Peer Review Report For: Factors Associated with Breastfeeding Duration in Tunisia: A Cross-Sectional Analysis Highlighting the Role of Early Initiation [version 2; peer review: 2 approved]

Background Breastfeeding is vital for maternal and child health, yet breastfeeding practices and duration vary globally. In Tunisia, data on factors influencing breastfeeding, especially initiation timing, are limited. This study assessed breastfeeding practices, initiation timing, and associated maternal and delivery factors among Tunisian women, focusing on breastfeeding duration up to 12 months postpartum. Methods Analytical cross-sectional study was conducted over a four-month period, from November 1, 2023, to February 29, 2024, in the Gynecology and Obstetrics Department B of Charles Nicolle Hospital in Tunis- Tunisia. Women who delivered during the study period were included. Data on sociodemographic characteristics, medical and obstetric history, breastfeeding knowledge and preparation, delivery, postpartum and breastfeeding practices were collected through a questionnaire. Breastfeeding duration was grouped into 1–3, 3–6, and >6 months. Associations with breastfeeding duration were analyzed. Results In total, 400 women were included. Most women were Tunisian (99%), urban residents (91.5%), and of higher socioeconomic status (84.3%). Obesity was present in 20.5%, and cesarean delivery rate was 52.8%. Early breastfeeding initiation (within 1 hour) occurred in only 19.3%, with 80.8% delayed initiation. Breastfeeding continuation at 12 months was 44% and was significantly associated with early initiation (p < 0.001); 77.9% of women who initiated breastfeeding within the first hour continued at 12 months, compared to markedly lower rates among those with delayed initiation. Maternal obesity predicted shorter breastfeeding duration (p = 0.026). Cesarean delivery showed no significant impact. Skin-to-skin contact was low (38.3%), and less than half received breastfeeding education (46%). Family support was not linked to breastfeeding duration. Conclusions Breastfeeding continuation at 12 months was associated with early initiation and negatively influenced by maternal obesity. Despite high breastfeeding intention, delays in initiation, obesity and limited breastfeeding education hinder optimal breastfeeding outcomes. Interventions promoting early initiation, skin-to-skin contact, and tailored postnatal support are needed to improve breastfeeding continuation.