Breastfeeding cessation decisions, practices, and support-seeking among mothers in Tehran, Iran: a cross-sectional study

Abstract

Background

Complete breastfeeding cessation is an important maternal–child health transition and is distinct from complementary feeding, which the World Health Organization defines as providing foods in addition to milk when milk alone is no longer adequate (generally from 6 to 23 months). Evidence on how mothers decide to stop breastfeeding and which practices they use remains limited in LMICs. This study described breastfeeding cessation timing, decision-making, practices, and support-seeking among mothers in Tehran, Iran, using a Social Ecological Model to organize influences at individual, interpersonal, healthcare/organizational, and broader contextual levels.

Methods

We conducted a cross-sectional online survey from March to August 2021 among mothers of healthy singleton children aged 6 months to <4 years, recruited from 28 public health centers in Tehran. The final analytic sample included 420 mothers. Data were collected using a 42-item questionnaire with structured items and optional open-text questions; open-text responses were provided by 98–380 mothers, depending on the item. Quantitative data were summarized descriptively, and associations were examined using bivariate tests. Open-text responses were analyzed using thematic content analysis to contextualize the survey findings. Findings were organized using the Social Ecological Model across individual, interpersonal, healthcare/organizational, and broader contextual levels.

Results

Most mothers were aged 25–34 years (69.3%), reported average financial status (79.8%), and held a university degree (45.5%); children were primarily aged 42–48 months. Breastfeeding cessation was mainly mother-initiated (86.4%), and 56.2% reported complete cessation between 18 and 24 months. Traditional practices to discourage breastfeeding were common, including applying bitter or adhesive substances (41.2%) and using medicinal products without prescription (32.9%). Only 34.8% consulted healthcare providers during cessation, most often for emotional reassurance. Family advice influenced some decisions (22.3%). Mothers reported mixed experiences after cessation, including relief as well as guilt and breast discomfort, while many reported child behavioral challenges (e.g., irritability and clinginess) alongside perceived increases in independence.

Conclusions

In this Tehran sample, breastfeeding cessation was largely mother-initiated but frequently involved traditional practices and limited professional support. Findings suggest a need for clear, culturally sensitive guidance and counseling on breastfeeding cessation within routine maternal–child health services, including family engagement and practical support for gradual cessation.

Trial registration

Not applicable, as this study did not involve a health care intervention.

Background

Early childhood development forms the foundation for children’s long-term health, well-being, and learning [1]. Optimal infant and young child nutrition, particularly breastfeeding, supports healthy growth and neurodevelopment, contributes to immune protection, reduces infant morbidity, and supports maternal well-being and early parent–child bonding [2, 3]. Breastfeeding is therefore widely recognized as a cornerstone of maternal and child public health [4–7].

Although breastfeeding initiation and continuation have been strongly emphasized, comparatively little attention has been given to how breastfeeding ends, including how mothers decide on the transition from breastfeeding to complete cessation and the information and methods that guide this process [6, 8]. Breastfeeding is widely recognized as a cornerstone of public health due to its substantial benefits for child survival, maternal health, and population-level health outcomes [4]. However, breastfeeding complete cessation, an inevitable and universal stage of the feeding trajectory, has received far less attention in public health [6, 7, 9]. In this study, breastfeeding cessation is defined as the complete discontinuation of any human milk feeding, that is, the point at which the child no longer receives human milk in any form. This definition is important because the term “weaning” is used inconsistently in the literature. In some contexts, weaning refers to the introduction of complementary foods, whereas in others it refers to the complete cessation of breastfeeding or human milk feeding To avoid ambiguity, the present study uses “breastfeeding cessation” to refer specifically to the complete discontinuation of human milk intake [9–11].

An important aspect of breastfeeding cessation is its timing, defined as the age at which breastfeeding stops. Cessation may be premature or timely [6, 9–18]. Premature breastfeeding cessation refers to the discontinuation of breastfeeding prior to public health recommendations, regardless of whether the cessation is planned or unplanned. In contrast, timely breastfeeding cessation aligns with global World Health Organization (WHO) recommendations, which advise continued breastfeeding up to two years of age or beyond alongside appropriate complementary feeding [4, 10, 15].

Despite its importance, the social, emotional, and practical dimensions of breastfeeding cessation remain underrecognized within public health frameworks, resulting in limited attention to cessation-related needs in program planning, clinical guidance, and support services [3, 16–18]. Although breastfeeding cessation is as critical as the introduction of complementary feeding, it is often treated as a discrete endpoint rather than a dynamic process. In practice, the transition away from breastfeeding may be gradual or abrupt and can involve substantial behavioral adjustments, emotional responses, and relational changes for both mother and child [16, 17]. Limited recognition of this transition may leave mothers unprepared for challenges associated with cessation, including emotional distress, physical discomfort, and social pressure [18–20].

In low- and middle-income countries (LMICs), deviations from recommended breastfeeding duration, particularly early or abrupt cessation are associated with greater health risks compared with high-income settings [21]. Despite this vulnerability, breastfeeding cessation remains under addressed within health policy and clinical practice, especially in contexts where cultural traditions and informal caregiving practices strongly shape maternal decision-making [22]. In Iran, national policies endorse breastfeeding for up to two years in accordance with international recommendations, yet guidance on breastfeeding cessation and the cessation process is limited and inconsistently incorporated into maternal–child health services [23]. As a result, many mothers rely on traditional or informal methods to stop breastfeeding, including the application of bitter or aversive substances to the breast, temporary mother–child separation, or the use of unprescribed remedies, often without professional oversight [22, 24]. These practices may potentially expose mothers and children to physical and psychological risks when implemented without evidence-informed support [25, 26].

Although Iranian studies have documented culturally rooted cessation practices and called for context-specific education [27, 28], Breastfeeding cessation remains insufficiently examined in terms of maternal perceptions, decision-making, and practices. To date, a few Persian-language studies has focused specifically on traditional cessation approaches [23, 29, 30], and regional variation in breastfeeding duration and cessation experiences has received limited scholarly attention, particularly regarding equitable and culturally responsive cessation guidance within Iran [31].

The Social Ecological Model (SEM) is commonly used to organize influences on health behaviors across multiple levels, including individual, interpersonal, community, organizational, and policy contexts [32]. In this study, SEM was used as an framework to structure the description of breastfeeding cessation decisions and practices, including mothers’ beliefs and experiences, family advice and support, prevailing community norms, access to healthcare guidance, and the broader policy environment [33, 34]. This framing recognizes that breastfeeding cessation is shaped by factors beyond individual preference alone and may reflect caregiving demands and contextual constraints, whether cessation is primarily mother-initiated or influenced by infant behavior [35, 36].

The goal of this study was to describe complete breastfeeding cessation behaviours among mothers in Tehran, Iran, including cessation timing, decision-making, practices, sources of support, and perceived maternal and child experiences. Using the Social Ecological Model as an interpretive framework, the study aimed to identify gaps in support and inform culturally responsive public health recommendations for maternal–child health services in Tehran, with potential relevance for LMIC settings with similar sociocultural contexts.

Methods

Study design and setting

This study was a cross-sectional online survey conducted in Tehran, Iran, with data collected from March to August 2021. The survey included structured questions and optional open-text items to capture additional context on breastfeeding cessation experiences. An online format was used due to COVID-19–related restrictions to support participant safety and accessibility. Recruitment followed a two-stage cluster approach. First, 28 public health centers affiliated with Tehran University of Medical Sciences were selected across five municipal districts representing diverse socioeconomic contexts. Second, eligible mothers were identified from electronic health records for recruitment purposes only. Trained research assistants contacted mothers by telephone, explained the study, and shared a secure link to the questionnaire via digital messaging platforms.

Operational definitions

This study applied standardized breastfeeding terminology informed by World Health Organization (WHO) recommendations to define exclusive breastfeeding, the breastfeeding cessation process (the transition from any breastfeeding to none), and complete breastfeeding cessation [10, 15]. Exclusive breastfeeding (EBF) was defined as the infant receiving only breast milk, with the exception of oral rehydration solution, vitamins, or medicines, for the duration reported by the mother [15]. Duration of any breastfeeding was defined as the time from birth until the complete discontinuation of breastfeeding, regardless of the introduction of other foods or liquids [7].

Breastfeeding cessation process was defined as the period during which mothers transitioned from any breastfeeding to none, whether gradual or abrupt, including reductions in breastfeeding frequency, strategies used by mothers to stop breastfeeding, sources of advice or support, and mothers’ reported physical and emotional experiences during this transition [11, 16, 17].

Complete breastfeeding cessation, the primary outcome of this study, was defined as the child’s age in months at the final breastfeed with no subsequent resumption, as reported by the mother. This definition aligns with WHO guidance and recent literature describing breastfeeding cessation as the complete discontinuation of human milk intake, after which the child is considered non-breastfed and relies on other milks and complementary foods [9, 10]. By distinguishing breastfeeding cessation as both a measurable outcome and a socially and emotionally embedded process, this study reflects the developmental, cultural, and health contexts emphasized in the background literature [6, 18].

Participants and eligibility criteria

Participants were mothers of healthy singleton children aged 6 months to under 4 years who reported a period of exclusive breastfeeding prior to introducing complementary foods and prior to initiating breastfeeding cessation. Children with chronic or acute medical conditions or congenital anomalies that could affect feeding were excluded. These criteria were intended to reduce confounding from medically indicated breastfeeding cessation and to limit recall by restricting the sample to children within the typical age range for breastfeeding cessation.

Sample size calculation

Using a 95% confidence level and an estimated prevalence of 55% for gradual breastfeeding cessation (non-abrupt cessation), the minimum required sample size was calculated based on a prior study among children attending urban health centers in Damghan, Iran [30], which was used as a proxy due to the absence of recent Tehran-specific estimates. With a margin of error of 5%, the standard cross-sectional sample size formula (Z = 1.96, p = 0.55, q = 0.45) yielded a minimum sample size of approximately 380 participants. To improve precision and account for potential non-response during COVID-19–related recruitment, the target sample size was increased to 500 mother–child pairs. A total of 420 mothers completed the survey and met inclusion criteria [37].

Because recruitment was conducted through multiple health centers, the effective sample size may be reduced by within-center correlation; however, ICC estimates were not available at the planning stage to incorporate a design effect into the initial calculation.

Recruitment and data collection

Eligible mothers were identified through electronic health records at 28 public health centers affiliated with Tehran University of Medical Sciences Recruitment was conducted across five municipal districts to capture socioeconomic diversity, with mothers recruited through participating centers. Trained research assistants contacted eligible mothers by telephone, explained the study objectives, and shared a secure link to the online questionnaire via digital messaging platforms. Electronic informed consent was obtained prior to participation. Data were collected anonymously using a secure online platform during the COVID-19 pandemic to support participant safety and may have reduced social desirability in responses. Participants completed a 42-item questionnaire with three sections: [1] demographic information (10 items) [2], fertility and birth history (4 items), and [4] breastfeeding cessation practices and experiences (28 items), including breastfeeding duration, age at complete cessation, decision-making, cessation methods, coping strategies, perceived maternal and child outcomes, healthcare use, and sources of advice. The questionnaire included 30 structured items and 12 optional open-text items. Open-text questions were intended to contextualize quantitative findings and capture additional detail on mothers’ reported decision-making, emotions, social influences, and recommendations. Example items included, “Please describe how you stopped breastfeeding and what strategies you used,” and “How did your child respond after breastfeeding stopped?” Between 98 and 380 participants provided open-text responses depending on the item; responses had no word limit and were typically two to four lines. Average completion time was approximately 30–40 min.

Instrument development and validation

The questionnaire was informed by and conceptually adapted from instruments developed by Gürarslan Baş et al. [24] to assess breastfeeding cessation practices among mothers in Turkey, providing a relevant starting point for a comparable regional context. The original instrument focused on maternal cessation strategies and related experiences, consistent with the aims of the present study. To ensure linguistic and conceptual equivalence, the questionnaire was translated into Persian and back-translated by bilingual maternal health professionals. Discrepancies were resolved through consensus to improve semantic accuracy and cultural appropriateness for use in Iran.

The instrument was designed to measure breastfeeding cessation timing and practices and to capture mothers’ reported experiences and contextual influences during the cessation period. Content and face validity were assessed by 15 faculty members with expertise in maternal and child health at Tehran University of Medical Sciences and one external reviewer from Türkiye [38]. Reviewers evaluated item clarity, cultural relevance, and contextual fit, and the questionnaire was revised iteratively to align with breastfeeding cessation terminology and the study’s social-ecological framework. A pilot test with 30 eligible mothers was conducted to assess usability, navigation, and response burden; pilot data were excluded from the final analysis. Internal consistency reliability was assessed using Cronbach’s alpha (α = 0.82) for the set of items intended to measure maternal perceptions and cessation experiences [39].

Final refinements included rewording unclear items and improving the digital interface and compatibility for online completion.

Data analysis

Data analysis included two components: [1] quantitative analysis of structured survey responses and [2] qualitative analysis of optional open-text responses to provide context for quantitative findings. Quantitative and open-text data were analyzed separately and then interpreted together. Analyses were conducted by two researchers with complementary expertise: one with training in reproductive health led analysis of open-text responses, and one with biostatistical expertise conducted quantitative analyses. During interpretation, findings were organized using the Social Ecological Model (SEM) as a framework to categorize influences at individual, interpersonal, community, healthcare/organizational, and policy levels [32, 33].

Quantitative analysis

Quantitative data were analyzed using IBM SPSS Statistics version 27. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize participant characteristics, breastfeeding duration, age at complete breastfeeding cessation, and cessation practices. Associations between cessation methods and selected maternal- and child-reported outcomes were examined using chi-square tests or Fisher’s exact tests, as appropriate. Statistical significance was set at p < 0.05 [40].

Missing data accounted for less than 5% of observations; therefore, analyses were conducted using listwise deletion, consistent with standard recommendations for handling minimal missing data in cross-sectional analyses [40].

Qualitative analysis of open-ended responses

Open-text responses related to breastfeeding cessation practices and perceived child reactions were analyzed using thematic content analysis [41]. Two researchers independently coded responses and resolved discrepancies through discussion. Responses were included if they contained at least one clause describing a practice, experience, influence, or recommendation related to breastfeeding cessation (i.e., more than a single-word or yes/no answer) and addressed the relevant question. All eligible open-text responses meeting these criteria were coded; responses were not sampled or excluded to achieve representativeness. Depending on the item, 98–380 participants provided open-text responses; responses were typically brief (approximately 15–80 words, one to three sentences). Analysis followed established steps of familiarization, initial coding, and development of themes [41]. Reflexivity was supported through independent coding, analytic memo writing, and peer debriefing [42].

Integration / SEM interpretation

After quantitative analyses and content analysis of open-text responses were completed, findings from the open-ended questionswere integrated to further contextualize quantitative results [41]. Quantitative results and qualitative themes were first separately and then jointly mapped to Social Ecological Model (SEM) levels (individual, interpersonal, community, healthcare/organizational, and policy), consistent with established SEM theory and its application in maternal and breastfeeding research [32, 33].

Qualitative findings were used to elaborate on and contextualize quantitative patterns, including areas of convergence and divergence across SEM levels. Two researchers independently assigned integrated findings to SEM levels and resolved discrepancies through discussion, documenting decisions in analytic memos. We created a SEM mapping matrix (rows = findings/themes; columns = SEM levels) and assigned each item to one primary level; disagreements were resolved by consensus discussion.

Ethical considerations

This study was approved by the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.IKHC.REC.1400.118) and conducted in accordance with the Declaration of Helsinki and national ethical guidelines [43]. Due to COVID-19–related constraints, informed consent was obtained remotely using a two-step process: study information was provided by telephone, followed by electronic confirmation before participants accessed the online survey. Participation was voluntary, and participants could withdraw at any time without penalty. No personally identifying information was collected. Survey responses were anonymized and stored on encrypted, password-protected institutional servers with access restricted to authorized personnel. Data will be retained for five years in accordance with institutional policy and then securely destroyed. No incentives were provided to minimize the risk of coercion. To support participant well-being, contact information for two licensed midwives was provided for optional consultation regarding maternal or child health concerns arising during or after participation.

Results

Participant characteristics

This study included 420 mother–child pairs recruited from 28 public healthcare centers across five districts in Tehran. Table 1 presents the demographic, socioeconomic, and reproductive characteristics of the sample. Most mothers were between 25 and 34 years of age, had one child, and were primarily housewives with an average household income. Nearly half of the mothers and 42% of their spouses held university degrees. Most children were aged 42–48 months, had a birth weight within the healthy range (2.5–3.99 kg), and had no history of hospitalization. Among the small subgroup of children with reported illness (n = 33), jaundice and seizures were the most frequently reported conditions. Cesarean section was reported as the mode of delivery for 78.6% of participants.

Table 1.

Demographic,socioeconomic, and maternal-child characteristics of mother–child pairs recruited from public healthcare centers in Tehran (N = 420)

Category	Subcategory	n	%
Mother’s employment status	Housewife	307	73.1
	Part-time employment	74	17.6
	Full-time employment	39	9.3
Household financial status	Poor	28	6.7
	Average	335	79.8
	Good	57	13.6
Mother’s education level	Elementary	65	15.5
	High school diploma	164	39
	University degree	191	45.5
Spouse’s education level	Elementary	58	13.8
	High school diploma	185	44
	University degree	177	42.1
Maternal age (years)	<24	53	12.6
	25–29	152	36.2
	30–34	139	33.1
	≥35	76	18.1
Residential district	District 10	60	14.3
	District 11	60	14.3
	District 16	120	28.6
	District 17	60	14.3
	District 19	120	28.6
Child age (months)	<42	103	24.5
	42–<45	173	41.2
	45–48	144	34.3
Child’s gender	Female	194	46.2
	Male	226	53.8
Parity (Number of pregnancies)	One	220	52.4
	Two	150	35.7
	≥Three	50	11.9
Number of living children	One	293	69.8
	Two	113	26.9
	Three	14	3.3
Birth weight of last child (kg)	<1.0	0	0
	1.0–1.49	7	1.7
	1.5–2.49	45	10.7
	2.5–3.99	367	87.4
	≥4.0	1	0.2
Mode of delivery	Vaginal delivery	90	21.4
	Cesarean section	330	78.6
Child hospitalization history	Yes	33	7.9
	No	387	92.1
History of Reported Illnesses in Children ( n = 33)
Type of illness	n	%
Jaundice	21	63.6
Seizures	7	21.2
Rectal bleeding	2	6.1
Heart disease	1	3
Asthma	1	3
Urinary tract infection	1	3
Total	33	100

Note. Data are self-reported. Percentages may not total 100% due to rounding. Illness history is reported only for children whose mothers reported a health condition

Sources of guidance and breastfeeding duration

Formal national or international guidance on breastfeeding cessation (the transition from any breastfeeding to none) was not commonly cited by participants as an information source. Instead, mothers frequently referred to religious and traditional beliefs when describing decisions about when and how to stop breastfeeding, including Islamic teachings supporting breastfeeding up to two years and recommendations associated with traditional Persian medicine (e.g., dietary modification or maintaining body warmth). All mothers reported a period of exclusive breastfeeding prior to the introduction of complementary foods. The mean duration of exclusive breastfeeding was 5.61 months (SD = 1.98). The age at complete breastfeeding cessation most commonly occurred between 18 and 24 months (mean = 21.49 months, SD = 3.13) (Table 2).

Table 2.

Duration of exclusive breastfeeding and age at complete breastfeeding cessation among mother–child Pairs (N = 420)

Variable	Category	n	%
Exclusive breastfeeding duration (months)	1 to < 6	117	27.9
	6 to < 7	208	49.5
	7–8	95	22.6
	Total	420	100.0
	Mean ± SD		5.61 ± 1.98
	Range (min–max)		1–8
Age at complete breastfeeding cessation (months)	< 18	32	7.6
	18–24	236	56.2
	25–30	152	36.2
	Total	420	100.0
	Mean ± SD		21.49 ± 3.13
	Range (min–max)		12–30

Note: Durations are reported in months (self-reported)

Breastfeeding cessation initiation, reasons, and strategies

Most mothers (86.4%) reported that breastfeeding cessation was mother-initiated, while 9.6% described cessation as baby-initiated and 4.0% as unplanned due to child refusal (Table 3). The most frequently cited reason for stopping breastfeeding was the mother’s perception that breastfeeding had continued for a sufficient duration (84.3%), followed by perceived milk insufficiency and the child’s interest in solid foods (both 14.8%). Less frequently reported reasons included employment demands (6.9%), pressure from others (5.7%), and health-related concerns. Most mothers (82.0%) described the cessation process as gradual, typically involving stepwise elimination of feeds; however, many reported completing cessation within one to two weeks. Participants reported using a combination of nutritional and emotional strategies, including increased dairy intake (38.1%) and distraction through play (71.0%). Smaller proportions reported spiritually oriented practices such as prayer or choosing a spiritually meaningful time (10.4%). Open-text responses were consistent with these patterns and frequently described maternal fatigue and perceptions of child readiness. One mother noted: “I was exhausted from long feeding and the constant clinging. It was no longer nutritional. She needed to breastfeed for comfort after every activity and before bedtime.”

Table 3.

Breastfeeding cessation patterns, timing, initiation, reasons, and strategies among mothers (N = 420)

Cessation pattern
Subcategory	n	%
Gradual, starting with night feeds	67	16
Gradual, starting with morning feeds	109	26
Gradual, starting with evening feeds	167	39.8
Abrupt cessation	77	18.3
Total	420	100
Duration of cessation process
Subcategory	n	%
<7 days	172	41
7–14 days	134	31.9
15–30 days	88	21
≥31 days	26	6.2
Total	420	100
Cessation initiation
Subcategory	n	%
Mother-initiated	363	86.4
Baby-initiated	40	9.6
Unplanned (child refusal)	17	4
Total	420	100
Reasons for stopping breastfeeding*
Reason	n	%
Breastfeeding duration perceived as sufficient	354	84.3
Perceived milk insufficiency	62	14.8
Child’s interest in solid foods	62	14.8
Employment	29	6.9
Pressure from others	24	5.7
To improve sexual functioning	12	2.9
Illness of mother or child	11	2.6
Other reasons	10	2.4
New pregnancy	4	1
Strategies used during cessation*
Strategy	n	%
Nutritional strategies
Increased dairy intake	160	38.1
Increased purees and soft foods	63	15
Increased protein-rich foods	64	15.2
Increased fluid intake	65	15.5
Keeping the child full	68	16.2
Emotional/psychological strategies
Reduced holding	60	14.3
Distraction through play	298	71
Use of prayer	27	6.4
Choosing a spiritually meaningful time	17	4
Other strategies	18	4.3

*Participants could select more than one reason and strategy; therefore, percentages do not sum to 100%

Perceived post-cessation outcomes

Mothers reported a wide range of maternal and child experiences following breastfeeding cessation, with many reporting more than one response. Children’s reactions were common and included distress (e.g., crying, irritability, restlessness) (87.1%), increased use of formula milk (29.3%), constipation (10.0%), and fever or fatigue (6.7%). Positive child changes were also reported, including improved appetite (59.3%) and greater independence (51.2%). Maternal experiences following cessation were mixed. Over half of mothers (52.4%) reported feeling relieved from breastfeeding-related challenges, and some reported feeling calmer after stopping breastfeeding. At the same time, many mothers reported physical discomfort and emotional strain, including breast engorgement (31.7%), breast pain (31.4%), feelings of guilt (29.8%), and concern about their child’s well-being (24.5%). These responses were not mutually exclusive, and many women reported overlapping emotional and physical experiences, with detailed distributions as shown in Table 4.

Table 4.

Maternal and child experiences reported after breastfeeding cessation (N = 420)

A. Maternal positive experience profile (mutually exclusive)
Outcome	n	%
Feeling relieved from breastfeeding-related difficulties	220	52.4
Feeling calm and relieved	63	15
Feeling relieved with increased sexual desire	57	13.6
Feeling calm, relieved, and increased sexual desire	33	7.9
Increased sexual desire	22	5.2
No positive outcomes reported	25	6
Total	420	100
B. Maternal physical and emotional experiences*
Outcome	n	%
Feeling guilty	125	29.8
Feeling regretful	118	28.1
Breast pain	132	31.4
Lactation-related fever	17	4
Breast engorgement	133	31.7
Sadness	37	8.8
Subsequent pregnancy	2	0.5
Social withdrawal	13	3.1
Fear and concern about child’s health	103	24.5
Feeling empty	16	3.8
C. Child experiences*
Outcome	n	%
Diarrhea and vomiting	10	2.4
Nail biting or teeth grinding	18	4.3
Fever and fatigue	28	6.7
Distress (e.g., crying, restlessness, irritability)	366	87.1
Weight loss or malnutrition	31	7.4
Constipation	42	10
Increased inclination toward formula milk	123	29.3
Increased desire to be held	89	21.2
Increased desire for food / improved appetite	249	59.3
Increased independence	215	51.2
Increased self-reliance	213	50.7
Greater liveliness	16	3.8
Improved weight gain	48	11.4

*Participants could report multiple experiences; therefore, percentages do not sum to 100%

Cessation methods and family/social context

A substantial proportion of mothers reported using traditional practices to discourage breastfeeding during cessation. Among participants, 41.2% reported applying chemical substances to the breast (e.g., adhesives, markers, or nail polish), 27.6% reported using food-based items (e.g., pepper, turmeric, or Qarehqoroot), and 32.9% reported using medicinal substances (Table 5). The most frequently reported medicinal products were hormonal medications (15.5%) and Bitterak drops (11.9%). Cessation methods varied by maternal education, employment status, and district of residence (Table 5). For example, mothers in District 16 reported the highest use of chemical substances (48.3%) compared with other districts (χ² = 42.02, p < 0.001).

Table 5.

Breastfeeding cessation methods by participant characteristics (N = 420)

Maternal and child characteristics	Food substances n (%)	Chemical substances n (%)	Medicinal substances† n (%)	Other substances n (%)	Statistical test (bivariate)
Education level					χ² = 13.761, df = 6, p = 0.032
Primary	25 (38.5)	24 (36.9)	8 (12.3)	8 (12.3)
Diploma	45 (27.4)	80 (48.8)	21 (12.8)	18 (11.0)
University	49 (25.7)	69 (36.1)	41 (21.5)	32 (16.8)
District of residence					χ² = 42.020, df = 12, p < 0.001
District 10	16 (26.7)	21 (35.0)	15 (25.0)	8 (13.3)
District 11	12 (20.0)	21 (35.0)	17 (28.3)	10 (16.7)
District 16	46 (38.3)	58 (48.3)	13 (10.8)	3 (2.5)
District 17	17 (28.3)	28 (46.7)	7 (11.7)	8 (13.3)
District 19	28 (23.3)	45 (37.5)	18 (15.0)	29 (24.2)
Employment status					χ² = 17.635, df = 6, p = 0.007
Housewife	94 (30.6)	120 (39.1)	47 (15.3)	46 (15.0)
Part-time	20 (27.0)	39 (52.7)	10 (13.5)	5 (6.8)
Full-time	5 (12.8)	14 (35.9)	13 (33.3)	7 (17.9)
Financial status					χ² = 4.239, df = 6, p = 0.644
Poor	10 (35.7)	12 (42.9)	3 (10.7)	3 (10.7)
Average	95 (28.4)	139 (41.5)	58 (17.3)	43 (12.8)
Good	14 (24.6)	22 (38.6)	9 (15.8)	12 (21.1)
Number of pregnancies					χ² = 7.881, df = 6, p = 0.247
1	60 (27.3)	87 (39.5)	41 (18.6)	32 (14.5)
2	48 (32.0)	59 (39.3)	20 (13.3)	23 (15.3)
≥ 3	11 (22.0)	27 (54.0)	9 (18.0)	3 (6.0)
Number of children					Fisher’s exact test, p = 0.825
1	85 (29.0)	123 (42.0)	48 (16.4)	37 (12.6)
2	30 (26.5)	43 (38.1)	20 (17.7)	20 (17.7)
3	4 (28.6)	7 (50.0)	2 (14.3)	1 (7.1)
Child’s gender					χ² = 3.099, df = 3, p = 0.377
Female	48 (24.7)	83 (42.8)	32 (16.5)	31 (16.0)
Male	71 (31.4)	90 (39.8)	38 (16.8)	27 (11.9)
Mother’s age (years), mean ± SD	29.44 ± 4.72	30.01 ± 4.51	30.30 ± 4.75	30.59 ± 5.35	ANOVA, p = 0.418
Child’s age (months), mean ± SD	42.19 ± 5.41	42.23 ± 4.78	42.67 ± 4.05	41.91 ± 6.38	ANOVA, p = 0.862

Notes. Values are presented as n (%) unless otherwise indicated. Percentages represent the proportion of mothers within each subgroup using the specified cessation method. Reported p-values reflect bivariate comparisons. †Medicinal substances include both prescribed and non-prescribed products reported by participants

Open-text responses commonly mentioned emotional fatigue, physical discomfort, and challenges managing caregiving responsibilities during the cessation period. Some mothers also described advice from relatives, particularly elder women, as relevant to their approach to cessation. References to fathers’ involvement were infrequent and typically described supportive activities such as play or assistance with sleep routines.

Healthcare consultation during breastfeeding cessation

Reported use of formal healthcare services during the breastfeeding cessation process was limited. Most mothers (65.2%) reported not consulting healthcare providers (Table 6). Among those who sought professional support (34.8%), the most commonly reported reason was emotional reassurance (64.4%), followed by concerns about child health (18.5%), breastfeeding-related difficulties (11.0%), and lack of prior experience (6.2%). In exploratory analyses, reported use of medicinal substances was associated with higher reported rates of maternal lactation-related fever (p = 0.015) and sadness (p = 0.003). No statistically significant associations were observed between healthcare consultation or medicinal substance use and reported child outcomes.

Table 6.

Consultation with healthcare providers during breastfeeding cessation (N = 420)

Consultation with healthcare providers	n	%
No	274	65.2
Yes	146	34.8
Total	420	100.0

Note. Healthcare providers included physicians, nurses, and staff at public health centers

Exploratory associations with cessation practices and timing

Exploratory analyses examined associations between selected maternal characteristics, breastfeeding cessation methods, and reported outcomes. Part-time employed mothers more frequently reported using chemical substances to discourage breastfeeding compared with other employment groups (52.7%; χ² = 17.635, p = 0.007) (Table 5). Breastfeeding cessation methods also differed by maternal education level (χ² = 13.761, p = 0.032) (Table 5). The mean age at complete breastfeeding cessation differed for some reported child outcomes: cessation age was higher among children whose mothers reported increased independence (p = 0.006) and self-reliance (p = 0.031) (Table 7), and lower among those whose mothers reported diarrhea and vomiting (p = 0.025) (Table 8). No statistically significant associations were observed between age at breastfeeding cessation and reported maternal outcomes.

Table 7.

Age at complete breastfeeding cessation by reported positive child outcomes (N = 420)

Positive child outcome	No (months), mean ± SD	Yes (months), mean ± SD	p-value
Increased desire to be held	21.59 ± 3.12	21.10 ± 3.18	NS
Increased appetite	21.50 ± 3.14	20.60 ± 3.21	NS
Increased independence	21.06 ± 3.17	21.89 ± 3.09	0.006
Increased self-reliance	21.15 ± 3.16	21.81 ± 3.04	0.031
Greater liveliness	21.47 ± 3.15	21.88 ± 3.08	NS
Better weight gain	21.43 ± 3.16	21.96 ± 3.02	NS

Note. Independent-samples t-tests were conducted. NS = not significant (p > 0.05)

Table 8.

Age at complete breastfeeding cessation by reported negative child outcomes (N = 420)

Negative child outcome	No (months), mean ± SD	Yes (months), mean ± SD	p-value
Diarrhea and vomiting	21.54 ± 3.11	19.30 ± 3.19	0.025
Nail biting / teeth grinding	21.48 ± 3.13	21.67 ± 3.02	NS
Fever and fatigue	21.49 ± 3.14	21.50 ± 2.92	NS
Distress/behavioral changes (e.g., crying, irritability, restlessness)	21.09 ± 2.98	21.55 ± 3.15	NS
Weight loss or malnutrition	21.43 ± 3.16	22.23 ± 2.59	NS
Constipation	21.47 ± 3.16	21.67 ± 2.87	NS
Increased craving for formula	21.55 ± 3.10	21.35 ± 3.19	NS

Note. Independent-samples t-tests were conducted. NS = not significant (p > 0.05)

Discussion

This cross-sectional survey provides descriptive evidence on complete breastfeeding cessation among mothers in Tehran, including the timing of complete cessation, reported decision-making processes, cessation practices, and mothers’ perceived maternal and child experiences. Organized using a social-ecological perspective [32–34], the findings suggest that cessation in this sample was predominantly mother-initiated, frequently involved traditional discouragement practices, and occurred in a context of limited engagement with professional guidance during the cessation period. These patterns indicate that breastfeeding cessation is a biopsychosocial transition that extends beyond nutrition and is shaped by emotional, relational, cultural, and structural factors [15, 44, 45]. This interpretation is consistent with broader frameworks that situate infant feeding decisions within early childhood development systems and caregiving environments rather than viewing them as isolated maternal choices [1, 4].

Cessation timing and the meaning of “gradual” in this context

The mean age at complete breastfeeding cessation (21.49 months) and the most common cessation window (18–24 months) align with international recommendations to continue breastfeeding for up to two years or beyond [15] and are also consistent with Iranian religious and cultural narratives that support extended breastfeeding [23]. Although the sample cannot be assumed to represent all Iranian mothers, the overall pattern suggests that many participants aimed to achieve a socially and culturally meaningful breastfeeding duration. In this sense, decisions about stopping breastfeeding appear to be shaped not only by child feeding needs but also by mothers’ interpretations of what constitutes an “appropriate” duration, a phenomenon reported across diverse cultural settings [22, 23, 25].

A key finding is the discrepancy between mothers’ self-description of cessation as “gradual” and the reported duration of the cessation process, which commonly occurred within one to two weeks, and for many within less than seven days. Clinical guidance and international recommendations typically conceptualize gradual cessation as a progressive reduction over weeks to months, allowing physiological adjustment and potentially reducing maternal and child distress [15, 46].

The present findings suggest that, for many mothers, “gradual” may primarily refer to the sequence of eliminating feeds (for example, stopping night feeds first) rather than a prolonged taper. Similar variability in how mothers understand and implement cessation has been documented in other contexts, underscoring the need for counseling that clearly defines what gradual cessation entails and provides practical, context-specific guidance [22, 24, 47]. Clearer education about expected timelines, common maternal symptoms (such as engorgement), and child reactions could help reduce anxiety and support safer approaches, particularly given pediatric concerns that abrupt or poorly managed feeding transitions may be associated with nutritional instability or gastrointestinal symptoms in young children [26, 46, 48].

Individual-level influences: maternal agency, thresholds, and emotional load

Most mothers in this study reported that cessation was mother-initiated, consistent with evidence from Turkey and other regional studies indicating that mothers often lead the timing and approach to breastfeeding cessation [22, 24]. This pattern may reflect maternal self-efficacy and perceived authority over infant feeding decisions [3]. However, the commonly reported belief that breastfeeding had continued “long enough” suggests that maternal agency operates within socially informed thresholds rather than being guided solely by physiological cues or clinical recommendations. This finding aligns with literature emphasizing that infant feeding practices are embedded in cultural norms, moral expectations, and shared understandings of good caregiving, rather than being determined exclusively by biomedical guidance [22, 44].

Mothers also described mixed emotional and physical experiences following cessation, including relief alongside guilt, sadness, breast pain, and engorgement. These experiences are consistent with literature characterizing breastfeeding cessation as psychologically meaningful and sometimes emotionally challenging, particularly when breastfeeding is closely tied to maternal identity and ideals of “good mothering” [49]. Feminist and relational ethics scholarship suggests that caregiving transitions can be morally charged, intensifying feelings of responsibility and self-judgment among mothers [50]. Although open-text responses in the present study were often brief, they indicate that fatigue and the emotional demands of frequent comfort feeding contributed to mothers’ decisions to stop breastfeeding. Similar emotional complexity has been reported in qualitative studies of infant feeding transitions, where the embodied and relational aspects of feeding shape maternal well-being [51]. The findings reinforce the importance of conceptualizing cessation not only as a nutritional endpoint but also as an emotional transition that may benefit from anticipatory guidance, reassurance, and normalization of mixed emotions [46].

Interpersonal and community influences: family advice and traditional discouragement practices

At the interpersonal and community levels, cessation practices appeared to be strongly situated within family networks and local norms, consistent with socio-ecological models that emphasize the role of relationships and community contexts in shaping health behaviors [32, 34]. A substantial proportion of participants reported using chemical substances, food-based aversives, or medicinal products to discourage breastfeeding. Comparable practices have been documented in Turkey and other settings, suggesting that such methods are often transmitted through intergenerational knowledge and peer advice rather than professional guidance [22, 24, 47]. Iranian studies similarly describe culturally embedded cessation practices, indicating that these strategies are not isolated phenomena but part of broader social traditions surrounding weaning [27, 28].

These practices raise important safety considerations that warrant careful, culturally sensitive discussion. For example, the use of Capsicum- or pepper-based substances may cause infant discomfort or oral irritation, and LactMed highpoints relevant concerns regarding Capsicum exposure during lactation [52]. Similarly, repeated use of medical adhesives has been associated with contact dermatitis and other skin complications, posing potential maternal risks [53]. The reported use of unprescribed medicinal products also raises concerns related to dosing, adverse effects, and medication exposure during lactation, consistent with evidence on non-prescribed medicine use in infants and medication use among breastfeeding mothers [54, 55]. Importantly, these risks are not uniform across all substances; therefore, counseling should avoid stigmatizing language and instead offer safer, acceptable alternatives that address families’ underlying goals reducing feeds and comforting the child while minimizing harm [46].

Beyond direct toxicological or dermatologic risks, reliance on informal advice without professional input may increase the likelihood of inconsistent or abrupt feeding transitions, potentially contributing to nutritional challenges or maternal distress [26]. The persistence of discouragement practices even among relatively well-educated mothers suggests that formal education alone does not necessarily displace culturally embedded strategies, particularly when these practices carry social legitimacy within families and communities [8, 27, 28, 56]. Evidence from implementation research indicates that community-based interventions engaging trusted social actors are often more effective than information-based approaches alone in shifting infant feeding practices [8]. In the Iranian context, involving elder women, midwives, and community health workers as culturally credible messengers may help promote safer cessation practices without undermining valued traditions.

Healthcare and organizational influences: limited consultation and a counseling gap

Only around one third of mothers reported consulting healthcare providers during the cessation period, and among those who did, emotional reassurance was the most common motivation. Similar gaps in professional support during breastfeeding cessation have been reported elsewhere, including qualitative evidence from Jordan indicating that mothers often perceive limited guidance during weaning transitions [8]. These patterns may reflect the limited availability of cessation-specific counseling in routine maternal and child health services or a perception that cessation is primarily a private or family matter rather than a clinical concern. They also align with broader observations that maternity services tend to prioritize breastfeeding initiation and exclusivity while offering less structured support for later transitions [15].

Data collection occurred during the COVID-19 pandemic, which may have further constrained access to in-person counseling and contributed to reduced service utilization [8]. Nevertheless, even beyond pandemic conditions, the findings highlight an important opportunity to integrate cessation counseling into routine maternal–child healthcare contacts, such as well-child visits or complementary feeding consultations. Such integration could provide mothers with practical guidance, symptom management strategies, and reassurance about common child reactions [15, 46, 57]. Given that many mothers sought emotional reassurance, provider training should also emphasize psychosocial communication skills and culturally responsive counseling, rather than focusing exclusively on biomedical advice [8].

The study also identified an association between reported medicinal substance use and higher rates of lactation-related fever and sadness. Although these findings should be interpreted cautiously due to the cross-sectional and self-reported nature of the data, they suggest that medicalized or substance-based approaches to cessation without adequate follow-up may not alleviate distress and may coincide with less favorable maternal experiences. This observation is consistent with broader critiques of maternal healthcare that emphasize the need to address psychological and relational contexts alongside physiological outcomes [45].

Policy context and equity considerations

Despite the presence of breastfeeding promotion initiatives in Iran, existing programs appear to focus primarily on initiation and continuation, with less explicit attention to the practicalities of cessation. This mirrors a broader global pattern in which health systems emphasize early breastfeeding outcomes while offering limited structured support for later transitions [8, 58]. In this study, mothers rarely cited formal national or international guidance as a resource for cessation decisions, instead relying on religious and traditional frameworks. Given that reported breastfeeding durations generally aligned with global recommendations and culturally valued norms [15, 23], there is an opportunity to develop cessation guidance that builds on these shared values while providing evidence-informed strategies for safe and supportive cessation [46]. Exploratory analyses also suggested variation in cessation practices by maternal education, employment status, and district, reflecting broader structural constraints on caregiving. Infant feeding decisions occur within gendered power relations, labor conditions, and unequal access to support, which may limit mothers’ ability to plan gradual or supported cessation even when knowledge is available [8, 56]. Strengthening workplace accommodations, encouraging family involvement (including fathers’ participation in soothing and caregiving), and integrating family-centered counseling may reduce maternal burden and support more gradual, emotionally supportive cessation experiences.

Theoretical and clinical implications

Taken together, these findings support several practical implications. First, healthcare providers could offer anticipatory cessation counseling that clarifies what gradual cessation typically entails, provides strategies for managing breast discomfort and child distress, and offers culturally acceptable alternatives to aversive practices. Second, interventions should engage family networks, particularly elder women who may be influential sources of advice and align messages with local values to enhance acceptability. Third, given the emotional dimension of cessation, supportive counseling should include reassurance and normalize mixed emotions during this transition. Finally, research using longitudinal designs and richer qualitative methods (e.g., interviews) could strengthen understanding of cessation trajectories and better inform culturally sensitive guidance, particularly across diverse Iranian regions and socioeconomic groups.

Implications for policy

Policy efforts to promote breastfeeding in Iran could be strengthened by explicitly addressing breastfeeding cessation as a distinct transition that requires practical, culturally appropriate guidance, rather than focusing only on initiation and continuation. Integrating brief, standardized cessation counseling into routine maternal–child health contacts (e.g., well-child visits and postnatal follow-up) could provide mothers with clear information on what “gradual cessation” means in practice, how to manage common maternal symptoms (e.g., engorgement) and child distress, and when to seek professional support .Given that many mothers described relying on religious and traditional frameworks, cessation guidance is likely to be most acceptable if it builds on the alignment between WHO recommendations for continued breastfeeding up to two years or beyond and prevailing Islamic and Persian cultural values Policy messaging can respect these norms while also discouraging potentially harmful aversive practices by offering safe, feasible alternatives and emphasizing child comfort and maternal well-being. The use of traditional practices to support complete breastfeeding cessation in Iran, as also reported in similar regional contexts such as Turkey, suggests that breastfeeding cessation may be shaped by shared cultural practices. Because some of these practices may be potentially harmful, they warrant further investigation to inform culturally sensitive regional public health recommendations. Community-based implementation strategies that engage trusted intermediaries such as midwives, community health workers, and influential family members (particularly elder women), may increase reach and credibility. Structural supports also matter. Strengthening workplace protections and practical accommodations for breastfeeding and pumping may reduce time pressure and reliance on abrupt or unsupported cessation, particularly for employed mothers. Finally, policies and programs that encourage family involvement, including fathers’ participation in soothing routines and caregiving during the transition, may reduce maternal burden and support more gradual, supportive cessation experiences.

Limitations and future research

The findings of this study should be interpreted in light of several limitations. The sample consisted mainly of well-educated, middle-income, first-time mothers attending public health centers in urban Tehran, which limits generalizability to rural and private-sector populations. Reliance on self-reported online data may have introduced recall and social desirability bias, particularly for emotional experiences and culturally sensitive practices. In addition, open-text responses were often brief, which may have limited the depth of contextual information captured. Limited internet access or digital literacy may also have contributed to selection bias. Finally, the absence of fathers’ and other caregivers’ perspectives restricted examination of breastfeeding cessation as a shared family process. Future research should include paternal and extended family viewpoints and use family-centered qualitative and/or longitudinal designs across diverse cultural and socioeconomic contexts to better capture how cessation decisions and related maternal and child outcomes evolve over time.

Conclusion

This study indicates that breastfeeding cessation among first-time, educated mothers in Tehran is a socially embedded and emotionally complex transition. Although most mothers reported initiating cessation themselves, their decisions and practices were shaped by cultural expectations, family advice, and limited use of professional guidance. The frequent use of traditional cessation practices including applying adhesive or bitter substances to the breast suggests that culturally embedded methods remain common even among well-educated women. Mothers also reported a range of physical and emotional experiences after cessation, including relief as well as breast discomfort and feelings of guilt. Improving breastfeeding cessation experiences requires support beyond individual-level education, including family-centered and culturally responsive counseling within routine maternal–child health services. Trusted community actors such as elder women, midwives, and community health workers may be well positioned to deliver anticipatory, respectful guidance and to promote safer alternatives to potentially harmful practices. At the policy level, developing explicit national guidance on breastfeeding cessation could complement existing breastfeeding promotion efforts. Aligning public health messaging, clinical support, and culturally rooted values help strengthen safer and more supportive cessation experiences for mothers and children.

Abbreviations

EBF

Exclusive breastfeeding

ECD

Early childhood development

LMIC

Low- and middle-income country

SD

Standard deviation

SEM

Social ecological model

WHO

World Health Organization

Author contributions

BH wrote the manuscript and, together with SSS and AR, contributed to the study design, data collection, and editing of the final manuscript. SH and BH performed the data analysis. SSS and AR provided critical revisions and final editing. DE provided consultation on study design, questionnaire development, and technical aspects. All authors reviewed and approved the final manuscript.

Funding

We would like to thank Tehran university of medical science for their funding support provided to the research team that enabled this research to be conducted.

Data availability

The datasets generated and analyzed during the current study are not publicly available due to privacy concerns but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.IKHC.REC.1400.118). Informed consent was obtained from all participants.

Consent for publication

Not applicable, as no identifiable personal data were published.

Competing interests

The authors declare no competing interests.