Knowledge, Attitudes, and Practices Regarding Exclusive Breastfeeding Among Tunisian Women: A Cross-Sectional Study

Abstract

Background: Breastfeeding is a key determinant of maternal and child health, offering optimal nutrition and immune protection. However, balancing breastfeeding with professional responsibilities remains a major challenge for active women.
Objective: To assess breastfeeding practices, difficulties, and influencing factors among employed women in Tunisia.
Methods: A cross-sectional descriptive study was conducted among 50 working mothers. Data were collected through a structured questionnaire focusing on sociodemographic characteristics, breastfeeding initiation, duration, workplace support, and perceived barriers.
Results: Most participants were aged between 35 and 44 years (44.9%). Exclusive breastfeeding for six months was practiced by only 22% of women. The main difficulties reported were lack of time (68%), absence of breastfeeding facilities at work (54%), and early return to employment (48%). Women who benefited from family and workplace support showed higher breastfeeding continuation rates.
Conclusion: Breastfeeding among working women remains insufficient despite its recognized benefits. Strengthening workplace policies, providing lactation spaces, and promoting flexible schedules are essential measures to support breastfeeding continuation in active mothers.

Keywords: Breastfeeding, Working women, Tunisia, Workplace support, Maternal health

Introduction

Breastfeeding is widely recognized for its benefits to both infant and maternal health. The World Health Organization (WHO) recommends exclusive breastfeeding during the first six months of life, followed by continued breastfeeding alongside complementary feeding up to two years or beyond (WHO, 2023) [1]. In Tunisia, despite official recommendations and awareness campaigns, breastfeeding practices remain below expected standards. The rate of exclusive breastfeeding at six months dropped to 13.4% in 2018 and reached only 17.8% in 2023, while early initiation within the first hour after birth declined from 87.4% in 2006 to 31.5% in 2018, with a slight increase to 34.3% in 2023 [2,3]. These figures highlight a gap between knowledge of breastfeeding benefits and actual practices, influenced particularly by the mother’s professional status. Stay-at-home mothers may have more time to breastfeed but often lack structured support or access to up-to-date medical information. Conversely, working mothers face logistical, professional, and social constraints that may hinder breastfeeding, despite potentially greater access to information.

Breastfeeding is not only a nutritional act but also a cultural, emotional, and social behavior shaped by family beliefs, community norms, and sometimes unfounded medical practices. Social pressures, conflicting medical advice, and the growing influence of formula milk advertising further contribute to confusion among new mothers. The role of the partner and family support, as well as workplace conditions—such as the lack of breastfeeding facilities or short maternity leave—are key factors affecting breastfeeding success. New technologies can both facilitate and complicate access to reliable breastfeeding information, offering trustworthy resources for some mothers while misleading others. In this context, the present study aims to compare breastfeeding knowledge and practices between stay-at-home and working mothers, identify the specific barriers faced by each group, analyze the impact of professional status on breastfeeding duration and quality, and propose tailored recommendations to improve breastfeeding practices according to mothers’ profiles.

Materials and Methods

This was a descriptive cross-sectional study conducted to assess women’s knowledge about breastfeeding. The study took place in the maternity ward of the Regional Hospital of Kairouan over a period of five weeks, from June 1 to June 30, 2025. The study population included all Tunisian women who agreed to participate in the survey, regardless of their sociocultural or educational background. Women who declined to complete the questionnaire were excluded from the study.

Data were collected using a structured questionnaire composed of 32 questions divided into three sections:

a. Part 1: Sociodemographic characteristics of the participants (6 questions);
b. Part 2: Knowledge about breastfeeding (7 questions);
c. Part 3: Other knowledge and perceptions related to breastfeeding (19 questions).

The questionnaire covered variables such as age, number of children, educational level, and sources of information about breastfeeding. The collected data were entered and analysed using Microsoft Excel 2007.

A literature search was conducted using the PubMed and ScienceDirect databases, with the following keywords: women’s knowledge about breastfeeding. From an ethical standpoint, participation in the study was entirely voluntary. The objectives and procedures of the study were clearly explained to each participant prior to inclusion to ensure free and informed consent. The questionnaire was anonymous, and no identifying information was requested, thus guaranteeing the confidentiality of the participants’ responses.

Results

During the study period, 50 valid questionnaires were collected. Most of the surveyed women were between 35 and 44 years old (44.9%), followed by those aged 25 to 34 years (28.6%). Participants aged 45 years and older represented 16.3%, while 10.2% were under 25 years old. Regarding educational level, more than half of the women (55%) had higher education, 39% had completed secondary education, and only 6% had a primary level, reflecting a generally good educational profile among participants. Most of the women had four to five children (60%), confirming a trend toward large families. More than half of the respondents (61.2%) were housewives, while 38.8% were employed. All women surveyed, regardless of their occupational status, reported having breastfed their children.

The family was the main source of information on breastfeeding for most of the women (27 housewives and 16 working mothers), while only a few (5 women) mentioned healthcare professionals, highlighting the still limited role of the health system in providing breastfeeding education. The majority of participants knew that breast milk meets the infant’s nutritional needs during the first six months of life, in accordance with WHO recommendations (26 housewives and 21 working mothers). However, the concept of exclusive breastfeeding remained partly misunderstood: nearly one-third of the women believed it included giving water or complementary foods. Most correctly identified six months as the recommended duration for exclusive breastfeeding, although some, especially among housewives, mistakenly cited twelve months. Most participants acknowledged the protective effects of breastfeeding against diseases and believed it could be continued even if the mother had a cold or flu. All women recognized that breastfeeding strengthens the emotional bond between mother and child, and most were aware of its role in reducing the risk of breast cancer.

Almost all women knew that breastfeeding should be done on demand and initiated within one hour after birth. They were also aware of the importance of colostrum for the newborn. However, some misconceptions persisted: the majority believed it was necessary to give water before six months, especially during hot weather, which contradicts WHO recommendations. Several women still wrongly believed that breast size affects milk production or that breastfeeding should stop when teeth appear, although most now recognized these beliefs as false. All participants knew that working does not prevent breastfeeding, but many were unaware of practical ways to manage both. Most women believed that the mother’s diet influences the taste of breast milk, while a minority did not see the connection. A concerning finding was that all respondents thought it was unnecessary to wash hands before breastfeeding, revealing a lack of awareness about hygiene practices. Knowledge about the storage of breast milk at room temperature was also limited, with most women responding “I don’t know’’.

Most participants were aware of WHO’s recommendation to breastfeed up to two years or beyond and knew that weaning should be gradual. They correctly identified the signs of effective feeding, such as regular urination and bowel movements, although a minority mistakenly cited prolonged sleep as an indicator. Regarding infant crying, most women believed it always indicated hunger, reflecting a partial understanding of infant needs. Uncertainty remained high concerning breastfeeding while taking medication, particularly among housewives, whereas working mothers demonstrated better knowledge. Most participants knew that breastfeeding is possible for diabetic mothers, although some housewives were still unaware of this.

The perception of public breastfeeding was generally negative, especially among housewives: twenty of them considered it “shameful,” compared with thirteen working women. Working women tended to be more accepting, likely due to greater social exposure. Most women had never breastfed in public, citing fear of judgment. Among those who had, several—particularly housewives—reported experiencing criticism or discomfort, emphasizing the influence of social norms and the need to promote public awareness to normalize breastfeeding practices.

Discussion

The study of women’s characteristics shows that several factors influence their knowledge and practices regarding Exclusive Breast Feeding (EBF). Maternal age plays an important role: older mothers are often better informed and more likely to practice EBF [4]. In Morocco, women over 30 were 3.38 times more likely to practice EBF than those under 25 [5]. Similar results were observed in Nigeria and Ghana, where women aged 28 to 37 demonstrated better knowledge and were up to six times more likely to practice EBF [6]. This effect is likely related to experience, educational level, and better access to healthcare. However, age alone is not sufficient: guidance, education, and social context remain determining factors. Parity also influences knowledge and practices regarding EBF, although the effect varies by context. In Kenya, a study showed no significant difference between primiparas and multiparas, with primiparas even having slightly higher knowledge scores without impacting practice [7]. In contrast, in Ethiopia (2022), multiparas had stronger knowledge, and in Indonesia, a metaanalysis showed they practiced EBF more frequently (52–70 %) (14). In Australia, multiparas were also more likely to initiate and maintain breastfeeding (≈ 90 % initiation, 60 % continuing ≥ 6 months) compared to primiparas (≈ 71 % and 45 %) [8]. These data suggest that experience promotes confidence and continuity in breastfeeding, although factors such as education, prenatal counseling, and social support remain essential.

Educational level is a key factor in knowledge and practice of EBF. Studies conducted in Brazil, Spain, and Ethiopia confirm that women with higher education are better informed about the duration and benefits of EBF, adopt more positive attitudes, and show greater intention to breastfeed [8]. In Gambia, education, partner support, and income were linked to better knowledge, although only 34.4 % of women received formal prenatal counselling [9]. In Marrakech, a survey showed that while 95.3 % of mothers had received information, more than half came from family members, and only 14 % from healthcare professionals [10]. This trend highlights the importance of strengthening the involvement of healthcare providers in delivering reliable information.

Professional status mainly influences breastfeeding practice rather than knowledge. A 2023 study in Makole, Tanzania, showed that knowledge of EBF was relatively similar between housewives (81.7 %) and working mothers (73 %), with no statistically significant difference (p = 0.071), but the actual practice of EBF was significantly higher among housewives (80.9 % vs 67.8 %, p = 0.019) [11]. Our study also shows that the predominance of housewives may influence availability and access to information, which is consistent with these results. Regarding specific knowledge, women’s understanding remains partial. Most are aware of WHO recommendations, but the exact duration of EBF or the relationship between breastfeeding and reduced breast cancer risk are often unknown. In Italy, 71 % of women knew that EBF should last at least six months, but this dropped to 48 % among primiparas, and better knowledge was associated with higher education and information received from healthcare professionals [10]. In Ethiopia, although 93.6 % of mothers had heard of EBF, only 34.7 % knew the recommended duration [8]. Concerning the reduction of breast cancer risk, in the United States, only 56 % of mothers knew that breastfeeding could decrease this risk, and only 16.6 % received this information from healthcare professionals [8]. In France, while 60 % of mothers had heard of this protective effect, only 16 % were informed by professionals [9].

The issue of breastfeeding and medications remains problematic: a global review highlighted that many mothers interrupt or avoid breastfeeding due to fear of medication effects, often without reliable information. In Saudi Arabia, 50 % of mothers had received no correct information from their doctor [10], and in Jordan, only 50 % of healthcare professionals knew the WHO/AAP recommendations on medication compatibility with breastfeeding [11]. Knowledge about breast milk storage is also insufficient. In Pune, India, only 48.5 % of women had good knowledge of milk storage conditions [10]. In Turkey, although 87.9 % claimed to know the storage procedures, the quality of information varied according to educational level [11]. Regarding feeding frequency, a 2008 study in Monastir, Tunisia, showed that 73 % of mothers practicing EBF breastfed on demand, without adhering to a predefined number of feeds per day [10,11]. Finally, among diabetic mothers, only 32 % knew that breastfeeding could help stabilize postpartum blood glucose and reduce the risk of type 2 diabetes in the child [7,12,13].

These findings highlight the need to strengthen prenatal and postnatal education, train healthcare professionals, develop appropriate educational materials, implement awareness campaigns, and adapt workplace environments to enable employed mothers to continue EBF. The involvement of partners and family members is also essential. From a research perspective, it would be relevant to explore perceptions and barriers to breastfeeding through qualitative studies and to assess the impact of educational interventions on women’s knowledge and practices. These measures aim to foster a culture favorable to breastfeeding based on a comprehensive, participatory, and continuous approach [14- 19].

Conclusion

Globally, breastfeeding is recognized as essential for both child and maternal health, yet its adoption remains uneven across sociocultural and economic contexts. In Tunisia, despite WHO recommendations advocating exclusive breastfeeding for the first six months, adherence remains low, particularly among working women. A descriptive, cross-sectional, and analytical study conducted in 2025 among women of childbearing age evaluated their knowledge, attitudes, and practices regarding breastfeeding. The results revealed often incomplete knowledge regarding the recommended duration of exclusive breastfeeding, its benefits for the mother (notably the reduction of breast cancer risk), and best practices for milk expression and storage. Homemakers appeared better informed and more available to implement these practices, unlike working women who face professional constraints. Additional barriers included lack of awareness, conflicting information from family or some healthcare providers, and social pressure favoring the use of formula. These findings highlight the need for a comprehensive approach combining enhanced prenatal education, continuous training of healthcare professionals, workplace accommodations, and effective dissemination of information on breastfeeding benefits and practices, to promote sustainable and beneficial practices for the mother-child dyad.

Acknowledgments

None.

Conflicting Interest

None.

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