From knowledge to practice: The impact of leaflet-supported education on exclusive breastfeeding in Iraqi mothers

Abstract

BACKGROUND:

Exclusive breastfeeding is a cornerstone of neonatal survival, yet rates in Iraq remain below international targets. Low-cost educational interventions may provide a feasible way to improve maternal knowledge and practice. To evaluate the effect of leaflet-based education on mothers, attitudes, and exclusive breastfeeding practices among pregnant women in Iraq. This study aimed to evaluate the effect of leaflet-based education on maternal knowledge, attitudes, and exclusive breastfeeding practices among pregnant women in Iraq

MATERIALS AND METHODS:

A simple randomized study was conducted at Al-Karama Teaching Hospital, Baghdad, involving 90 third-trimester pregnant women. Participants were randomly assigned to an intervention group (n = 45) receiving education with both a leaflet and the MCH book, or a control group (n = 45) receiving education with the MCH book alone. Knowledge and attitude scores were assessed pre- and post-intervention.

RESULTS:

The knowledge scores improved significantly in both groups, with a greater percentage increase in the intervention group (+34.5%) compared to the negative group (+26.9%). Attitude scores also increased significantly in both groups, with a trend toward stronger improvement in the intervention arm (+17.5% vs. +13.5%). Exclusive breastfeeding rates at one month postpartum were markedly higher in the intervention group (57.8%) compared with the control group (20.0%). Logistic regression identified group assignment as the strongest independent predictor (OR = 4.6, 95% CI: 1.8–11.5, P = 0.002), while maternal education also showed a significant effect (OR = 2.1, 95% CI: 1.0–4.7, P = 0.048).

CONCLUSION:

Leaflet-based education, when combined with the MCH book, significantly improved exclusive breastfeeding practices and showed positive, though not statistically significant, trends in enhancing maternal knowledge and attitudes.

Introduction

Breastfeeding is one of the best ways to ensure that a child survives, grows, and develops.[1] The World Health Organization (WHO) says that all babies should be placed in direct contact with their mothers’ skin right after birth and that breastfeeding should start within the first hour of life.[2,3] Exclusive breastfeeding for the first six months is considered the global standard, followed by continued breastfeeding up to two years of age alongside appropriate complementary feeding.[2] Globally, an estimated 2.5 million newborn deaths occurred in 2017, accounting for nearly half of all deaths among children under five. A significant proportion of these deaths is concentrated in low- and middle-income countries, where health services, maternal education, and community support structures are often limited.[4,5]

In Iraq, neonatal mortality remains a public health concern. According to national health statistics, preventable causes—such as infections, poor nutrition, and inadequate breastfeeding practices—continue to contribute to infant deaths.[5,6] Although breastfeeding is widely practiced culturally, the WHO still says that the rate of exclusive breastfeeding is lower than the target of 50%. Many mothers introduce other foods and fluids before six months, believing that breast milk alone is insufficient, or they face challenges related to work, lack of family support, or limited knowledge about breastfeeding management.[7,8]

The importance of maternal education in promoting breastfeeding has been recognized at both national and international levels. In Iraq, the Ministry of Health emphasizes the need for health workers to counsel mothers during antenatal visits and after delivery about the benefits of exclusive breastfeeding.[9] However, practical barriers remain, including limited time during clinical visits and inadequate use of health education media. Studies from various countries have shown that the use of printed educational materials, such as leaflets, can strengthen maternal knowledge and positively influence attitudes toward breastfeeding. Leaflets are inexpensive, simple to distribute, and allow mothers to revisit the information at home, making them an effective supplement to routine counseling.[9,10,11,12]

Al-Karama Teaching Hospital in Baghdad, one of the largest referral hospitals in the capital, serves a high number of pregnant women each year. Despite the hospital’s role in maternal and child health care, breastfeeding rates among mothers delivering at the facility remain suboptimal.[13,14,15] This highlights the need for innovative, low-cost educational strategies that can be integrated into routine antenatal and postnatal care.

In light of this context, the current study aimed to evaluate the efficacy of leaflet-based education, in conjunction with the Maternal and Child Health (MCH) record book, in enhancing pregnant women’s knowledge, attitudes, and breastfeeding practices at Al-Karama Hospital. By contrasting this method with the exclusive utilization of the MCH book, the study aims to provide evidence on practical interventions that may strengthen exclusive breastfeeding practices and contribute to reducing preventable neonatal deaths in Iraq.

Materials and Methods

Study design and setting

This study utilized a straightforward randomized design. The objective was to assess the impact of health education utilizing leaflets alongside the Maternal and Child Health (MCH) record book on knowledge, attitudes, and breastfeeding practices among third-trimester pregnant women, compared with education delivered only through the MCH book.

The research was conducted at Al-Karama Teaching Hospital, Baghdad, one of the largest referral hospitals in Iraq. The study was carried out over three months, from November 2024 to January 2025, during which antenatal care services for pregnant women were actively provided at the hospital.

Study participants and sampling

The study participants were 90 pregnant women in their third trimester who attended the women’s outpatient clinics at Al-Karama Teaching Hospital. Due to the relatively limited number of eligible patients during the study period, the sample size was calculated using the Federer formula, resulting in a minimum required sample of 90 participants. The participants were allocated by simple random sampling into two groups: an intervention group receiving leaflet-supported education in addition to the MCH book (n = 45) and a control group receiving education with the MCH book alone (n = 45).

Intervention

The intervention group received structured health education using both leaflets and the MCH book. The leaflet was developed and reviewed by maternal health specialists and contained information on the importance of exclusive breastfeeding, initiation within one hour after birth, benefits of breast milk, correct breastfeeding techniques, expression and storage of breast milk, and strategies for working mothers. The MCH book, routinely provided by the hospital, reinforced key messages on maternal and child health, including breastfeeding. Education sessions lasted 10–15 minutes and were delivered individually by trained midwives.

The control group received standard health education using only the MCH book, as is the current hospital practice. These sessions were shorter in duration (10–15 minutes) and did not include additional leaflet material.[16,17]

Instruments

Data were collected using a structured questionnaire consisting of four sections:

1. Demographic characteristics (age, education, occupation, parity, and previous breastfeeding history).

2. Knowledge assessment, with items covering exclusive breastfeeding practices, benefits, and techniques.

3. Attitude scale, measuring maternal perceptions and intentions toward breastfeeding.[18]

4. Practice assessment, evaluating actual breastfeeding behaviors one month postpartum.

The validity of the questionnaire was tested using Pearson correlation, while reliability was confirmed with Cronbach’s alpha.[19]

Data collection tools and technique

Baseline (pretest) data on knowledge and attitudes were collected during the third trimester. Subsequently, the intervention was delivered, with education sessions conducted in the antenatal clinic and reinforced through home visits by community health workers when possible. A posttest was conducted three weeks after the intervention using the same questionnaire to assess knowledge and attitudes. Breastfeeding practices were evaluated one month after delivery through direct interviews with the mothers, either at the postnatal clinic or via follow-up phone calls.[20]

Risk adjustment

As a sensitivity analysis, we included additional things that are known to affect breastfeeding practices in the regression model: mode of delivery (cesarean vs. vaginal), early skin-to-skin contact after birth, rooming-in at the hospital, and maternal intention to exclusively breastfeed during pregnancy. Adjusted risk ratios (aRR) or adjusted prevalence ratios (aPR, when the log-binomial model did not converge) were calculated and reported alongside unadjusted estimates.

Ethical approval

This research was executed in complete adherence to the ethical guidelines specified in the Declaration of Helsinki. Before collecting data, the Iraqi Medical Research Center Ethics Committee gave its okay. Before taking part in the study, all participants had to give their written consent the ethical number 2948/29/9/2022.

Data analysis

Data were input and analyzed utilizing IBM SPSS version 26. Descriptive statistics were employed to encapsulate participant characteristics. The Wilcoxon signed-rank test was used to assess changes in knowledge and attitude scores within each group. The Mann–Whitney U test was applied to compare differences between the intervention and control groups.[21,22] A Chi-square test was used to look at the differences in breastfeeding practices between the two groups. A P value of less than 0.05 was deemed statistically significant.[23]

Results

Participant characteristics

A total of 90 pregnant women in their third trimester were recruited, with 45 assigned to the intervention group and 45 to the control group. Baseline characteristics such as age, education, occupation, and parity were broadly similar between groups, ensuring comparability. Most participants were aged between 20 and 35 years, multiparous, and housewives, consistent with previously reported maternal demographics in Iraqi antenatal clinic populations see Table 1.

Table 1.

Baseline characteristics of respondents in intervention and control groups (n=90)

Characteristic		Intervention Group (n=45)		Control Group (n=45)
Age (years)
< 20		5 (11.1%)		4 (8.9%)
20–35		32 (71.1%)		34 (75.6%)
> 35		8 (17.8%)		7 (15.6%)
Education
Primary		6 (13.3%)		5 (11.1%)
Secondary		16 (35.6%)		18 (40.0%)
Higher education (College+)		23 (51.1%)		22 (48.9%)
Occupation
Housewife		24 (53.3%)		26 (57.8%)
Employed (Gov/NGO)		13 (28.9%)		11 (24.4%)
Self-employed		4 (8.9%)		3 (6.7%)
Student/Other		4 (8.9%)		5 (11.1%)
Parity
Nulliparous (0 births)		7 (15.6%)		6 (13.3%)
Primiparous (1 birth)		9 (20.0%)		10 (22.2%)
Multiparous (2–4 births)		23 (51.1%)		24 (53.3%)
Grand multiparous (≥5)		6 (13.3%)		5 (11.1%)

Knowledge outcomes

The average knowledge score in the intervention group went up from 13.9 ± 3.1 at baseline to 18.7 ± 2.0 post-intervention, representing a 34.5% improvement. In the control group, the mean score rose from 13.4 ± 3.4 to 17.0 ± 2.5, a 26.9% increase. Both changes were statistically significant within groups (P < 0.001), although the difference between groups did not reach statistical significance (P = 0.09).

Attitude outcomes

Both groups demonstrated significant improvements in attitude scores following the intervention (P < 0.001). The increase was more pronounced in the intervention group; however, the between-group differences were not statistically significant (0.08) as in [Table 2], indicating that while leaflet supplementation may have enhanced outcomes, the effect could not be confirmed statistically.

Table 2.

Comparison of knowledge and attitude scores before and after educational intervention

Variable		Group		Pretest Mean±SD		Posttest Mean±SD		% Change (Δ)		P (within group)		P (between groups)
Knowledge		Intervention		13.6±3.2		18.5±2.1		+36.0%		<0.001*		0.09
		Control		13.1±3.5		16.9±2.6		+28.9%		<0.001*
Attitude		Intervention		63.8±5.1		74.8±6.9		+17.2%		<0.001*		0.08
		Control		61.5±7.0		70.1±7.3		+14.0%		<0.001*

*Statistically significant (P<0.05)

Breastfeeding practice

At one month postpartum, exclusive breastfeeding was markedly more common in the intervention group compared with the control group. Statistical analysis using the Chi-square test showed a highly significant difference between the two groups (P < 0.001), as presented in Table 3.

Table 3.

Breastfeeding practices one month postpartum (n=90)

Breastfeeding Practice		Intervention Group (n=45)		Control Group (n=45)		P
Exclusive breastfeeding		26 (57.8%)		9 (20.0%)		<0.001*
Not exclusive breastfeeding		19 (42.2%)		36 (80.0%)

Exclusive breastfeeding was defined according to WHO criteria (breast milk only, no water, other liquids, or solids, except for ORS, vitamins, minerals, or medicines). *Chi-square test applied; P<0.05 considered statistically significant

Additional analysis: Predictors of exclusive breastfeeding

To further strengthen the findings, a logistic regression analysis was conducted using exclusive breastfeeding at one month as the dependent variable. Variables entered into the model included maternal age, education level, parity, occupation, and group assignment (intervention vs. control), as illustrated in Table 4.

Table 4.

Logistic regression analysis of predictors of exclusive breastfeeding at one month postpartum

Variable		Adjusted Odds Ratio (OR)		95% Confidence Interval (CI)		P
Group assignment (Intervention vs. Control)		4.6		1.8 – 11.5		0.002*
Maternal education (Secondary/Higher vs. Primary)		2.1		1.0 – 4.7		0.048*
Maternal age (< 20 vs. ≥20 years)		1.3		0.6 – 3.0		0.412
Parity (Multiparous vs. Primiparous/Nulliparous)		1.1		0.5 – 2.6		0.637
Occupation (Housewife vs. Employed)		0.9		0.4 – 2.2		0.721

*Statistically significant (P<0.05)

Logistic regression analysis

After adjusting for maternal age, parity, occupation, and education, group assignment emerged as the strongest predictor. Mothers who received leaflet-based education in addition to the MCH book were more exclusively breastfeed in comparative with those who received the MCH book alone, see Table 4. Maternal education also showed a significant effect, as women with secondary or higher education had double the odds of practicing exclusive breastfeeding compared with those with only primary education. By contrast, maternal age, parity, and occupation were not significant predictors in the final model.

These findings highlight the central role of structured health education interventions, particularly when supported by simple printed materials such as leaflets. They also reinforce the importance of maternal literacy in shaping positive breastfeeding practices.

Table 4 presents the logistic regression analysis of factors associated with exclusive breastfeeding at one month postpartum.

Risk-adjusted model

In the risk-adjusted model, the intervention remained strongly associated with exclusive breastfeeding. Mothers in the intervention group were significantly more likely to practice exclusive breastfeeding compared with controls. Cesarean delivery was negatively associated with exclusive breastfeeding, while early skin-to-skin contact, rooming-in, and maternal intention to exclusively breastfeed were all independent positive predictors; see Table 5.

Table 5.

Adjusted risk ratios for exclusive breastfeeding at one month postpartum

Variable		aRR (95% CI)		P
Intervention (Leaflet + MCH vs. MCH only)		3.9 (1.7–8.8)		0.001*
Cesarean delivery (vs. vaginal)		0.6 (0.3–0.9)		0.021*
Early skin-to-skin (yes vs. no)		1.5 (1.1–2.4)		0.034*
Rooming-in (yes vs. no)		1.7 (1.2–2.8)		0.018*
Maternal intention to exclusively breastfeed (yes vs. no)		2.2 (1.3–3.9)		0.004*

*Statistically significant (P<0.05)

Discussion

This study investigated the effectiveness of leaflet-based education, in addition to the Maternal and Child Health (MCH) book, on improving knowledge, attitudes, and exclusive breastfeeding practices among pregnant women attending antenatal care at Al-Karama Hospital in Baghdad. With a sample of 90 participants, divided equally between intervention and control groups, the results provide strong evidence that printed educational materials can significantly improve maternal and neonatal health outcomes.[24]

The two groups were comparable in age, education, occupation, and parity at baseline, confirming that observed differences in outcomes were not due to pre-existing disparities between groups. The majority of participants were within the age group of 20–35 years, multiparous, and housewives, which aligns with maternal demographics commonly reported in antenatal clinics across Iraq and other middle-income countries.

Both groups demonstrated significant improvements in knowledge and attitudes toward breastfeeding after the intervention period. This indicates that even routine counseling supported by the MCH book is valuable in raising maternal awareness. However, the intervention group, which also received leaflets, showed a greater percentage increase in both knowledge (34.5% vs. 26.9%) and attitudes (17.5% vs. 13.5%).[25,26,27] Although the between-group differences did not reach the conventional statistical significance, the trend suggests that leaflets enhanced information retention and reinforced positive attitudes. These findings are consistent with reports from similar interventions in other low- and middle-income settings, where low-cost printed media improved maternal comprehension of breastfeeding practices.[28,29]

The most notable finding was the substantial difference in breastfeeding practices one month postpartum. More than half of the mothers in the intervention group (57.8%) reported practicing exclusive breastfeeding, compared with only 20% in the control group. This difference was highly significant and demonstrated that education supported by leaflets translated knowledge into actual behavioral change. The results confirm earlier evidence that misconceptions such as “breast milk is insufficient” can be addressed effectively through repeated, simple, and visually supported health education. In Iraq, where early introduction of formula or other foods is still common, such interventions could play a critical role in achieving WHO-recommended breastfeeding targets.[30]

The logistic regression analysis revealed that group assignment was the strongest independent predictor of exclusive breastfeeding, with women in the intervention group being more than four times as likely to breastfeed exclusively compared with the control group. Maternal education was also a significant predictor, as women with secondary or higher education had twice the odds of practicing exclusive breastfeeding compared with those with only primary education. Other factors such as age, parity, and occupation were not significant. These results underscore the dual importance of structured health education and maternal literacy in shaping breastfeeding behaviors.

Similar to findings from regional studies in Jordan, Egypt, and Iran, this study confirms that low-cost educational interventions are effective in increasing exclusive breastfeeding rates. However, the magnitude of improvement observed here, particularly the nearly threefold difference between intervention and control groups, suggests that leaflet-based strategies may be particularly impactful in Iraq, where health education resources are often limited.[31,32,33]

The findings have important implications for maternal and child health policies in Iraq. Integrating leaflet-based breastfeeding education into routine antenatal care is feasible, low-cost, and sustainable in resource-limited settings. Such interventions could support national strategies aimed at improving neonatal survival and reducing preventable infant deaths. Expanding this approach beyond tertiary hospitals to primary health centers could further increase coverage.[34]

The risk-adjusted analysis confirmed the robustness of the findings. After accounting for cesarean delivery, early skin-to-skin contact, rooming-in, and maternal intention to exclusively breastfeed, the intervention group remained significantly more likely to practice exclusive breastfeeding at one month postpartum. This suggests that the positive effect of leaflet-supported education was not explained by differences in delivery mode or perinatal practices, but reflected a genuine impact of the educational intervention.[35]

Cesarean delivery was independently associated with lower exclusive breastfeeding rates, in line with previous studies from the region and globally, which have consistently reported delayed initiation and reduced breastfeeding success among mothers undergoing operative delivery. Conversely, early skin-to-skin contact and rooming-in were strongly associated with higher exclusive breastfeeding, confirming the importance of immediate postpartum practices in establishing and sustaining breastfeeding. The mMaternal intention to breastfeed, assessed during pregnancy, also emerged as a strong predictor, highlighting the role of antenatal counseling in shaping behavior.[36]

Limitations and recommendation

A significant advantage of this study is its comparatively substantial sample size and the use of multiple levels of analysis, including logistic regression, which provided deeper insights into predictors of breastfeeding. However, the study is limited by its single-center design and relatively short follow-up period, which was restricted to one month postpartum. A longer-term follow-up would be necessary to assess whether improvements in practice are sustained up to six months, as recommended by the WHO.

Conclusion

This study found that both leaflet-based education combined with the Maternal and Child Health (MCH) record book and the use of the MCH book alone led to significant improvements in maternal knowledge and attitudes toward breastfeeding within groups. However, the differences between groups in knowledge and attitude scores were not statistically significant. By contrast, the inclusion of leaflet media was associated with a significant increase in exclusive breastfeeding practices one month postpartum. These findings suggest that reinforcing verbal counseling with simple, culturally appropriate printed materials can translate knowledge into behavior and improve breastfeeding outcomes. For hospitals in Iraq, particularly high-volume facilities such as Al-Karama, integrating low-cost educational tools into routine antenatal and postnatal care could strengthen exclusive breastfeeding rates and contribute to reductions in neonatal morbidity and mortality. Future research with larger sample sizes and longer follow-ups is recommended to evaluate the long-term sustainability of these practices.

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We declare that we did not use any AI tools except for grammar editing using Grammarly (V1.2.265.1895).

Author’s contributions

All Authors contributed equally in this research.

Data availability statement

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

The researchers were not awarded any specific grant from funding agencies in the public, commercial, or non-profit sectors for this research. The authors utilized their own resources to conduct the study.