Exclusive breastfeeding during the first six months of life is a foundational intervention for child survival and healthy development. Human milk supplies macronutrients, micronutrients, immunoglobulins, antimicrobial factors, hormones, enzymes, oligosaccharides, and living cells that are biologically adapted to the infant. The World Health Organization recommends exclusive breastfeeding from birth to six months, followed by nutritionally adequate complementary feeding while breastfeeding continues to two years or beyond.¹ Beyond direct nutritional value, breastfeeding protects against common childhood infections and contributes to maternal health; accordingly, it is embedded in global strategies for maternal, newborn, and child health.^1,2

Despite strong biological and public-health justification, breastfeeding practices remain below recommended levels in many countries. Recent global syntheses describe breastfeeding as a multilevel behaviour shaped by maternal characteristics, infant conditions, household relationships, social norms, commercial influences, employment, and the organization of health services.^2–4 This framework is important because failure to maintain exclusive breastfeeding should not be interpreted simply as a lack of motivation or knowledge. A mother may understand the recommendation yet discontinue exclusive breastfeeding when she experiences pain, attachment problems, perceived insufficient milk, pressure to introduce water or formula, competing work, or limited access to skilled help.^3,4

Indonesia has made measurable progress, but national improvement masks substantial local variation. WHO and UNICEF reported that exclusive breastfeeding among infants younger than six months increased from 52% in 2017 to 66.4% in 2024, while also emphasizing that many infants still do not receive exclusive breastfeeding for the full recommended duration.⁵ Earlier national reporting highlighted persistent weaknesses during the critical newborn period, including delayed initiation, prelacteal feeding, and inadequate skin-to-skin contact.⁶ These patterns indicate that national prevalence alone cannot identify where the continuum of support fails or which groups require additional assistance.

Current evidence indicates that maternal age is an important but context-dependent determinant. Adolescent mothers often face limited breastfeeding experience, low self-efficacy, dependence on family decision-making, stigma, educational disruption, and inadequate access to tailored care. A 2023 systematic review and meta-analysis found that supportive interventions involving education, counselling, home visits, and peer support improved breastfeeding outcomes among adolescent mothers.⁷ In Indonesia, appropriate postnatal care was strongly associated with continued exclusive breastfeeding among adolescent mothers, highlighting the interaction between age-related vulnerability and service quality.⁸ Older maternal age may involve different pathways, including chronic health conditions, obstetric complexity, fatigue, accumulated caregiving demands, and prior feeding experiences that may or may not align with current recommendations.^3,9

Parity and prior breastfeeding experience are similarly complex. Primiparous women frequently report a gap between expectations and the early reality of breastfeeding, with attachment difficulties, pain, uncertainty about milk adequacy, and emotional distress during the first postpartum days.¹⁰ Multiparity can offer practical experience, yet previous unsuccessful breastfeeding or household responsibilities may also undermine current practice. A recent systematic review of predictors of exclusive breastfeeding identified parity, maternal education, maternal age, economic conditions, mode of delivery, early initiation, and caregiving support among recurring determinants, while emphasizing heterogeneity across populations.³

Maternal nutrition is another relevant dimension, particularly in agrarian communities where food availability does not necessarily guarantee dietary diversity. Adequate energy and nutrient intake supports maternal health and recovery, while selected components of human milk—especially fatty acids and some vitamins—can vary with maternal diet. An updated systematic review found increasing evidence linking maternal diet to human-milk fatty-acid profiles, but also substantial methodological heterogeneity and limited evidence for many other milk components.¹¹ Therefore, dietary diversity should be interpreted as a marker of maternal nutritional conditions and household food practices rather than as a direct or exclusive determinant of milk volume.

Health-service contact is among the most modifiable determinants. An overview of systematic reviews found that breastfeeding education and support generally improve early initiation and exclusive breastfeeding, with community-based packages integrated into antenatal or postnatal care showing particular promise in low- and middle-income settings.² An updated evidence review for the US Preventive Services Task Force similarly concluded that behavioural and educational support can increase any and exclusive breastfeeding through six months, although effects vary by intervention intensity, timing, and delivery model.¹² A 2024 midwife-led postpartum intervention improved breastfeeding self-efficacy and maintenance of exclusive breastfeeding, supporting the value of structured, repeated contact beyond routine advice.¹³ Immediate postnatal counselling trials likewise support repeated, problem-oriented education rather than a single informational encounter.²⁰

Family relationships can facilitate or constrain breastfeeding. Fathers may provide emotional reassurance, practical assistance, protection from inappropriate supplementation, and support for accessing professional care. A multicentre study reported that paternal breastfeeding-support self-efficacy was positively associated with exclusive breastfeeding at six weeks postpartum.¹⁴ At the same time, broad measures of support may conceal differences in actual behaviour: verbal approval is not equivalent to sharing household work, defending exclusive breastfeeding against family pressure, or helping mothers obtain care. Cultural beliefs and food taboos are also relevant in South Sulawesi, where community studies have documented restrictions and inherited beliefs affecting maternal food practices and infant feeding.^15,16

Rural Enrekang provides a distinctive setting for examining these interactions. Curio District is an agrarian area comprising 11 villages, with dispersed settlements and varying travel distances to health services.¹⁷ Women may combine infant care, domestic responsibilities, and agricultural work, while postnatal counselling may depend on limited health-center staff, community health posts, and cadres. Evidence from Enrekang has shown that implementation of exclusive-breastfeeding policy depends not only on formal regulation but also on health-worker engagement, community communication, and the management of local beliefs.¹⁶

Existing studies often focus on a single determinant or use urban and facility-based samples. Fewer studies integrate maternal age, parity, dietary diversity, infant characteristics, social factors, and post-discharge breastfeeding education within one model in a rural Indonesian population. This gap matters because determinants may change after adjustment: a factor associated in bivariate analysis may reflect underlying age, experience, or access to counselling rather than an independent effect. The present study therefore assessed maternal, infant, social, nutritional, and health-service factors associated with exclusive breastfeeding among mothers of infants aged 0–6 months in the Sumbang Primary Health Center catchment area and identified factors independently associated with non-exclusive breastfeeding.

This study documented a low prevalence of age-appropriate exclusive breastfeeding in a rural Enrekang population: only 12.4% of mothers reported exclusive breastfeeding at interview. The estimate is markedly below recent national figures, although direct comparison requires caution because national indicators, survey methods, infant-age distributions, and recall windows may differ.^5,6 The local prevalence nonetheless identifies an important service and behavioural gap. Most participants simultaneously experienced one or more potential constraints: age outside 20–35 years, parity at risk, inadequate dietary diversity, low household income, employment, and absence of postnatal breastfeeding education. The clustering of these conditions illustrates why breastfeeding should be approached as a multilevel practice rather than a single maternal decision.^2–4

The most robust maternal characteristic was age. Mothers younger than 20 years or older than 35 years had approximately sixfold higher adjusted odds of non-exclusive breastfeeding than mothers aged 20–35 years. This finding is consistent with contemporary syntheses identifying maternal age as a recurring predictor, although the direction and magnitude vary across countries and study designs.^3,9 Age likely operates through different mechanisms at the two extremes. Adolescents may have limited experience, lower confidence, less control over household decisions, disrupted education, and dependence on older relatives. Supportive interventions for adolescent mothers—including counselling, home visits, and peer support—have been shown to improve breastfeeding outcomes.⁷ Indonesian evidence further indicates that adequate postnatal care is particularly important for continued exclusive breastfeeding among adolescent mothers.⁸

For mothers older than 35 years, age-related risk should not be assumed to reflect the same pathway. Older mothers may have greater autonomy and experience, but may also have chronic conditions, obstetric complications, fatigue, multiple children, or competing responsibilities. A 2025 study from Japan identified older maternal age and primiparity among factors associated with lower exclusive breastfeeding, illustrating that age and experience can interact rather than act independently.⁹ Because the present study combined mothers younger than 20 and older than 35 years, it cannot determine which subgroup generated the association. The wide confidence interval also indicates limited precision, resulting partly from only 22 mothers in the 20–35-year reference category. Future studies should model age in finer categories or as a continuous variable and test interaction with parity, employment, and postnatal care.

Parity was associated with exclusive breastfeeding in bivariate analysis but not after adjustment. The unadjusted pattern is plausible: only 10.2% of mothers with parity at risk exclusively breastfed, compared with 35.3% in the two-to-four-birth category. Primiparous mothers commonly experience unexpected pain, ineffective attachment, uncertainty about milk transfer, and a mismatch between prenatal expectations and postpartum reality.¹⁰ Grand multiparous mothers may have substantial caregiving workloads or rely on earlier feeding practices. However, the adjusted estimate crossed the null, suggesting that the bivariate association was partly shared with age and education exposure. The result also underscores that parity categories that combine primiparity and grand multiparity may obscure distinct mechanisms.

Dietary diversity showed a similar pattern: a significant bivariate relationship but no statistically independent association after adjustment. Mothers with adequate diversity had a higher exclusive-breastfeeding proportion than those with inadequate diversity, yet only 12 participants met the minimum diversity threshold. This imbalance produced a wide confidence interval and limited statistical power. Maternal diet is relevant to health, recovery, and selected milk constituents, but it should not be represented as the sole biological driver of milk production. The updated review by Petersohn et al. found the strongest and most rapidly growing evidence for associations with human-milk fatty acids, while evidence for carbohydrates, proteins, vitamins, and minerals remained heterogeneous.¹¹ Thus, dietary counselling should support maternal nutritional wellbeing without implying that mothers with limited food diversity are inherently unable to breastfeed.

The high prevalence of inadequate dietary diversity—93.8%—remains programmatically important even though it was not independently associated in the final model. Nearly all households reported income below the regional minimum wage, suggesting that affordability, market access, workload, meal allocation, and food taboos may shape intake. In South Sulawesi, food restrictions during pregnancy and lactation have been documented among Indigenous and local communities.¹⁶ In an agrarian district, nutritional interventions should therefore go beyond generic advice. They should identify affordable local sources of animal protein, legumes, vegetables, fruits, and nutrient-dense foods; address culturally specific restrictions; and involve household decision-makers.

Postnatal breastfeeding education was the strongest factor identified. Only 20.2% of mothers received education after returning home, and mothers without education had approximately 20-fold higher adjusted odds of non-exclusive breastfeeding. The magnitude is large and the confidence interval is wide, so it should not be interpreted as a precise causal effect. Nevertheless, the direction is strongly consistent with current evidence. An overview of systematic reviews found that education and support interventions can improve breastfeeding initiation and exclusive breastfeeding, particularly when community-based packages are integrated into antenatal and postnatal care.² The updated USPSTF evidence review also concluded that breastfeeding-support interventions increase the prevalence of any or exclusive breastfeeding through six months.¹² Randomized evidence further supports immediate or structured postpartum counselling as a means of improving exclusive breastfeeding and maternal confidence.^13,20

The timing of education is critical. Advice delivered before discharge may not address difficulties that emerge at home, such as frequent infant crying, breast engorgement, pain, uncertainty about swallowing, family pressure to supplement, or concern that milk is insufficient. A midwife-led postpartum programme improved self-efficacy and exclusive breastfeeding at six months, supporting the principle that structured follow-up can convert knowledge into practical problem solving.¹³ Immediate postpartum counselling has also shown benefits in randomized research,²⁰ while supportive interventions for adolescent mothers are more effective when they include repeated contact, home visits, or peer support rather than a single information session.⁷

For Curio, continuity of care may require a layered delivery model. The primary health center alone may be unable to provide frequent individualized contact across 11 villages. Home visits by midwives, counselling during community health-post sessions, trained cadres, telephone or messaging follow-up, and clear referral pathways could extend reach. However, quality must be protected. “Education” should include direct assessment of positioning and attachment, observation of milk transfer, management of breast problems, explanation of normal infant feeding patterns, safe expression and storage when needed, and counselling that avoids blame. Intervention fidelity, provider competence, timing, dose, and content should be measured in future implementation studies.^12–14

Although all mothers reported husband and family support, these variables could not be analysed because there was no variation. Universal reported support may reflect genuinely supportive families, but it may also reflect broad questions, courtesy bias, or social desirability. Contemporary evidence suggests that paternal support is multidimensional. Father-support self-efficacy has been positively associated with exclusive breastfeeding, indicating that fathers need not only favourable attitudes but also confidence and practical skills to assist mothers.¹⁵ Future questionnaires should distinguish emotional encouragement, household assistance, protection from inappropriate supplementation, financial support, accompaniment to services, and response to lactation problems.

Exposure to breastfeeding myths was not statistically significant, although non-exclusive breastfeeding was slightly more common among mothers who endorsed myths. The binary indicator may have been too broad: believing that certain foods should be avoided is qualitatively different from advising water, honey, formula, or early complementary feeding. Previous work in Enrekang and South Sulawesi indicates that local beliefs and food taboos remain relevant to maternal and infant practices.^16,17 Qualitative research could identify which beliefs are common, who transmits them, and how they influence decisions during the first days after birth.

Infant characteristics were not significantly associated with the outcome. This should not be interpreted as evidence that low birth weight, illness, or ineffective sucking are unimportant. The sample contained only 10 low-birth-weight infants, eight infants with illness, and 20 with ineffective sucking, limiting the ability to detect differences. Contemporary evidence shows that low-birth-weight and preterm infants often require specialized feeding support, while the optimal duration and implementation of exclusive breastfeeding in these groups remain areas of uncertainty.^26,27,30 In this study, the lack of association may reflect small exposed groups, effective compensatory care, or measurement based mainly on maternal report rather than standardized clinical assessment.

Mode of delivery was also not associated, but only 17 mothers delivered by cesarean section. Cesarean birth may interfere with early contact through anesthesia, postoperative pain, delayed mobility, maternal-infant separation, or clinical monitoring; however, these effects can be mitigated by skin-to-skin contact, rooming-in, and skilled assistance. A recent scoping review found that vaginal birth was generally associated with better initiation and continuation outcomes than cesarean birth, although supportive maternity practices can reduce this gap.^21,24 The universal report of early initiation in this study is encouraging, but it also raises measurement questions. When all participants report early initiation, it is impossible to evaluate its contribution, and recall or differing interpretations of initiation may be present. Future research should verify timing from records and distinguish uninterrupted skin-to-skin contact from brief assisted attachment.

Maternal education and employment were not associated with exclusive breastfeeding. Most mothers had upper-secondary or higher education, reducing variation. Employment was common, but the study did not capture occupation type, hours, distance from the infant, maternity leave, workplace flexibility, expression facilities, or family childcare arrangements. Evidence from employed populations shows that maternity leave, workplace conditions, job flexibility, and opportunities to express milk can materially influence breastfeeding continuation.^24,25,29 A binary employed/not-employed classification is therefore unlikely to represent the mechanisms through which work influences feeding. Rural agricultural work may allow proximity to the infant in some families but impose physically demanding schedules in others.

Psychological risk was not associated, but only eight mothers were classified as at risk, and the study used a 12-item local screening measure rather than a validated diagnostic scale. Anxiety, depressive symptoms, stress, breastfeeding self-efficacy, and perceived milk insufficiency may have distinct effects and should be assessed separately. Recent systematic reviews indicate that postpartum depression and anxiety are associated with lower breastfeeding self-efficacy, whereas higher self-efficacy supports the initiation and maintenance of exclusive breastfeeding.^22,23,28 The strong association with education may partly reflect the role of counselling in improving confidence and reducing uncertainty, but this hypothesis was not tested. Future studies should use validated scales and evaluate whether self-efficacy mediates the effect of postnatal support.

The study contributes evidence from a rural Indonesian district that is rarely represented in breastfeeding research. Its analytic value lies in evaluating maternal, infant, dietary, social, and service variables together and showing that associations observed for parity and dietary diversity weakened after adjustment, whereas maternal age and postnatal education remained. The results identify a modifiable service gap rather than attributing failure primarily to mothers. They support a shift from one-time health education toward a continuum of skilled, responsive support adapted to rural geography.

Several limitations should guide interpretation. The cross-sectional design cannot establish whether the absence of education preceded supplementation in every case, and reverse selection is possible if mothers experiencing problems were more or less likely to seek counselling. Infant ages varied from 0 to 6 months, so younger infants had a shorter period in which supplementation could occur. Feeding data and several exposures depended on maternal recall and may be affected by social desirability. Some categories were extremely imbalanced, leading to unstable estimates and wide confidence intervals. The age-risk category combined adolescents and mothers older than 35 years; the parity-risk category combined primiparity and grand multiparity. Education exposure was measured only as ever/never after discharge without information on timing, dose, provider, content, or quality.

Additional analytical limitations include the absence of reported model-fit diagnostics, multicollinearity assessment, interaction testing, and sensitivity analyses. The number of exclusive-breastfeeding outcomes was small relative to the number of candidate variables. Although the final model contained four predictors, sparse cells can still inflate odds ratios. Future studies should recruit larger samples, stratify by infant age, measure the exact timing of supplementation, use repeated follow-up from birth to six months, and apply causal frameworks to pre-specify confounders. A cluster-randomized or stepped-wedge evaluation of structured post-discharge counselling would be particularly valuable.

From a service perspective, the most defensible implication is to strengthen postnatal breastfeeding support while targeting mothers who may need greater assistance. Risk-based follow-up should not stigmatize younger or older mothers; instead, it should ensure early contact, direct observation of a feed, rapid management of problems, and family-inclusive counselling. Nutrition support and attention to work conditions remain important complementary strategies. Because breastfeeding is shaped by systems, interventions should combine competent clinical care, community outreach, supportive families, and protection from inappropriate promotion of breast-milk substitutes.^4–6,12,13

Exclusive breastfeeding was reported by 12.4% of mothers in the Sumbang Primary Health Center catchment area. Maternal age outside 20–35 years and absence of postnatal breastfeeding education were independently associated with non-exclusive breastfeeding, while parity and dietary diversity were associated only before adjustment. The study adds rural Indonesian evidence that continuity and quality of breastfeeding support after discharge are central, modifiable components of exclusive-breastfeeding promotion. Programmes should prioritize timely, practical, family-inclusive counselling and follow-up for mothers with age-related or early lactation vulnerabilities. Longitudinal and intervention studies are needed to determine causality, distinguish adolescent from older maternal pathways, and identify the effective timing, intensity, and content of counselling.

No figures are included in this manuscript.

Ethical approval was granted by the Health Research Ethics Committee, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia (approval number 3376/UN4.14.1/TP.01.02/2024; protocol number 121124093079; 19 October 2024). The protocol underwent full-board review. Written informed consent was obtained before data collection. Participation was voluntary, responses were confidential, and participants could withdraw without penalty.

R.R., C.C., M.M., and A.N.U. contributed to conceptualization and methodology. R.R., Z.Z., A.A.N., and N.S.N.L. conducted the investigation and data curation. R.R., M.M., and A.M. performed the formal analysis. C.C., M.A., R.I., and A.N.U. contributed to validation, supervision, and interpretation of the findings. R.R. prepared the original draft. All authors contributed to manuscript review and editing, approved the final manuscript, and agreed to be accountable for all aspects of the work.

Not applicable.