This retrospective, analytic and cross-sectional study was approved by the Harran University Clinical Research Ethics Committee (26.08.2024 date, HRU 24.12.12). All data collected in this study were kept strictly confidential and used solely for research purposes. Participants’ identities were anonymized and were not disclosed at any stage of the research. The study was conducted in accordance with the principles of the Declaration of Helsinki and relevant national ethical guidelines.

The study was conducted in the BSC, affiliated with the Department of Family Medicine at Harran University Hospital. Since 2018, this center has been providing structured breastfeeding education and support services to mothers. The breastfeeding profile of mothers in a high TFR region as well as the effect of CS/Ds, educational level and seasonal work status on breastfeeding outcomes, are focused.

Study data were obtained from data collection forms (YDR.33) used for routine follow-up and training purposes which contains questions about the mothers’ obstetrical, breastfeeding, and contraceptive use status. It is not as a standardized or psychometrically validated scale and no scores could be assigned to the answers of the participants (see Supplementary Material S1).

The study population included mothers who received breastfeeding support services at the accredited BSC between 2020 and 2024 in Şanlıurfa. A total of 6,264 applications were initially recorded. Although the sample size had been calculated a priori to ensure efficiency, it was decided to evaluate the entire dataset of mothers who met the inclusion criteria so as to maximize statistical power and generalizability.

Inclusion criteria were as follows:

Mothers over 18 years old without certain medical conditions that affect breastfeeding ability;

A priori power analysis was conducted using G*Power 3.1 software. The following parameters were used:

Since data from all mothers who met the inclusion criteria were analysed, the final sample size was n = 2,714, which far exceeds the minimum required size and thus provides adequate power for all planned analyses.

Statistical analyses were performed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). The distribution of quantitative variables was assessed through evaluations of skewness and kurtosis coefficients, as well as the Kolmogorov–Smirnov test. Variables demonstrating acceptable conformity with the normal distribution were reported as mean ± standard deviation. For group comparisons involving normally distributed continuous variables, independent samples t-tests or One-Way ANOVA were used as appropriate. However, when the normality assumption was not met or when sample sizes were insufficient for parametric testing, non-parametric alternatives were employed. Specifically, the Mann–Whitney U test was used to compare two independent groups, as it does not assume normal distribution and is more suitable for ordinal or non-normally distributed data. For comparisons across three or more groups, the Kruskal–Wallis test was applied in similar non-parametric cases.

Categorical variables were presented as frequencies (n) and percentages (%). To examine associations between categorical variables, chi-square tests were primarily used. However, when expected counts in one or more cells of the contingency tables fell below 5—violating chi-square test assumptions—the Monte Carlo simulation method was applied to obtain more reliable p-values. This simulation was conducted with 10,000 iterations at the 95% confidence level. Effect sizes for significant associations were reported using eta squared (η²) where applicable.

The distribution of missing data was examined and ranged from 0.4% to 4.1%. To determine whether the missingness was random, Separate Variance t-tests, Little's MCAR test, and tabulated missing data patterns were analyzed. Based on these analyses, the data were deemed missing completely at random (MCAR). As a result, missing values were imputed using the mean for normally distributed variables and the median for non-normally distributed variables, ensuring the integrity of the dataset for subsequent analysis. A significance level of p < 0.05 was considered statistically significant for all tests.

Contraceptive use was found to be significantly associated with variables such as occupation (χ² = 36.462, p < 0.001) education level (χ² = 217.996, p < 0.001), duration of breastfeeding for the first child (χ² = 344.564, p < 0.001), and the most recent mode of delivery (p = 0.003). In particular, women who exclusively breastfed for only the first 6 months were observed to have higher rates of contraceptive use. However, no significant association was found between the timing of breastfeeding initiation and postpartum contraceptive use (p = 0.840) (Table 1). These findings suggest that contraceptive use is influenced by personal, sociocultural and breastfeeding-related factors.

Comparative analysis of contraceptive use and breastfeeding durations in Table 2 show contraceptive users were slightly older on average (32.6 vs. 31.2 years; p < 0.001, Cohen's d = 0.26), and had fewer miscarriages, vaginal deliveries, and cesarean sections, although these differences had small effect sizes (Cohen's d = 0.14–0.29). In contrast, breastfeeding durations showed much stronger associations. Women who used contraception had notably longer breastfeeding durations for their first child (16.7 vs. 11.2 months; p < 0.001, Cohen's d = 0.74), and higher average breastfeeding duration for all living children (18.8 vs. 13.1 months; p < 0.001, Cohen's d = 0.90). Results displayed in Table 2 suggest that while demographic and obstetric variables had a limited association, breastfeeding practices were more strongly linked to postpartum contraceptive use.

There was a statistically significant association between maternal education level and EBF duration (χ² = 61.884, 99% CI: <0.001 to <0.001, p < 0.001). Mothers with EBF duration of less than 6 months were more frequently illiterate (47.7%) or had only primary education (42.8%) (Table 3). This finding suggests that higher maternal education is positively correlated with prolonged EBF, possibly reflecting increased awareness of breastfeeding benefits and better access to health information among more educated mothers.

The analysis revealed a significant association between contraceptive method use and EBF duration. Mothers who exclusively breastfed for less than 6 months predominantly reported not using any contraceptive method (87.2%), whereas nearly half (49.8%) of those who exclusively breastfed for 6 months used no contraception. Notably, 43.9% of the latter group preferred LAM. Usage rates of other contraceptive methods, including condoms, pills, and intrauterine devices, were minimal across both groups (Table 3).

Although the chi-square test could not be calculated (Monte Carlo p-value unavailable), the marked differences in contraceptive choices suggest a strong relationship with breastfeeding duration. The pattern indicates that extended EBF is associated with a higher preference for natural contraception methods such as LAM, potentially due to concerns over hormonal or device-related interventions during the breastfeeding period.

A statistically significant association was observed between seasonal agricultural work and EBF duration (p < 0.001). Mothers engaged in seasonal agricultural labor were considerably less likely to exclusively breastfeed for the recommended 6 months. The Monte Carlo simulation of the chi-square test confirmed this association, although confidence intervals could not be calculated due to sparse data (Table 3). The distribution of EBF by seasonal work can be seen in Figure 2. These findings suggest that participation in seasonal agricultural work may negatively impact the likelihood of maintaining EBF for the recommended 6-month period.

In the total sample of 2,714 mothers, 434 (15.99%) breastfed their first child for up to 24 months, and 33 (1.21%) for 25 months or longer (Figure 3).

First-time mothers may have more time, motivation, or social pressure to follow recommended breastfeeding practices, potentially explaining the relatively higher percentages of breastfeeding for 24 months or longer. They may receive more focused attention from healthcare providers or family members, which could support longer breastfeeding durations.

Both mean breastfeeding duration of the first child and the overall mean breastfeeding duration were higher among mothers who used contraceptive methods (Figure 4).

The timing of breastfeeding initiation differed markedly by mode of delivery. Among those who delivered via CS/D (n = 2,631), 1,733 (65.9%) initiated breastfeeding after the first hour postpartum, while only 898 (34.1%) did so within the first hour. In contrast, nearly all mothers who had a vaginal delivery (n = 83) initiated breastfeeding within the first hour (n = 82; 98.8%), These findings suggest that cesarean delivery is associated with delayed initiation of breastfeeding, highlighting the need for targeted support and interventions to promote early breastfeeding among cesarean-delivered mothers (Figure 5).

Maternal age was included as a key variable in our study because of its well-documented influence on breastfeeding practices, including initiation, duration, and exclusivity, through intertwined biological, psychological, and social mechanisms. Literature suggests that older mothers tend to breastfeed for longer durations, but much of this association is mediated by parity and educational attainment rather than age alone (33–35). In our findings, younger mothers used significantly lower levels of contraception and had more miscarriages compared to older mothers. In a setting such as Şanlıurfa, where modern contraceptive use and access to FPCs remain limited, this pattern has broader implications: older mothers are more likely to space births and avoid some obstetric complications, which promotes maternal recovery and allows for more sustained breastfeeding. Some studies reflect similar findings (33), while others show differing trends (34), often depending on the region's sociocultural norms. For example, in the United States, a study showed that the positive association between increased maternal age and longer breastfeeding duration was largely mediated by higher parity and education rather than age itself (35).

Maternal education has been consistently implicated in global literature as a key determinant of breastfeeding initiation and duration. For instance, Tang et al. in China demonstrated that higher education increases the likelihood of early breastfeeding initiation, yet paradoxically is associated with lower EBF rates for the first six months, particularly among more educated working mothers (36). Similarly, a systematic review and meta-analysis reported that while education supports early initiation, its positive effects may be mitigated once factors like employment, socioeconomic status, and cultural norms intervene (37).

In this study, we found concordant trends: very low maternal education was strongly correlated shorter EBF duration. However, our setting exhibits a unique clustering of risk factors—high cesarean and miscarriage rates, low contraceptive use, seasonal work—that amplify the negative impact of low education more visibly than in many studies from United Arab Emirates and (UAE) China (32, 36). These observations suggest that in contexts with compounded obstetric and socioeconomic vulnerabilities, education alone may be necessary but not sufficient; it must be integrated with broader health, reproductive, and social interventions to substantially improve EBF outcomes. It is concluded that well-educated women can access information resources and services more easily. Moreover, they can be more advantageous in learning and developing attitudes, more motivated to use contraceptive methods by being aware of the harms of multiple births at frequent intervals on the health of the mother and baby. As a matter of fact, in line with the literature (36, 38), this study revealed that there is a strong relationship between high education level and contraceptive use, and this situation was interpreted with the advantages of being well-educated, as emphasized above. However, this may have a negative impact on the continuation of breastfeeding for ideal periods, because the early return of women with a high level of education to active working life constitutes a significant obstacle to the continuation of breastfeeding. This underscores the complex interplay between education, contraception, and breastfeeding behaviors.

In presented study, high rates of cesarean deliveries were observed, which was associated with delayed initiation of breastfeeding or reduced continuation. This aligns with findings from O'Connell et al.'s meta-analysis in the UAE and Perrella et al.'s in Australia (7, 39) where cesarean delivery was identified as a negative factor for both early initiation and maintenance of EBF. In the cross-sectional study by Al Sabbah et al. in Dubai, mixed feeding was significantly more common among mothers who had cesarean births, indicating that cesarean delivery adversely affects EBF (32).

In our study, the unusually high cesarean rate can be attributed to several interrelated factors. Firstly, many pregnancies in Şanlıurfa are classified as high-risk, often due to complications or prenatal conditions, which increases the need for cesarean delivery to ensure maternal and fetal safety. Secondly, our study center (BSC) is affiliated with a tertiary care hospital, resulting in a referral bias: more complicated and higher risk cases are sent to this institution, including patients with prior cesareans or obstetric complications, which naturally elevates the proportion of cesarean births. Thirdly, medical indications such as fetal distress, cephalopelvic disproportion, placenta previa, or other obstetric pathologies frequently drive the decision toward cesarean delivery, especially when vaginal delivery is deemed risky. Taken together, these conditions reflect both the pregnancy profile of the population served and the healthcare referral structure in the region; thus, the high rate does not necessarily reflect overuse but rather the concentration of high-risk cases and medical necessity in a tertiary hospital setting. This effect is amplified by very low maternal education and other reproductive health and socioeconomic barriers, making the impact on breastfeeding outcomes more pronounced in our context.

CS/D showed a significant relationship with contraceptive use. We observe the same interventions and agree with the comment that women undergoing cesarean sections—who often have closer surgical follow-up and counseling—receive more structured postpartum contraceptive guidance (33). Encouragingly in line with literature (40), many cesarean mothers in our study eventually established breastfeeding, indicating that dedicated lactation support and early skin-to-skin contact even in surgical settings can mitigate this delay These findings support the need for cesarean section-specific breastfeeding protocols in hospitals to bridge the gap between mode of delivery and initiation of feeding (41). A similar trend was identified in a study from Uganda, where cesarean delivery was independently associated with a significant increase in immediate postpartum contraceptive uptake (42). These findings may be explained by the more intensive clinical engagement that typically accompanies cesarean births—longer hospital stays, increased surgical follow-up, and routine postpartum counseling—creating a strategic window for contraceptive counseling and method provision. Importantly, these contexts allow health providers to address the need for adequate birth spacing and postoperative recovery, framing FP as a critical component of maternal care.

The findings of this study, supported by the literature (43), revealed a clear, intrinsic link between contraception counseling and breastfeeding support. A key implication is the need to expand the number of BSCs and to integrate FPCs into these centers. Barriers to postpartum FP—such as misconceptions about contraceptive safety during lactation—can be more effectively addressed in centers that already provide breastfeeding support and peer counseling. Doing so would strengthen postpartum care, promote healthy birth spacing, and improve both maternal and infant health outcomes.

According to the literature first-time mothers, widely due to lack previous exposure to breastfeeding, may feel uncertain or anxious about their ability to nurse effectively (44). Low breastfeeding self-efficacy has been consistently linked with early cessation of breastfeeding. Nipple pain or trauma, delayed onset of lactation can lead them to early supplementation with formula.

In this study, the duration of breastfeeding of mothers’ first babies was found to be below ideal levels and one of the reasons can be not having adequate information about breastfeeding. Supportingly Choedon et al.'s study revealed that primiparous mothers had generally insufficient knowledge about EBF (45). According to the findings of this study, approximately one in five mothers with their first breastfeeding experience continue to breastfeed their child for up to 24 months, which is particularly promising. Possible explanations for this outcome include that mothers in their first breastfeeding experience may possess stronger motivation, have more time available, and receive more focused support from healthcare providers or family members, all of which can contribute to longer breastfeeding durations.

In this study, contraceptive use, and preference for modern methods among mothers were found to be very low. Similar findings have been reported in literature; reasons often cited include fear of side effects, lack of information, the return of menstruation being used as a marker for when to adopt contraception, weak partner support, and limited access to preferred modern methods (46). The main reason behind their lack of protection in study area may be the belief that mothers with many children will have more power (47). However, the fact that multiple births at frequent intervals pose a major threat to the health of the mother and the baby should not be overlooked, and these points should be emphasized when providing counseling.

A key positive finding of this study is the strong association between postpartum contraceptive use, particularly the LAM, and improved breastfeeding outcomes. LAM not only facilitates birth spacing but also reinforces the practice of EBF through behavioral conditioning (48). Lactation is regulated hormonally by prolactin—essential for milk production in response to postpartum hormonal shifts and infant suckling—and oxytocin—which triggers milk ejection and supports emotional bonding and maternal relaxation. Recent evidence shows that efficient oxytocin release, especially pulsatile runs in early postpartum, correlates with higher milk output and longer breastfeeding duration, while maternal stress dampens this response (49). However, mothers should be made aware that starting supplementary foods reduces the effectiveness of this method. Increasing the awareness of mothers and mother candidates about not only the contraceptive aspect of breastfeeding but also all its unique benefits on mother and baby health can contribute positively to improving breastfeeding rates (50). LAM is reported to be, when correctly practiced, reliable and is often preferred due to its natural, hormone and intervention free approach (51). Our data supports global research indicating that women who use LAM tend to breastfeed more likely to achieve six months of EBF (52).

It is reported that effective breastfeeding as a contraceptive method can provide protection up to 98% compared to many traditional methods if amenorrhea and EBF are present in the first 6 weeks after birth (53). Thus, in settings like Egypt, a previous study has shown an inverse relationship between EBF and modern contraceptive uptake, suggesting that prolonged breastfeeding may delay the adoption of hormonal or barrier methods (54). Postpartum women should be provided with accurate information about LAM, along with guidance on when and how to transition to other effective contraceptive options beyond the LAM window. Findings of presented study underscore the necessity of integrating FP and breastfeeding counseling into a unified, proactive, and continuous service model. This integration should be systematically implemented within a single center, ensuring that postpartum women receive consistent and periodic guidance on both LAM and subsequent contraceptive options. Such an approach would enhance the continuity of care, address the evolving contraceptive needs of mothers, and support informed decision-making throughout the postpartum period.

In the Şanlıurfa region, our data highlight the impact of economic hardship and inequalities in formal employment on inadequate breastfeeding outcomes. The findings of this study revealed a significant association between maternal involvement in seasonal agricultural work and shorter durations of EBF. A recent systematic review by Gupta also clearly reported the negative effects of agricultural work such on nutrition outcomes (55).

In line with literature (56) our findings also revealed that women doing seasonal agricultural work are inadequate in terms of contraception and use of modern methods, and this situation negatively affects ideal breastfeeding. Women were reported to return to physically demanding work shortly after childbirth, with limited workplace flexibility, no maternity leave, and poor lactation accommodations It is inevitable that seasonal agricultural work will negatively affect effective contraception and ideal breastfeeding under all adverse conditions such as exposure to physical and mental factors (57) In this period when access to health institutions will be difficult, providing breastfeeding support and FPCs with structured mobile health services may be a solution.

A recent Systematic Review and Meta-Analysis (2025) of 34 randomized and experimental studies (n = 4,698) to assess antenatal interventions aimed at improving breastfeeding self-efficacy by Koruk et al. found that model-based education combined with counseling yielded the greatest effect size, outperforming standard education alone and simulation or counseling without prior education (58).

Wong et al. suggest multicomponent, theory-based intervention with ≥3 sessions delivered via both face-to-face teaching and telephone follow-ups across antenatal and postnatal period can be effective to enhance EBF over 6-month, partial breastfeeding and breastfeeding self-efficacy over 2-month postpartum (59). Breastfeeding counseling given by a lactation consultant for up to 10 weeks has been shown to provide significantly successful results for EBF, breastfeeding maintenance, and effective breastfeeding compared to the control group (21). Support given via WhatsApp messaging application is shown to significant positive effect on breastfeeding durations (60). Chipojola et al. (2022) show that breastfeeding promotion programs are effective in increasing EBF rates in the early postpartum period (<1 month), but that for breastfeeding to be sustained through months 1–5, multifaceted interventions with continuity are required (61). Pezley at al. and Gavine at al. supported the field by offered interventions (62, 20).

Studies have shown that structured breastfeeding support services have significant positive contributions to breastfeeding rates (63–67). However, if improvements cannot be made in women's reproductive problems and the accompanying domestic, physical and psychological problems, reaching the desired target in breastfeeding rates does not seem easy at all. The most reasonable solution seems to be to plan interventions suitable for the regional structure and implement them decisively.

While this study offers important insights into breastfeeding barriers in Şanlıurfa, several limitations should be acknowledged:

Retrospective Design: The study relies on medical and institutional records collected in the past. Such data sources may have missed, incomplete, or inconsistently recorded elements.

Based on these findings, the following implications and recommendations are proposed for policy makers and health program planners in Şanlıurfa to reduce breastfeeding barriers and improve EBF rates:

Enhance Prenatal Education and Health Literacy