Evaluation of women’s knowledge, attitudes, and practices regarding continued breastfeeding of children aged 6–24 months in the Bertoua Health District, Cameroon

Abstract

Context:

Breastfeeding is essential for the health and survival of infants, with WHO and UNICEF recommendations for exclusive breastfeeding for the first 6 months, followed by complementary feeding for up to 2 years. However, breastfeeding rates remain a cause for concern, particularly in Cameroon, where various socio-economic and cultural factors influence mothers’ behavior.

Methodology:

A cross-sectional, quantitative, and analytical study was conducted in the Bertoua Health District between April and June 2024. A non-probabilistic convenience sampling method was used to recruit 405 consenting participants out of 532 approached (participation rate: 70.68%). Data were collected using a structured questionnaire, designed by the Cameroon Pediatric Association, which assessed target mothers’ knowledge, attitudes, and practices regarding continued breastfeeding. Descriptive statistics and multivariate logistic regression analyses were performed, using a significance level of p < 0.05.

Results:

The results revealed that 70.21% of women demonstrated poor knowledge of breastfeeding, 60% held negative attitudes, and 50.62% engaged in poor breastfeeding practices. Notably, being single or in a common-law relationship, as well as holding a negative attitude, significantly increased the likelihood of poor knowledge. Furthermore, both unfavorable attitudes and poor practices were more prevalent among women who reported having no religion or identified as Christian. Thus, two key sociodemographic predictors consistently associated with suboptimal outcomes were marital status and religious affiliation. Specifically, single mothers and those without a religious affiliation or those identifying as Christian were more likely to exhibit unfavorable attitudes and lower levels of knowledge regarding continued breastfeeding.

Conclusion:

This study highlights the need for targeted interventions to improve mothers’ knowledge and attitudes toward breastfeeding. Educational programs adapted to socio-economic realities are essential to promote favorable breastfeeding practices and improve infant health in Bertoua.

Introduction

Breastfeeding is recognized as one of the most effective means of ensuring the health and survival of infants. WHO and UNICEF recommend exclusive breastfeeding for the first 6 months of life, followed by appropriate complementary feeding, with continued breastfeeding up to 2 years of age or beyond. ¹ Breast milk promotes sensory and cognitive development and protects infants against infectious and chronic diseases. ² Exclusive breastfeeding for the first 6 months, coupled with appropriate complementary feeding for up to 2 years, significantly reduces infant mortality due to common illnesses ³ such as diarrhea and pneumonia, while promoting faster recovery from illness. ⁴ In addition to its nutritional and immune benefits for the child, breastfeeding also contributes to women’s health ⁵ It reduces the risk of post-partum hemorrhage, ⁶ postnatal depression, and obesity, ⁷ as well as the risk of breast and ovarian cancer, and promotes natural birth spacing. ⁸

Breastfeeding is a fundamental pillar of child health worldwide, but practice rates remain worryingly low, especially in certain regions. According to UNICEF, only 41% of infants under the age of 6 months are exclusively breastfed worldwide, with marked disparities between regions. ⁹ In Africa, the situation is even more alarming, with exclusive breastfeeding rates often as low as 37%, due to a variety of socio-economic and cultural factors. ¹⁰ In Cameroon, according to the Demographic and Health Survey, the rate of exclusive breastfeeding among children under 6 months is 39.7%, while the rate of prolonged breastfeeding up to 2 years is 23.2%, with a median duration of 16 months ¹¹

Despite these recommendations and the proven benefits of breastfeeding for up to 2 years, breastfeeding rates remain low in many parts of the world, particularly in sub-Saharan Africa, due to various factors influencing mothers’ knowledge, attitudes, and practices. ⁵ Worldwide, many children are not breastfed as recommended, with serious consequences for child health. ¹² 60% of deaths in children under five are linked to inappropriate feeding practices, more than two-thirds of which occur during the first year of life. ¹³ A non-breastfed infant is 14 times more likely to die (from all causes) than a breastfed infant. ¹²

The SMART 2019 survey indicates that in the East Cameroon region, which is the site of our study, the prevalence of exclusive breastfeeding is 44.8%, while the rate of extended breastfeeding up to the age of two is 30.8%. The median duration of breastfeeding in this region is 13.9 months. However, these figures reveal a major concern, as the region has the lowest rate of continued breastfeeding up to 2 years of age, underlining the need for targeted interventions to improve these practices. ¹⁴ The Bertoua Health District was selected as the study site due to its distinct sociodemographic and public health profile. Located in Cameroon’s East region, Bertoua combines semi-urban and semi-rural settings and hosts a heterogeneous population shaped by high internal and cross-border migration (from Chad, the Central African Republic, Nigeria, and Congo-Brazzaville). ¹⁵ According to the 2019 SMART survey, the East region, where Bertoua is situated, has the lowest prevalence of continued breastfeeding up to 24 months in the country (30.8%), along with a median duration of only 13.9 months. ¹⁴ Additionally, women in this region are less likely to be formally educated and face barriers to accessing health care, particularly postnatal services. ¹⁵ These characteristics make Bertoua a strategically relevant and representative district for exploring the sociocultural determinants of breastfeeding behaviors in Cameroon.

In this context, this study aims to assess women’s levels of knowledge, attitudes, and practices regarding continued breastfeeding of children aged 6–24 months in the Bertoua Health District. By identifying the factors influencing these practices, the study will seek to formulate concrete recommendations for improving child health in this region, thus responding to an urgent need for breastfeeding awareness and education.

Material and method

Setting and study period

This study took place in the Bertoua health district, with a 3-month data collection period from April to June 20224. The Bertoua health district, located in the East Cameroon region, more precisely in the Lom et Djerem department, comprises 16 health areas, four of which were selected for the present study: ENIA, MOKOLO 1, NKOLBIKON, AND MANDJOU. It is a semi-urban/semi-rural district with public, semi-public, and private health structures. It covers an area of 100 km², with an estimated population of 3,824,477 in 2024, at a density of 3,825 inhabitants/km². ¹⁵

Population growth is linked to significant migration from other administrative units in the East, other regions of Cameroon, and neighboring countries (Chad, CAR, Congo-Brazzaville, Nigeria). However, girls are far less likely than boys to attend school. ¹⁵ This site was chosen for the following reasons: in the Bertoua health district, women have less schooling than men, which can directly influence access to information on good breastfeeding and infant nutrition practices; access to hospital facilities is not always obvious due to low-income levels, which can affect postnatal follow-up and advice on breastfeeding; moreover, this is an area with a high population density (382,477 inhabitants), ¹⁵ offering a representative sample for the study and a diversity of family situations.

Study design and population

The study was a quantitative, analytical cross-sectional study with non-probabilistic The study was a quantitative, analytical cross-sectional study with non-probabilistic convenience sampling of mother-child pairs or dyads aged 6–24 months residing in 04 health areas of the Bertoua Health District.

For this study, eligible participants were mother-child dyads with children aged 6–24 months, residing in one of the four selected health areas of the Bertoua Health District (Enia, Mokolo 1, Nkolbikon, and Mandjou), of Cameroonian nationality, and who provided written informed consent. Dyads living outside the selected areas or whose questionnaires were incomplete were excluded from the study.

Sample size and procedure

The minimum sample size was set at 368 dyads, using Rea’s formula ¹⁶ based on knowledge of the child population in each selected health area and expressed as follows.

Hence n = 368 dyads

$$n=\frac{tp^2\times p(1-p)\times N}{\times p(1-p)+(N-1)\times Y^2}tp^2$$

With n: sample size; N: size of the actual or estimated target population; P: expected proportion of a population response or actual proportion set at 0.5; tp: sampling confidence interval, with a confidence interval (CI) of 95%, we’ll have 1.96; y: margin of sampling error, which is 5%.

Applying the non-response rate set at 10%, we have: n = 368+ 36.8 = 404.8 ≈ 405 dyads.

A non-probability convenience sampling method was used to recruit participants. Mothers with children aged 6–24 months were mainly selected from vaccination units in selected health facilities, taking into account pre-established inclusion criteria, such as residence status in one of the selected health zones (Enia, Mokolo 1, Nkolbikon, and Mandjou) and Cameroonian nationality. Before data collection, each participant was informed of the study objectives and procedures. Written informed consent was obtained to ensure that participants understood the voluntary nature of their participation and the confidentiality of their responses. The interviews were conducted in private spaces to ensure a conducive environment for discussion, and participants were selected based on their availability and willingness to participate, thereby maximizing the response rate.

Data collection technique and tools

Data collection was based on a survey of mother-child pairs, using a structured questionnaire. Each part of the questionnaire included targeted questions to obtain precise and relevant information. The questionnaire included sections on participants’ socio-demographic characteristics, as well as questions on women’s knowledge, attitudes, and practices regarding continued breastfeeding. A pre-test of the questionnaire was carried out on 10 mother-child pairs meeting the selection criteria for this study, in order to assess the clarity of the questions and the effectiveness of the collection method. This made it possible to adjust the questionnaire prior to its deployment in the four selected health areas within the Bertoua health district, thus optimizing the reliability of the data collected. Each interview lasted approximately 15–20 min, depending on the respondent’s understanding and engagement.

Definition and operationalization of variables

In this study, the main dependent variables, knowledge, attitudes, and practices concerning continued breastfeeding were treated as categorical variables, each classified as good or poor. Knowledge was assessed using 8 closed questions (score from 0 to 8), with scores of 0–4 indicating poor knowledge and 5–8 good knowledge. Attitudes and practices were assessed using 6 questions (score 0–6); scores of 0–3 reflected negative attitudes or poor practices, while scores of 4–6 were considered positive or good, respectively.

The questionnaire was developed on the basis of an exhaustive literature review and validated by a multidisciplinary group of experts, including pediatricians, nutritionists, and public health professionals, to ensure content validity. Face validity was confirmed by a pilot test with 10 eligible mother-child dyads in the neighboring health district to assess the clarity and relevance of the questions. Internal consistency reliability was assessed using Cronbach’s alpha coefficient, which gave satisfactory coefficients: 0.78 for the knowledge section, 0.82 for attitudes, and 0.75 for practices, demonstrating acceptable internal consistency for all concepts. Sample questions included: for knowledge, “At what age should complementary foods be introduced?” and “Does breast milk alone meet the nutritional needs of an infant until six months?”; for attitudes, “Do you think it is appropriate to continue breastfeeding until the child is two years old?” and “Would you recommend continued breastfeeding to another mother?”; for practices, “Did you exclusively breastfeed your child for the first six months?” and “Do you breastfeed on demand?.”

Data collection procedure

After obtaining administrative authorization from the Délégation régionale de la santé publique de l’Est, we sought the agreement of the chief medical officer of the Bertoua health district. Once in the field, we introduced ourselves to the local managers of the health facilities, explaining the objectives of the study and presenting the official authorizations. Participants were recruited mainly in vaccination departments where mother-child dyads were identified according to our inclusion criteria.

Data were collected through face-to-face, semi-structured interviews conducted by trained field workers in private spaces to ensure confidentiality. Each questionnaire was reviewed on the spot for completeness, and daily debriefing sessions were held to ensure data quality. This methodological approach enabled us to gather precise and exhaustive information on mothers’ knowledge, attitudes, and practices concerning the continuation of breastfeeding. Before closing each interview, the questionnaire was systematically checked to identify and complete any missing data. A daily debriefing was held to assess the quality of the data collected and to discuss any difficulties encountered during the survey day.

Data processing and analysis

Data collected using the Kobo Collect software were imported into RStudio (version 4.2.4) for analysis. Microsoft Word and Excel 2013 were also used to generate figures and tables. The analysis of this study was based on dependent variables, namely level of knowledge, level of attitude, and level of practice, as well as on several independent variables, mainly sociodemographic characteristics. Descriptive statistics were calculated for all the variables studied. Odds ratios (OR) and 95% confidence intervals were estimated to assess the association between dependent and independent variables. Analyses were performed with a significance level alpha (α) = 0.05, and only those variables whose OR was associated with a p-value of less than 0.05 were considered to be significantly related to women’s level of knowledge, attitude, and practice regarding continued breastfeeding in the Bertoua Health District.

The reporting of this study conforms to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines (von Elm et al., 2007), and the completed checklist is provided as a Supplemental File. ¹⁷

Results

In the present study, we collected data over a 2-month period from April 04 to June 06, 2024, during which 532 participants were recruited. Of the 532 people targeted, 405 agreed to participate in the study, that is, a 70.68% participation rate.

Description of respondent characteristics

Table 1 below shows the distribution of respondents by age, gender, mother’s age, mother’s level of education, mother’s religion, mother’s profession, and health area of residence. The table shows that the average age of the mothers’ participants is 28.7 ± 4.27 years, and the most represented age group was between 12 and 24 months (60.49%). Girls outnumbered boys (54.32% vs 45.68%). Most respondents were representative of the 25–34 age bracket (57.04%), had a high school education (38.58%), and were of the Christian faith (73.33%). In addition, the majority of participants lived in the Enia health area (30.86%), had married mothers (57.28%), and were housewives (46.91%).

Table 1.

Distribution of participants by socio-demographic characteristics.

Variables	Absolute value	Relative frequency (%)
Age group (years) of children
6–11 months	160	39.51
12–24 months	245	60.49
Child’s gender
Female	220	54.32
Male	185	45.68
Age group (years) of mothers
18–24	114	28.15
25–34	231	57.04
35 and over	60	14.81
Education level
Didn’t go to	55	13.58
Primary	81	20.00
Secondary	156	38.52
Higher/university	113	27.90
Religion
No	15	3.70
Christian	297	73.33
Muslim woman	93	22.96
Profession
Students	54	13.33
Housekeeper	190	46.91
Private sector worker	123	30.37
Public sector worker	38	9.38
Marital status
Single	141	34.81
Concubinage	20	4.94
Marriage	232	57.28
Common-law union	11	2.72
Widow	1	0.25
Health area
Bonis	32	7.90
Enia	125	30.86
Kano	40	9.88
Mandjou	64	15.80
Mokolo 1	80	19.75
Nkolbikon	64	15.80

Assessment of women’s knowledge of continued breastfeeding

Table 2 shows the distribution of respondents’ knowledge of breastfeeding according to participant characteristics. It shows that 86.91% of children aged 6 months are exclusively breastfed. The majority of mothers (39.75%) felt that breastfeeding could be extended to 24 months or more, and 90.12% recognized that complementary foods could be introduced from 6 months. As for the benefits of breastfeeding, 98.77% of respondents said it was beneficial for children, while 66.42% said it was equally beneficial for mothers. However, 63.21% of mothers agree that breast milk alone does not meet a baby’s nutritional needs after 6 months. Furthermore, 54.57% consider that breastfeeding promotes the emotional bond between mother and child, while 62.22% say they have no knowledge of how to manage breastfeeding-related pain.

Table 2.

Women’s knowledge of continued breastfeeding.

Variables	Absolute value	Relative frequency (%)
Age of exclusive breastfeeding
<6 months	19	4.69
6 months	352	86.91
1 months	5	1.23
I don’t know	26	7.17
Age of continued breastfeeding
6 months	2	0.49
12 months	114	28.15
24 months and over	161	39.75
I don’t know	128	31.6
Age of food introduction
6 months	365	90.12
Less than 6 months	17	4.20
Over 6 months	19	4.69
I don’t know	4	0.98
The benefits of breastfeeding for the mother
No	136	33.58
Yes	269	66.42
Well done with breastfeeding for children
No	5	1.23
Yes	400	98.77
Breast milk covers all your child’s needs from the age of 6 months.
No	256	63.21
Yes	149	36.79
Breastfeeding establishes an emotional bond between mother and child
No	184	45.43
Yes	221	54.57
Information on how to manage breastfeeding pain
No	252	62.22
Yes	153	37.78

Distribution of participants according to mothers’ level of knowledge about continuing breastfeeding

Figure 1 illustrates the distribution of participants according to their level of knowledge about continuous breastfeeding. The data reveal that, although a majority of mothers (70.12%) demonstrated good knowledge, almost a third (29.88%) had poor knowledge.

Figure 1.

Mothers’ level of knowledge about continuing breastfeeding.

Socio-demographic factors associated with mothers’ knowledge of breastfeeding continuation

The results of the bivariate analysis of socio-demographic factors, associated with mothers’ level of knowledge about continuing breastfeeding, show that belonging to the Christian religion (OR = 3.58 (95% CI: 1.93–7.19); p-value = 0.000123], single status (OR = 3.17 (95% CI: 2.00–5.06); p-value = 0.001), and unfavorable attitude (OR = 2.48 (95% CI: 1.56–4.02); p-value = 0.001) were factors significantly associated with a lower level of knowledge about breastfeeding.

Multivariate analysis of factors associated with the level of knowledge about continued breastfeeding

Table 3 presents the results of multivariate analyses performed on significant variables in order to control for confounding factors and identify independent predictors of the level of knowledge about continuing breastfeeding. The results indicate that single status (AOR = 2.47 (95% CI: 1.51–4.07); p-value = 0.001) and unfavorable attitude (AOR = 1.93 (95% CI: 1.17–3.23); p-value = 0.010) were the factors significantly associated with a reduced level of knowledge about breastfeeding.

Table 3.

Multivariate analysis of the level of knowledge about continuing breastfeeding.

Explanatory variables	AOR [IC]	p-value
Religion
No religion	2.72 [0.75–9.56]	0.117
Christian	1.85 [0.92–3.92]	0.090
Muslim woman	1
Marital status
Single	2.47 [1.51–4.07]	<0.001***
Concubinage	1.62 [0.55–4.38]	0.348
Married	1
Common-law union	4.23 [1.18–15.78]	0.025*
Attitude
Good	1
Wrong	1.93 [1.17–3.23]	0.010*

AOR: adjusted odds ratio; CI: confidence interval; p-value: significance level. ***p < 0.001; **p < 0.01; *p < 0.05.

Women’s attitudes to continuing breastfeeding

Table 4 shows the distribution of respondents according to their attitude toward continuing breastfeeding. The data show that 46.91% of mothers have a positive perception of breastfeeding up to 2 years of age. However, 57.04% would not advise other mothers to breastfeed until this age, and 53.33% were influenced by their family and friends in their decision to continue breastfeeding. What’s more, 56.79% feel that their job or lifestyle does not make it difficult for them to continue breastfeeding, while 60.49% have never considered stopping for personal reasons.

Table 4.

Evaluation of women’s attitudes to continued breastfeeding.

Variables	Absolute value	Relative frequency (%)
Breastfeeding a child up to 2 years of age
It’s not right	187	46.17
Good for you	190	46.91
I don’t know	28	6.91
Advises other mothers to breastfeed until age 2
No	231	57.04
Yes	174	42.96
Advice for mothers who no longer wish to breastfeed their children
Ask your partner/husband for advice	80	19.75
To continue feeding, the baby must take breast milk for up to 2 years and beyond.	110	27.16
Ask a healthcare professional for advice	88	21.73
She’s right to stop giving milk	5	1.23
I don’t know	91	22.47
Give her baby milk	31	7.65
Influence of peer support on the decision to continue breastfeeding
No	189	46.67
Yes	216	53.33
Feeling that your job or lifestyle makes it difficult to continue breastfeeding
No	230	56.79
Yes	175	43.21
Has already considered stopping breastfeeding for personal reasons
No	245	60.49
Yes	160	39.51

Distribution of participants according to their level of attitudes to continued breastfeeding

Figure 2 shows the distribution of participants according to their attitude to continued breastfeeding after 6 months. The results show that 60% of mothers surveyed had unfavorable attitude, while only 40% had good attitudes toward the practice.

Figure 2.

Level of women’s attitudes toward continued breastfeeding.

Socio-demographic factors associated with mothers’ attitudes toward continued breastfeeding

The results of the bivariate analysis of socio-demographic factors associated with mothers’ level of attitude toward continuing breastfeeding show that age 35 and over (OR = 1.55 (95% CI: 0.82–2.95); p-value = 0.012), belonging to the Christian religion (OR = 5.17 (95% CI: 3.14–8.69); p-value = 0.001) or not belonging to a religion (OR = 4.45 (95% CI: 2.42–8.34); p-value = 0.001) as well as being employed in the private sector (OR = 2.10 (95% CI: 0.81–6.11); p-value = 0.004) were significantly associated with mothers’ unfavorable attitude toward continued breastfeeding. In addition, being single (OR = 2.27 (95% CI: 1.46–3.58); p-value = 0.001) and having poor practices (OR = 1.71 (95% CI: 1.14–2.56); p-value = 0.008) were also factors significantly associated with an unfavorable attitude.

Multivariate analysis of factors associated with the level of attitude toward continued breastfeeding

Table 5 presents the results of multivariate analyses on significant variables to identify independent predictors of mothers’ attitudes toward continued breastfeeding. The results show that belonging to the Christian religion (AOR = 4.45 (95% CI: 2.42–8.34); p-value = 0.001) and not belonging to a religion (AOR = 3.86 (95% CI: 1.09–15.0); p-value = 0.039) were significantly associated with mothers’ unfavorable attitude toward continued breastfeeding.

Table 5.

Multivariate analysis of attitude to continued breastfeeding.

Explanatory variables	AOR[IC]	p-value
Mother’s age
18–24 years	1
25–34 years	1.21 [0.71–2.07]	0.471
35 and over	1.79 [0.82–3.95]	0.141
Religion
No religion	3.86 [1.09–15.02]	0.039 *
Christian	4.45 [2.42–8.34]	<0.001***
Muslim woman	1
Profession
Student	0.77 [0.36–1.63]	0.502
Housekeeper	1
Private sector worker	0.93 [0.52–1.66]	0.828
Public sector worker	0.51 [0.23–1.17]	0.110
Marital status
Single	1.56 [0.94–2.60]	0.086
Concubinage	1.24 [0.43–3.92]	0.688
Married	1
Common-law union	0.62 [0.17–2.30]	0.459
Widow	0.34 [0.19–0.59]	0.981
Practice
Good	1
Wrong	1.26 [0.80–1.98]	0.297

AOR: adjusted odds ratio; CI: confidence interval; p-value: significance level. ***p < 0.001; **p < 0.01; *p < 0.05.

Women’s practices regarding continued breastfeeding

Table 6 shows the breakdown of respondents’ breastfeeding practices. The results show that 51.85% of mothers were breastfeeding up to 6 months, and 52.10% had children who were currently breastfeeding. In addition, 51.85% of respondents were not breastfeeding on demand, while 74.57% had participated in breastfeeding support groups. Furthermore, 60.25% of mothers breastfed in public without hesitation, and 52.35% had given their child a breast milk substitute.

Table 6.

Evaluation of women’s breastfeeding practices.

Variables	Absolute value	Relative frequency (%)
Exclusive breastfeeding for up to 6 months
No	195	48.15
Yes	210	51.85
The child is breastfeeding
No	194	47.90
Yes	211	52.10
Breastfeeding on demand
No	210	51.85
Yes	195	48.15
Have participated in breastfeeding support groups
No	103	25.43
Yes	302	74.57
Breastfeeding in public without hesitation
No	161	39.75
Yes	244	60.25
Giving the child a breast milk substitute
No	193	47.65
Yes	212	52.35

Distribution of participants according to their level of practice in continuing breastfeeding

Figure 3 shows the distribution of participants according to their practices regarding continued breastfeeding after 6 months of life. It was observed that 50.62% of the mothers surveyed reported a poor level of practice regarding continued breastfeeding, while 49.38% adopted poor practices.

Figure 3.

Levels of women’s practice regarding continued breastfeeding.

Socio-demographic factors associated with mothers’ level of practice in continuing breastfeeding

The results of the bivariate analysis of socio-demographic factors, associated with the mothers’ level of practice regarding continued breastfeeding, reveal that mothers with a higher level of education (OR = 3.37 (95% CI: 1.72–6.82); p-value = 0.001) or secondary (OR = 2.74 (95% CI: 1.44–5.38); p-value = 0.002), those who are Christian (OR = 3.54 (95% CI: 2.14–6.00); p-value = 0.001) or belong to no religion (OR = 10.88 (95% CI: 3.15–50.72); p-value = 0.001), as well as students/pupils (OR = 3.41 (95% CI: 1.81–6.62); p-value = 0.001) and those who have worked in the private sector (OR = 2.07 (95% CI: 1.30–3.29); p-value = 0.001) or the public sector (OR = 2.68 (95% CI: 1.32–5.64); p-value = 0.007), as well as single mothers (OR = 1.82 (95% CI: 1.19–2.79); p-value = 0.005) were significantly associated with poor practice on continued breastfeeding.

Multivariate analysis of factors associated with mothers’ level of practice on continued breastfeeding

Table 7 presents the results of multivariate analyses on significant variables in order to identify independent predictors of the level of practice concerning continued breastfeeding. The results show that belonging to the Christian religion (AOR = 2.48 (95% CI: 1.29–4.85); p-value = 0.006) or not belonging to a religion (AOR = 7.22 (95% CI: 1.83–36.77); p-value = 0.007) as well as being a student/pupil (AOR = 2.02 (95% CI: 1.29–4.28); p-value = 0.049) were significantly associated with poor maternal practices regarding continued breastfeeding.

Table 7.

Multivariate analysis of practice level on breastfeeding continuation.

Explanatory variables	AOR [IC]	p-value
School level
Didn’t go to school	1
Primary	1.04 [0.47–2.31]	0.920
Secondary	1.28 [0.59–2.81]	0.521
Higher/university	1.30 [0.54–3.12]	0.547
Religion
No religion	7.22 [1.83–36.77]	0.007**
Christian	2.48 [1.29–4.85]	0.006**
Muslim woman	1
Profession
Student	2.02 [1.29–4.28]	0.049*
Housekeeper	1
Private sector worker	1.19 [0.69–2.05]	0.515
Public sector worker	1.49 [0.62–3.65]	0.369
Marital status
Single	1.14 [0.71–1.84]	0.571
Concubinage	1.68 [0.61–4.90]	0.317
Married	1
Common-law union	1.04 [0.29–3.85]	0.949
Widow	1.30 [0.29–4.90]	0.319

AOR: adjusted odds ratio; CI: confidence interval; p-value: significance level. ***p < 0.001; **p < 0.01; *p < 0.05.

Discussion

This study explored the knowledge, attitudes, and practices of mothers of children aged 6–24 months regarding continued breastfeeding in the Bertoua health district. Our results show that just over a quarter of participating mothers (29.88%) had significant gaps in their understanding of the recommendations for continued breastfeeding, compared with 70.21% with good knowledge. These findings are in line with research by Gueye et al. ¹⁸ in Senegal in 2023 and Ara et al. ¹⁹ in Bangladesh in 2021, where over a quarter of mothers (37% and 26.5% respectively) were also identified as having a low level of knowledge about breastfeeding. In contrast, Sarojini et al. ²⁰ in India in 2024 and AbdelAty et al. ²¹ in Egypt in 2024 reported that just under a quarter of mothers had poor knowledge on the subject. This disparity could be explained by cultural, economic, and educational variations between the contexts examined.

The knowledge deficit observed in the present study was strongly correlated with sociodemographic factors such as marital status and participants’ attitudes toward breastfeeding. In particular, single and cohabiting mothers, as well as those with an unfavorable attitude toward continued breastfeeding, were more likely to fail to grasp breastfeeding recommendations. These results are in line with those obtained by Takassi et al. ²² in Togo in 2023, Somé, ²³ in Burkina Faso in 2020, and a UNICEF survey ²⁴ in 2020. This result may be explained by the fact that single or cohabiting mothers may face specific obstacles to accessing reliable information. Indeed, they may not benefit from the same level of social support as married mothers, which limits their opportunities for exchange and learning about continued breastfeeding. The lack of support networks, whether family or community-based, can make it difficult to adopt recommended practices such as continued breastfeeding. In addition, an unfavorable attitude toward continued breastfeeding may be largely influenced by deep-rooted cultural beliefs and social pressures. In this health district, among different communities, continued breastfeeding may be perceived as a less valued or even stigmatized practice, which may deter mothers from adopting this method.

Regarding participants’ attitudes, our results reveal that the majority of women surveyed (60%) adopted unfavorable perceptions and behaviors toward continued breastfeeding. This Observation is similar to that of studies carried out by Nguefack-Tsague, G et., al ²⁵ in 2018 in Cameroun, southern India, where over 60% of mothers displayed positive attitudes toward continued breastfeeding. This significant discrepancy could be attributed to different cultural and social contexts, where the values and beliefs surrounding breastfeeding are perceived more favorably.

Furthermore, this study revealed that attitudes toward continued breastfeeding were strongly influenced by religious affiliation. More specifically, women identifying themselves as Christian or with no religious affiliation were more likely to have an unfavorable attitude toward the practice an observation consistent with the findings of Jonathan ²⁶ in Ireland and Awawdi et al. ²⁷ in Israel in 2025 and opposed to that of Bahaa Eldin et al. ²⁸ in Egypt in 2024 and Tarabeih et al. ²⁹ in Israël in 2025, which had revealed a positive significance between religion and attitude toward continued breastfeeding. While Christian doctrine does not explicitly oppose breastfeeding, this association can be better understood in the local socio-cultural and religious context. In the Bertoua health district, where the majority of respondents identify themselves as Christian, prolonged breastfeeding is sometimes culturally perceived as a sign of poverty or a rural way of life. As a result, some mothers may choose to introduce breast milk or complementary foods earlier in order to conform to modern norms or socially accepted practices. These community perceptions, rather than religious teachings themselves, appear to play a key role in shaping maternal attitudes and decisions regarding continued breastfeeding.

However, regarding breastfeeding continuation practices, our results show that around 50.62% of mothers surveyed did not adopt appropriate behaviors for breastfeeding continuation. This result is in line with those of Takassi et al., ²² en 2023 au Togo, Sananda et al. ³⁰ in India in 2022, and AbdelAty et al. ²¹ in Egypt in 2024, who found that over 50% of mothers adopted appropriate practices. This discrepancy could be attributed to cultural differences, better access to breastfeeding education, or more effective support programs in the contexts studied. However, these practices were closely linked to socio-demographic factors, such as the mothers’ religion and profession. These results concur with those obtained by Bernard et al., ³¹ Habibi et al. ³² in Morocco in 2018, and Michael et al. ³³ in Israel in 2024. These results may be explained by the fact that mothers from religious backgrounds may have specific traditions and expectations that shape their attitudes toward breastfeeding. Similarly, occupation may affect the availability of time and support for breastfeeding, as well as social perceptions of motherhood.

So, our results therefore have important implications for public health policy. They align with the objectives of WHO and UNICEF ³⁴ in 2003 and the recommendations of the World Health Organization in 2023, which advocate exclusive breastfeeding for the first 6 months and continued breastfeeding for up to 2 years or more. At the national level, these results directly support Cameroon’s National Nutrition Strategy ³⁵ (2016–2025), which focus on improving maternal knowledge and promoting breastfeeding within communities. Strengthening breastfeeding support at both the health facility and community level could therefore contribute to the implementation of these frameworks at the local level.

Study limits

There are several limitations to this study that should be considered when interpreting the results. The methodology was based on non-probability sampling, as the participants available and motivated to participate do not necessarily reflect the overall population of mothers in the Bertoua health district, which may introduce a selection bias and limit the generalizability of the results to the population of the Bertoua health district. In addition, data collection via self-administered questionnaires may generate reporting bias, as participants may provide answers perceived as socially acceptable rather than their true opinions. Finally, although the data collection period was adequate to constitute a significant sample, it does not take into account seasonal or contextual variations likely to influence breastfeeding behavior. These factors need to be taken into account to better understand the results and guide future research.

Conclusion

This study revealed critical gaps in women’s knowledge, attitudes, and practices regarding continued breastfeeding in the Bertoua Health District. Specifically, 70.21% of participants demonstrated poor knowledge, 60% had unfavorable attitudes, and 50.62% reported inadequate practices. Key sociodemographic determinants such as marital status and religious affiliation were found to negatively influence these behaviors. In light of these findings, there is an urgent need for targeted, culturally sensitive interventions. These should include the integration of breastfeeding education into religious settings, particularly churches, through partnerships with faith leaders, who can serve as influential agents of behavioral change. Community-based education programs should prioritize single, young, or cohabiting mothers, who may face greater vulnerability to misinformation or a lack of support. Moreover, the creation of breastfeeding-friendly environments, such as dedicated spaces in workplaces and markets, can facilitate practice among employed or informal-sector mothers. Strengthening the capacity of community health workers to deliver context-specific messages, along with the use of mass media (e.g. local radio programs and testimonial campaigns), can further promote positive attitudes toward continued breastfeeding. Based on the study findings, it is recommended to strengthen community-based support for single and cohabiting mothers through targeted postnatal counseling and peer groups, engage religious institutions such as churches, mosques, and faith-based organizations in disseminating culturally appropriate breastfeeding messages, and promote breastfeeding-friendly environments in workplaces and markets by providing flexible schedules and designated nursing areas. Collectively, these measures offer a practical framework for operationalizing national and international breastfeeding policies within the Bertoua Health District and similar settings.