Decline in exclusive breastfeeding beyond early infancy, regional variations, socioeconomic influences, and growth outcomes: a population-based study from northeastern Iran

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BACKGROUND: Exclusive breastfeeding (EBF) for the first six months is a cornerstone of optimal infant nutrition and development. However, sustaining EBF beyond early infancy remains a major challenge globally, including in Iran. This study aimed to examine early feeding patterns, determinants of EBF, and associated growth outcomes among infants in northeastern Iran. METHODS: This population-based cross-sectional study analyzed data from 548,318 neonates registered in the National Electronic Health System between 2018 and 2024. EBF status was assessed at two time points: during the first week of life and at six months of age, based on caregiver-reported feeding practices recorded by health workers during routine health visits. Continuous exclusive breastfeeding since birth was defined according to WHO criteria as the infant receiving only breast milk-with no intake of formula, other types of milk, liquids, or solid foods-except for oral rehydration solutions, or drops and syrups containing vitamins, minerals, or medicines. Independent variables included maternal education, occupation, place of residence, mode of delivery, neonatal hospitalization, prematurity, and infant anthropometric indicators. RESULTS: This study included a total of 548,318 neonates over seven years. While EBF prevalence was 95.9% in the first week of life, it declined to 52.3% at six months. Rural residence, full-term birth, vaginal delivery, and maternal unemployment were positively associated with sustained EBF. Conversely, prematurity (OR 3.21; 95% CI 3.07,3.42), cesarean section (OR 2.26; 95% CI 2.21,2.33), urban residence (OR 1.83; 95% CI 1.63,2.13), history of neonatal hospitalization (OR 1.61; 95% CI 1.55,1.67), maternal employment (OR 1.52; 95% CI 1.46,1.59), and lower education (OR 1.25; 95% CI 1.23,1.31) significantly predicted non-EBF. Infants exclusively breastfed demonstrated better growth metrics up to six months, though differences narrowed by two years. CONCLUSION: Despite high initiation rates, sustained EBF sharply declines by six months, particularly among urban, employed, less-educated, and immigrant mothers, as well as in cases of cesarean delivery or neonatal hospitalization. Tailored interventions including postpartum support, breastfeeding education, and workplace accommodations are critical to improve EBF continuation. CLINICAL TRIAL NUMBER: Not applicable.

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