes	14 (26.4%)	28 (25.9%)	40 (16.7%)

Active smoking was uncommon across all groups, with 3.8% of women smoking in the 1–3 month group, 0.9% in the 3–6 month group, and 1.3% in the >6 month group (p = 0.420; not significant). Passive smoking exposure was reported by 34.0%, 27.8%, and 25.5% of women respectively (p = 0.266; not significant).

Obesity showed a significant difference between groups (p = 0.026). It was reported in 26.4% of women in the 1–3 month group, 25.9% in the 3–6 month group, and only 16.7% in the >6 month group.

3. Pregnancy and delivery factors

Cesarean section was the most common delivery mode in all groups, reported in 54.7% of the 1–3 month group, 52.8% of the 3–6 month group, and 52.3% of the >6 month group (p = 0.789; not significant).

Preterm delivery (<37 weeks) occurred in 9.4%, 9.3%, and 7.9% of the women, respectively (p = 0.635; not significant).

Macrosomia was similarly distributed among groups (5.7%, 8.3%, and 7.5%; p = 0.864; not significant) (See Table 8).

Table 8. Univariate analysis of pregnancy and delivery factors across postpartum breastfeeding duration groups (1–3 months, 3–6 months, and >6 months).

Pregnancy & Delivery factors	Category	1–3 months	3–6 months	>6 months	p -value
Delivery Mode	Cesarean section	29 (54.7%)	57 (52.8%)	125 (52.3%)	0.789
	Vaginal delivery	24 (45.3%)	51 (47.2%)	114 (47.7%)
Term Delivery	Preterm (<37 weeks)	5 (9.4%)	10 (9.3%)	19 (7.9%)	0.635
	Term (≥37 weeks)	48 (90.6%)	98 (90.7%)	220 (92.1%)
Macrosomia	No	50 (94.3%)	99 (91.7%)	221 (92.5%)	0.864
	Yes	3 (5.7%)	9 (8.3%)	18 (7.5%)

4. Breastfeeding practices and support

The univariate analysis of breastfeeding practices and support factors across postpartum breastfeeding duration groups (1–3 months, 3–6 months, and >6 months) is summarized in Table 9:

• ▪ Breastfeeding initiation:

  • - Timely breastfeeding initiation (within 1 hour) showed a significant difference between groups (p < 0.001). Only 13.2% of women in the 1–3-month group and 2.8% in the 3–6 month group initiated breastfeeding early, compared to 28.0% in the >6-month group.

  • - Consequently, delayed breastfeeding initiation was more prevalent in the 1–3 month (86.8%) and 3–6-month (97.2%) groups than in the >6-month group (72.0%), which was also statistically significant (p < 0.001).

• ▪ The use of formula milk was reported by 34.0% of women in the 1–3-month group, 22.2% in the 3–6 month group, and 26.4% in the >6-month group (p = 0.750; not significant).

• ▪ Skin-to-skin contact was practiced in 37.7%, 36.1%, and 39.3% of the cases in the respective groups (p = 0.633; not significant).

• ▪ Family support was present for 79.2% of the 1–3 month group, 71.3% of the 3–6 month group, and 71.5% of the >6-month group (p = 0.450; not significant).

• ▪ Breastfeeding continuation

Table 9. Univariate analysis of breastfeeding practices and support factors across postpartum breastfeeding duration groups (1–3 months, 3–6 months, and >6 months).

Breastfeeding practices & Support	Category	1–3 months	3–6 months	>6 months	p -value
Timely Initiation (<1h)	Yes	7 (13.2%)	3 (2.8%)	67 (28.0%)	0.000
Delayed Initiation	Yes	46 (86.8%)	105 (97.2%)	172 (72.0%)	0.000
Formula Use	Yes	18 (34.0%)	24 (22.2%)	63 (26.4%)	0.750
Skin-to-Skin Contact	Yes	20 (37.7%)	39 (36.1%)	94 (39.3%)	0.633
Family Support	Yes	42 (79.2%)	77 (71.3%)	171 (71.5%)	0.450

An analysis of breastfeeding duration in relation to the timing of breastfeeding initiation reveals a clear trend: the earlier the initiation, the higher the likelihood of sustained breastfeeding, particularly at 6 and 12 months ( Figure 2).

Figure 2. Breastfeeding duration in relation to the timing of breastfeeding initiation among the study population.

At 3 months postpartum, breastfeeding rates remained relatively high across all initiation groups. Women who initiated breastfeeding within the first hour had a breastfeeding rate of 92.2%, comparable to those who initiated between 1 and 6 hours (92.9%). Even among those who initiated breastfeeding after 24 hours or did not initiate at all during hospitalisation, rates remained high (80.0% and 100.0%, respectively). This suggests that in the short term, other factors—such as initial motivation or support in the early postpartum period—may help maintain breastfeeding regardless of initiation timing.

However, differences became more pronounced at 6 months. Women who initiated breastfeeding within the first hour had the highest rate (90.9%), whereas rates dropped to 70.5% among those who initiated between 1 and 6 hours, and to 66.7% for those initiating between 6 and 12 hours. The lowest rates were seen among those with later initiation (60–70%) and no initiation (75%). These findings suggest that early initiation is linked to better breastfeeding continuity.

At 12 months, the trend was even more marked. The breastfeeding rate remained relatively high in the group that initiated within the first hour (77.9%), while it fell drastically in all other groups. Only 28.6% of women who initiated between 1 and 6 hours, 24.2% of those between 6 and 12 hours, and 25.0% of those who did not initiate at all during hospitalisation were still breastfeeding at 12 months. This demonstrates the long-term benefit of early breastfeeding initiation, especially within the first hour of birth.

5. Discussion

The findings from our study examining breastfeeding practices among Tunisian women reveal important similarities and differences when compared with international research.

Our observation of a 44% breastfeeding rate at 12 months postpartum aligns closely with Yalçin et al.’s findings¹⁶ in Turkey (55.9%), yet surpasses rates reported in high-income countries like Australia (31.8%)¹⁷ and Korea (33.7%).¹⁸ This suggests cultural factors in Tunisia may be more supportive of prolonged breastfeeding than in some Western contexts, though substantial room for improvement remains.

A critical finding from our study was the powerful association between early initiation and breastfeeding duration - while only 19.3% of mothers initiated breastfeeding within the first hour, this group accounted for 77.9% of those still breastfeeding at 12 months. This dose-response relationship echoes Meedya’s intervention research¹⁹ showing early practices significantly influence long-term outcomes. Our multivariate analysis further quantified these effects: early initiation demonstrated a U-shaped importance, with strong positive effects at 3 months (389% increased odds) and 12 months (728% increased odds), while showing no significant association at 6 months. This indicates that early initiation has both immediate and long-lasting benefits for breastfeeding continuation.

However, our 80.8% delayed initiation rate indicates systemic challenges in immediate postpartum care that mirror Bond et al.’s identification of hospital routines as barriers.²⁰

The analysis of breastfeeding intention highlighted its overwhelming predictive value at 3 months, with more than 400-fold increased odds of continued breastfeeding. Although the effect diminished over time, it remained substantial at later postpartum periods, emphasizing the critical role of prenatal intention formation in early breastfeeding success.

Our study identified maternel obesity (present in 20.5% of participants) as a significant predictor of shorter breastfeeding duration, consistent with the findings of Achike and Akpinar-Elci’s systematic review,²¹ which analyzed 23 studies on the impact of pregestational maternal BMI on breastfeeding outcomes. Their review showed that elevated maternal BMI prior to pregnancy is linked to reduced intention to breastfeed, delayed initiation, and shorter duration of both exclusive and overall breastfeeding. This association likely reflects a combination of physiological barriers (delayed lactogenesis, hormonal dysregulation), psychological challenges (low confidence, negative body image), and systemic factors (less support, provider bias).²¹ In our multivariate analysis, maternel BMI also emerged as a consistent determinant across all postpartum periods, with each unit increase in BMI associated with approximately 10% lower odds of breastfeeding continuation at 3 months, 12% lower odds at 6 months, and 4% lower odds at 12 months. This findings underscore the importance of weight management and related support throughout the first postpartum year to optimize breastfeeding outcomes.

Similarly, smoking behavior showed a time-dependent negative effect, with active smoking significantly reducing the odds of breastfeeding continuation by 85% at 3 months and 87% at 6 months, although this association was no longer significant by 12 months. These results suggest that smoking cessation interventions may be particularly crucial in the early postpartum period.

The socioeconomic gradient we observed confirms Chimoriya et al.’s Sydney-based findings,²² though the mechanisms may differ in our context. Low socioeconomic status showed a trend toward reducing breastfeeding odds by ~50% at 12 months, and knowledge of breastfeeding benefits approached significance with a 62% increased odds at 12 months. In contrast, higher educational attainment showed no significant association at any time point, suggesting that formal education alone may not determine breastfeeding success.

Contrary to expectations from Bond et al.’s work,²⁰ we found no association between cesarean delivery (52.8% rate) and breastfeeding outcomes, suggesting cultural or healthcare adaptations may mitigate this typically negative relationship.

Our study was conducted in a tertiary-level maternity hospital (level 3), which manages a high volume of high-risk deliveries, including cesarean sections, preterm births, and neonates requiring intensive care. This setting contributes to institutional barriers to early initiation and skin-to-skin contact: routine postnatal monitoring, separation of mother and infant for neonatal intensive care, and the high workload of healthcare staff can delay the first breastfeeding session. Such organizational constraints are consistent with Bond et al.’s findings on hospital routines as impediments to early breastfeeding.²⁰

In addition, cultural factors in the Tunisian context, such as family influence on postpartum practices and traditional beliefs regarding colostrum and neonatal care, may further delay initiation. Mothers may defer breastfeeding or skin-to-skin contact due to guidance from elders or perceptions that immediate feeding is not essential, reflecting deeply rooted postpartum customs. Together, the tertiary hospital setting and local cultural norms help explain the low rates of early initiation (19.3%) and skin-to-skin contact (38.3%) observed in our cohort.

Postpartum practices documented in our study highlight several evidence-practice gaps. Our low skin-to-skin contact rate falls far below standards advocated by the American Academy of Pediatrics,²³ while limited breastfeeding education (46%) contrasts with Park and Ryu’s²⁴ meta-analysis showing education’s effectiveness. Skin-to-skin contact demonstrated a borderline protective effect at 3 months, and delayed feeding showed a trend toward reducing breastfeeding success at 6 months. These implementation shortcomings help explain our population’s challenges, particularly when combined with Niu et al.’s findings²⁵ about the importance of early metabolic programming through breastfeeding.

Our health outcome data contribute new perspectives to existing research. While Delgado et al.²⁶ focused on long-term mental health outcomes and Niu et al.²⁵ examined metabolic benefits, our documentation of immediate postpartum challenges (20% neonatal intensive care unit admission, 46.5% severe pain) identifies understudied barriers to breastfeeding establishment. These findings suggest Cordell and Elverson’s²⁷ call for improved postpartum support applies particularly strongly in our context.

The policy implications emerging from our study both confirm and extend existing recommendations. Our results strongly support implementing the World Health Organisation (WHO)’s “Ten Steps” as analyzed by Binns and Lee,²⁸ while also suggesting adaptations for local factors such as obesity prevalence. Addressing both institutional and cultural barriers, along with reinforcing education and support for mothers, could help improve early initiation, skin-to-skin contact, and overall breastfeeding outcomes in Tunisian tertiary care settings.

Beyond the determinants analyzed in our study, several additional factors recently highlighted in the literature may also influence breastfeeding outcomes. Pham et al.²⁹ reported that maternal burnout, particularly among healthcare professionals, can negatively affect lactation performance and breastfeeding continuation. Their findings emphasize the need to consider maternal psychological well-being and stress management as integral components of breastfeeding promotion strategies, especially in high-pressure hospital environments.

Furthermore, Nguyen et al.³⁰ demonstrated that preterm birth—often resulting from high-risk pregnancies and complex obstetric conditions—has substantial implications for neonatal outcomes and early mother-infant interactions. In our tertiary-level setting, where high-risk and preterm deliveries are frequent, such factors may partly explain the challenges observed in early breastfeeding initiation and skin-to-skin contact.

In addition, Nguyen et al.³¹ highlighted the role of non-pharmacological interventions, including dietary counseling and physical activity, in the management of gestational diabetes mellitus (GDM). Since GDM and maternal metabolic health directly influence both lactation physiology and postpartum recovery, integrating nutritional and lifestyle support into perinatal care could further enhance breastfeeding success.

Together, these complementary perspectives—addressing psychological stress, high-risk pregnancy, and maternal metabolic health—broaden the understanding of breastfeeding determinants and underscore the need for multidimensional, context-specific interventions to optimize breastfeeding outcomes in tertiary maternity settings such as ours.

6. Conclusions

This study provides robust, context-specific evidence that early initiation of breastfeeding within the first hour of life is a decisive factor for sustained breastfeeding up to 12 months in Tunisia. Despite high maternal motivation, systemic barriers including delayed initiation, limited skin-to-skin contact, postpartum pain, maternal obesity and smoking continue to hinder breastfeeding success.

Strengthening early postpartum hospital practices, integrating mental-health and pain-management support, and promoting culturally adapted education are key to improving outcomes. Aligning Tunisian maternity services with WHO “Ten Steps” and BFHI principles, while addressing local constraints, could significantly enhance maternal-child health and contribute to achieving global breastfeeding targets.

Ethical considerations

Ethical approval for this study was obtained from the Institutional Ethics Committee of Charles Nicolle Hospital, Tunis, Tunisia (Approval number: FWA00032748 – IORG0011243) on October 24, 2023, prior to data collection.

Consent to participate

Verbal informed consent was selected instead of written consent due to the specific context of the study population. Data were collected from postpartum women during the immediate or early postnatal period, when participants were often physically exhausted, emotionally vulnerable, and had limited time. Requesting written consent in this setting risked creating additional stress or discouraging participation, particularly among women with lower literacy levels.

This approach was reviewed and approved by the Institutional Ethics Committee of Charles Nicolle Hospital as the study involved minimal risk, collected no identifying or sensitive information, and ensured complete anonymity of responses.

All participants received clear information about the study objectives and procedures. Verbal informed consent was obtained, emphasizing the voluntary nature of participation and the right to withdraw at any time without consequence. Confidentiality was strictly maintained: no identifying information was collected, and all responses were recorded anonymously.