The effect of prenatal education on exclusive breastfeeding among women in Quito: prospective cohort study

Abstract

Background

Breast milk is the optimal food for humans, however, many mothers face challenges in sustaining exclusive breastfeeding (EBF). Prenatal education (PE) has been suggested as a strategy to promote EBF, but there is evidence that its impact on EBF duration remains inconclusive. This study aimed to evaluate the effect of PE on EBF continuation among mothers who gave birth in private and public hospitals in Quito, Ecuador, and to identify modifiable risk factors associated with EBF discontinuation.

Methods

A prospective cohort study was conducted, recruiting 278 mothers, of whom 152 received PE and 126 did not. Participants were followed from birth to six months postpartum. Data collection included a structured survey, with baseline clinical information obtained through face-to-face interviews before hospital discharge and follow-up telephone interviews at one, four, and six months postpartum.

Results

Comparisons between the PE and non-PE groups revealed significant differences in education level, health insurance, antenatal care visits, rooming-in rates, parity, and maternal breastfeeding (BF) intentions. Participants who received PE had a significantly longer mean EBF duration (89.4 ± 77.2 days vs. 66.1 ± 70.2 days, p = 0.004). The incidence rate of EBF abandonment was 11.81 per 100 person-months in the PE group and 14.91 per 100 person-months in the non-PE group. Cox survival analysis indicated a lower risk of EBF cessation among mothers who received PE (adjusted hazard ratio [aHR] = 0.58, 95% CI = 0.40-0.84, p = 0.004). Other factors associated with EBF discontinuation included delivery at a public health facility, postpartum depression, insufficient milk supply, return to work, healthcare provider recommendations, family advice, and negative BF experiences.

Conclusion

Standardized PE programs have a significant and independent positive impact on EBF duration among mothers in Quito, Ecuador. Integrating PE into routine prenatal care and providing comprehensive postpartum support is essential to promoting BF continuation. Targeted interventions should address modifiable risk factors, such as postpartum mental health, return-to-work policies, and healthcare provider recommendations regarding BF.

Background

Breast milk is the optimal food for humans [1]. Breastfeeding (BF) offers numerous benefits to both mothers and children. It reduces health costs by lowering maternal and infant morbidity and mortality and is also beneficial for the environment as it is a natural, safe, and renewable resource [2]. BF fosters essential bonds between mothers and their children, contributing to the child’s overall physical, psychoemotional, and social development [1]. Despite these well-documented benefits, globally, exclusive breastfeeding (EBF) rates remain suboptimal, and many mothers discontinue BF earlier than recommended [3].

Prenatal education (PE) programs provide expectant mothers with essential knowledge and support for pregnancy, childbirth, postpartum, and newborn care. These programs often include prenatal classes, counseling sessions, and educational materials aimed at promoting EBF [4, 5]. While PE holds promise as a potential intervention to improve EBF rates, the evidence regarding its effectiveness remains inconclusive and subject to debate [6]. In Ecuador, the standardized PE program includes six sessions, one of which is specifically dedicated to breastfeeding. This session covers essential breastfeeding topics, including the benefits of breastfeeding, early initiation, positioning and latch techniques, common breastfeeding challenges, and how to manage milk supply [7].

Several studies have investigated the impact of PE on EBF outcomes, yielding mixed results. Some studies have reported positive associations between PE and increased rates of EBF initiation and duration, suggesting that well-designed educational interventions can positively influence BF practices [6, 8]. However, other studies have not demonstrated a significant effect, likely due to heterogeneity in research designs, study populations studied, and the content or format of PE sessions [9, 10].

This study specifically assessed EBF, which is defined as feeding infants only breast milk with no other liquids or solids, following the WHO definition [11]. Additionally, we collected data on early breastfeeding initiation, maternal intentions regarding breastfeeding duration, and reasons for discontinuation of EBF. In 2015, Ecuador mandated a PE program in public and private health facilities as part of national strategies to reduce maternal mortality. However, despite being a national guideline, its implementation is uneven, and access y not universal. No previous studies have evaluated its impact on breastfeeding practices. Given Quito’s diverse cultural, social, and economic context, this study aims to evaluate the influence of standardized PE on the duration of EBF and to identify modifiable factors associated with its discontinuation. The findings will help inform public health strategies to promote and support breastfeeding in Quito and similar settings.

Materials and methods

Study design

A prospective cohort study was conducted to assess the effect of PE on EBF duration. The study followed two groups of mothers (exposed and unexposed to PE) from delivery up to six months postpartum. Exposure status was not assigned by the investigators but occurred naturally, based on participants’ attendance or non-attendance to the PE program.

Setting

The study was carried out in Quito, Ecuador’s capital in both public and private hospitals located in urban areas. Quito has a population of approximately 2.78 million people, with diverse characteristics in terms of educational level, ethnicity, and access to healthcare services. Women represent 51.7% of the population, and the majority identify as mestizo (mixed ethnic background). Most women in Quito have completed primary and secondary education, and 33.7% hold higher education qualifications [12].

Sampling

A convenience sampling method was used due to the absence of a centralized database of pregnant women and logistical limitations. Participants were recruited between May 2019 and March 2020, after delivery and before hospital discharge. Although PE is part of a national policy in Ecuador, its implementation is not universal. Attendance is voluntary and often limited by structural and individual barriers, including lack of promotion, inconsistent availability across facilities, and scheduling conflicts with maternal responsibilities.

Women were not randomized to receive PE. Instead, their exposure status reflected real-world conditions, allowing for the comparison of two naturally occurring groups. Despite the non-random sampling, statistical adjustments were made during the analysis to account for baseline differences and reduce potential confusion bias.

Sample size calculation

The sample size was calculated using GRANMO version 7.12 to detect a statistically significant relative risk of 1.5 or greater in the rate of EBF [13]. The expected EBP prevalence at five months in the unexposed group was estimated at 40%, based on the 2012 National Health and Nutrition Survey of Ecuador. Assuming a two-sided alpha error of 0.05 and a beta error of 0.20 (80% power), the initial required sample size was 107 participants per group (exposed and unexposed). To account for a potential 30% loss to follow-up, the adjusted sample size increased to 153 participants per group [14]. At the end of the study, we included 152 women in the exposed group and 126 in the unexposed group, which represents an overall follow-up rate above expectations and closely matches the calculated target, ensuring adequate statistical power.

Inclusion and exclusion criteria

Inclusion criteria for exposed mothers included: being in the postpartum period after delivery and before discharge, completing all six PE sessions, giving birth in the same healthcare facility, and being over 18 years old.

Exclusion criteria for exposed mothers included: a history of prenatal depression and giving birth to an infant requiring neonatal intensive care.

Similar inclusion and exclusion criteria were applied to non-exposed mothers, except for the requirement of attending six PE sessions.

Participants who were not reachable after five follow-up contact attempts were considered lost to follow-up.

Data collection

The cohort was divided based on exposure to PE. Data was gathered through structured surveys administered by trained interviewers with experience in maternal and child health. Before data collection, the interviewers completed a two-day training session covering the study objectives, informed consent procedures, administration of structured surveys, the use of the PHQ-9 for depression screening, and effective communication techniques for conducting phone interviews. Informed consent was obtained from all participants before enrollment. Surveys were administered at four distinct time points: after birth and before hospital discharge in a face-to-face encounter; and, by phone, at one, four, and six months postpartum.

Baseline clinical data were obtained through a review of perinatal clinical history records, with written authorization from participants. The baseline survey included socio-economic and demographic status, obstetric history, prenatal education attendance, intentions regarding BF, and newborn feeding practices during the hospital stay.

Follow-up telephone interviews were conducted to collect information on infant feeding practices, and maternal working status, and to administer the Patient Health Questionnaire 9 (PHQ9) to assess postpartum depression [15, 16]. The first phone interview was scheduled at one month postpartum, when the risk of postpartum depression is highest. The second was conducted at four months postpartum, aligning with the end of statutory maternity leave in Ecuador (12 weeks) by the current Labour Code [17]. Additionally, some women extend this period by adding vacation days. The third follow-up contact occurred at six months postpartum to assess the EBF outcome [18]. To maximize response rates, up to five contact attempts were made for each telephone follow-up on different days and times, including evenings and weekends. Participants who could not be reached after five attempts were considered lost to follow-up for that round. All women, whether in the PE or non-PE group, received basic information on postpartum depression and were referred for clinical care if symptoms were identified during follow-up interviews.

Variables

Dependent variable

EBF before six months: Defined as infants under six months of age who were exclusively fed with breast milk on the day before the assessment, following the World Health Organization operational definition [11]. EBF status was determined through specific questions regarding breastfeeding practices and the consumption of any other food or liquid, including water, teas, formula, porridge, or solid foods. This was supplemented by a recall-based approach to assess the duration of EBF since birth. The outcome variable was categorized dichotomously as “Maintenance” (continued EBF) or “Abandonment” (introduction of any complementary feeding or complete cessation of EBF). Additionally, EBF duration was analyzed as a continuous variable, based on the number of days the mother reported exclusively BF [18]. Finally, incidence rates of EBF abandonment were calculated for both exposure groups.

Independent variables

Main explanatory variable

Prenatal education: To be considered as having completed the PE program, participants were required to attend all six group sessions during pregnancy, as recorded in the Perinatal Clinical History Form (form 051). The sessions are delivered every two weeks starting from 20 weeks of gestation, each lasting two hours. One hour focused on strengthening knowledge and self-care, and one hour devoted to physical exercises (e.g., gestational gymnastics, neuromuscular relaxation, breathing techniques). Women may attend with a companion, and each group includes a maximum of 20 participants. The content of the PE program is standardized nationwide by the Ministry of Public Health. Each session addresses specific topics:

• Session 1: Importance of prenatal education, physiological changes in pregnancy, and danger signs.

• Session 2: Antenatal care activities, nutritional and hygiene guidance, common discomforts, the rights of users of health facilities, and the development of a birth plan.

• Session 3: Preparation for childbirth, recognizing labor signs, differentiating uterine contractions from false alarms, pain versus fear, and when to seek care.

• Session 4: Labor and delivery care, including information on vaginal birth and cesarean, early skin-to-skin contact, initiation of breastfeeding in the first hour of life, and the importance of supportive birth environments.

• Session 5: Breastfeeding and postpartum care, including benefits of EBF initiation in the first hour, proper positioning and latch, dealing with common challenges, delayed cord clamping, and rooming-in with newborns to facilitate breastfeeding on demand.

• Session 6: Preparation for the hospital environment. Women are familiarized with the delivery room and revisit key practices of respectful maternity care, such as staying with the newborn at all times during hospitalization and initiating breastfeeding early.

Throughout all sessions, danger signs during pregnancy and the importance of having a birth plan are reiterated. The repetition and reinforcement of essential newborn care practices throughout the course are intended to prepare women not only for birth but also for the immediate initiation and continuation of exclusive breastfeeding.

It is important to note that, although classified as “unexposed,” some participants may have received partial prenatal education (e.g., attended one or two sessions), but only women who completed all six sessions were considered exposed.

Other co-variables: The demographic variables analyzed include age, ethnicity, marital status, cohabitation, education, employment, occupation, and health insurance status. Obstetric variables examined include the frequency of antenatal visits, contraceptive use, medical history, health facility delivery, parity (primiparous or multiparous), mode of delivery (vaginal or cesarean), postpartum complications, presence of a companion during labor, skin-to-skin contact, and rooming-in. Infant feeding variables encompass early initiation of breastfeeding (newborns put to the breast within one hour of birth), feeding practices at discharge, maternal intentions regarding breastfeeding duration and method, reasons for discontinuation of EBF, alternative feeding methods, and access to support groups. Additionally, psychological, and social support variables include availability of household assistance, maternal leave policies, and assessment of postpartum depression at follow-up intervals after childbirth.

Data analysis

Chi-square tests and Mann-Whitney U tests were employed to compare categorical and continuous variables for the exposed PE group and the unexposed group concerning sociodemographic, obstetric characteristics, birth care, breastfeeding practice, introduction of complementary foods, psychological and social support variables (Tables 1 and 2).

Table 1 Demographic, obstetric, and birth care characteristics of exposed and unexposed participants (n = 278)

Table 2 Comparison of breastfeeding, complementary feeding, and support over time in exposed and unexposed groups

We calculated incidence rates of abandonment between both groups, PE and non-PE. Survival analysis was conducted to examine differences in the time to abandoning EBF between women who received PE and those who did not. The Kaplan-Meier method was used to estimate the probability of continuing EBF over time, and the log-rank test was used to assess statistical differences between the survival curves of both groups.

In addition, Cox proportional hazards regression models (univariate and multivariable) were applied to the entire cohort to estimate the hazard ratio (HR) for EBF cessation, adjusting for covariates such as place of delivery, parity, maternal intention to breastfeed, depression, return to work, insufficient supply, healthcare provider recommendation to cease BF, family advice, negative BF experiences and EBF at hospital discharge. The multivariable model was built using a forward stepwise approach. Variables considered relevant in clinical practice and variables found to be statistically significant (p < 0.05) in univariate analysis were included in the multivariable regression models. Statistical analyses were performed using Stata 16.1 (StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC.) and Jamovi 2.3.28 (The Jamovi project 2024), and significance was determined based on confidence intervals and p-values (p < 0.05).

Results

A total of 307 women were initially enrolled in the study. During the follow-up period, 29 participants (9.4%) were lost to follow-up, resulting in a final analytic sample of 278 women. Among these, 152 women completed all six sessions of the PE program (exposed group), while 126 did not complete the full program and were classified as unexposed (Fig. 1). This level of follow-up loss remained within the 30% margin anticipated in the sample size calculation. The mean age was 28, mainly Mestizo (87.4%), with 40.3% married and 35.5% cohabiting. Most had secondary education (45.5%), unemployed (73.3%) and accessed public health facilities (73.7%). Obstetric data showed high antenatal care attendance (≥ 5 visits, 95.3%), no use of contraception methods (53.6%), and primiparity (54.3%). Vaginal delivery was common (56.1%), skin-to-skin contact (64.4%), and most intended to breastfeed exclusively (98.2%), with 51.5% practicing it at discharge.

Fig. 1

Flow diagram of participants’ recruitment

Comparison between groups showed similarities in age, ethnicity, marital status, and living arrangements but differed in education level and health insurance. The exposed group had more highly educated individuals and better public health insurance access. They had higher antenatal care visits (≥ 5) and 24-hour rooming-in. Parity and maternal breastfeeding intentions differed significantly (p<0.05, chi-squared) (Table 1).

Regarding breastfeeding practices, the exposed group had longer exclusive breastfeeding duration (89.4 ± 77.2 days) than the unexposed (66.1 ± 70.2 days), significant at p=0.004 (Table 2).

The incidence rate of EBF abandonment was 11.81 per 100 person-months in the PE group and 14.91 per 100 person-months in the non-PE group. By month six, 28.9% in the exposed group practiced EBF compared to 10.3% in the unexposed (p<0.001). Reasons for cessation EBF differed significantly (p<0.001), with work return and milk supply cited more in the unexposed, while healthcare provider advice and family advice were more common in the exposed. The percentage of women still breastfeeding at six months was higher in the unexposed group. However, in many of these cases, exclusive breastfeeding had already ended, and these women were therefore not included in the analysis of reasons for EBF discontinuation. The unexposed group had a higher use of breast milk substitutes at month four. Porridge was the main substitute for EBF at six months for the unexposed group. Furthermore, differences in psychological and social support, such as assistance with household labor and maternity leave, were observed between the groups across different time points (p < 0.001). The prevalence of postpartum depression varied significantly between the groups in the first month, 8.6% in the exposed group and 42.6% in the unexposed group (p<0.001), but not at months 4 and 6 (Table 2).

Figure 2 shows the Kaplan-Meier survival curves comparing time to EBF cessation between mothers who received PE and those who did not. The analysis was performed using the entire sample to estimate and compare EBF duration between groups.

Fig 2

Kaplan-Meier plot of time to abandoning EBF among women who received and not PE

The results indicate that mothers in the PE group had a significantly lower probability of early EBF abandonment compared to those in the unexposed group (log-rank test, p = 0.004). The Cox regression analysis, adjusted for key covariates, showed that PE was associated with a significant reduction in the risk of EBF cessation (adjusted HR = 0.58, 95% CI: 0.40–0.84, p = 0.004). Kaplan-Meier survival analysis showed a significant difference in breastfeeding cessation risk between groups (adjusted hazard risk [aHR]=0.58, 95% CI=0.40–0.84, p=0.004), with a protective effect of PE versus not receiving PE (Fig. 2). Cox regression models, adjusted by relevant co-variables, confirmed this, showing lower hazards in the exposed group by comparison with their counterparts (aHR=0.29, 95% CI=0.18–0.46, p<0.001). Similarly, exclusive breastfeeding (EBF) at hospital discharge was associated with a decreased hazard of discontinuing EBF (aHR: 0.56, 95% CI: 0.33–0.93, p = 0.026). In contrast, several factors were significantly associated with an increased risk of EBF cessation. These included delivery at a public health facility (aHR: 4.19, 95% CI: 1.98–8.82, p < 0.001), primiparity (aHR: 1.83, 95% CI: 1.19–2.83, p = 0.006), and maternal depression at four months postpartum (aHR: 2.06, 95% CI: 1.24–3.41, p = 0.005). Additionally, specific reasons for discontinuing EBF such as returning to work (aHR: 6.30, 95% CI: 3.33–11.93, p < 0.001), healthcare provider recommendation to stop breastfeeding (aHR: 4.24, 95% CI: 2.30–7.81, p < 0.001), family advice (HR: 10.10, 95% CI: 4.69–21.89, p < 0.001), and other negative breastfeeding experiences (aHR: 11.54, 95% CI: 3.71–35.82, p < 0.001) were also found to increase the likelihood of EBF discontinuation (Table 3).

Table 3 Multivariable Cox regression model of factors associated with exclusive breastfeeding discontinuation before six months

Discussion

EBF is crucial for infant health and development, but many mothers face challenges in maintaining it [19]. This study provides evidence that PE significantly contributes to the continuation of EBF during the first six months postpartum. Women who received standardized PE were likely to abandon EBP, showing the program’s positive effect on breastfeeding practices in Quito, Ecuador.

The PE program evaluated is based on Ecuador’s national maternal health policy and consists of six structured group sessions. Breastfeeding is addressed specifically in session five, but related content is reinforced throughout the course. This session addresses the importance of EBF, its benefits for the mother and child, techniques for effective latching and positioning, early initiation, management of common breastfeeding difficulties, and the value of continued breastfeeding for up to two years or more. Delivered in an interactive group format and complemented by physical preparation, the program aims to combine knowledge-building and skill development, which may explain the protective effect observed in our findings [7].

Our results align with international literature showing that PE improves breastfeeding outcomes, particularly when it includes focused content, is grounded in behavioral theory, and includes emotional support. A recent meta-analysis of 40 randomized controlled trials demonstrated that breastfeeding education significantly improves maternal breastfeeding self-efficacy, a key predictor of breastfeeding duration (SMD = 1.20; 95% CI = 0.75–1.64) [20]. Similarly, findings from systematic review confirmed that prenatal breastfeeding education enhances self-efficacy, knowledge, and breastfeeding initiation, contributing to improved breastfeeding uptake postpartum [8]. Studies also highlight that prenatal education is more effective when it integrates psychological components like coping planning and when combined with postnatal support [21,22,23].

However, several qualitative studies emphasize the importance of realistic and practical breastfeeding education. Research from Australia and Ireland shows that women often feel unprepared for breastfeeding despite having attended prenatal classes, especially when sessions present an idealized view and fail to include practical guidance or anticipate common difficulties [24, 25]. The gap between what new mothers expect and what they experience can lower their confidence. Our findings show that structured content is valuable, but we also need to make the information delivery more realistic and adaptable.

Despite being a government-endorsed program, PE in Ecuador is not the same everywhere. Access to PE varies widely across the country. In our study, women who attended PE tended to have higher education levels, better access to public insurance, and more antenatal visits, suggesting disparities in program reach. Barriers to participation include issues like voluntary attendance, lack of promotion, and scheduling conflicts. These challenges are similar to those seen in other places, such as Pakistan and Latin America. In these regions, efforts are being made to standardize curricula, involve mental health resources and partners, and create more interactive sessions [26, 27]. A scoping review of interventions in Spanish-speaking countries found that programs were most effective when they combined prenatal and postnatal education, provided practical skill-building, and offered community or peer-based support [27]. Additionally, recent trials such as the REST program in Hong Kong demonstrated that real-time online prenatal education, when combined with postpartum follow-up, improved EBF duration and maternal self-efficacy [28]. These findings support the idea that successful PE programs are those that are theory-informed, adaptable, accessible, and combined with continued support after birth.

It is important to note that diverse populations and geographic settings may contribute to these discrepancies, which can limit the generalizability of findings from this research to specific communities [9].

While PE was the primary focus or this study, we also identified other factors associated with EBF discontinuation. Maternal intention to breastfeed for six months or more was found to lower the risk of ceasing EBF, aligning with prior research indicating that intending EBF increases its duration [10, 19]. In contrast, a US cohort study revealed that although more participants in the post-intervention group expressed intentions for any BF and aimed for a year or longer compared to the pre-intervention group, no significant difference was found in EBF rates between the two cohorts [29].

EBF at hospital discharge, as observed in this study, is vital for prolonged BF aligning with the literature. Supplementing with commercial milk formula during hospital stays often leads to premature BF discontinuation, particularly among women from lower socioeconomic backgrounds [30].

We found that factors influencing early cessation of BF include delivery at a public health facility, maternal depression, and specific reasons for stopping breastfeeding. Public health facility delivery emerged as a significant predictor of breastfeeding discontinuation. In a study in Mexico healthcare professionals often recommend commercial milk formula despite recognizing breastfeeding benefits, influencing maternal choices [31].

In our study maternal depression significantly relates to early BF cessation. In the first month, depression incidence was twice as high in the non-prenatal education group, evening out by months four and six. The presence of maternal depression may contribute to decreased motivation and ability to initiate and sustain BF. Addressing maternal mental health through support and resources could mitigate its detrimental effect on BF [2].

Other specific reasons for stopping breastfeeding were also found in our study to influence early cessation, including insufficient milk supply, return to work, and healthcare provider recommendations to cease BF [2]. Although our data did not capture the specific reasons for these clinical recommendations, their occurrence highlights the need to ensure that breastfeeding counseling is aligned with current evidence and supportive of continued breastfeeding whenever possible. These findings reinforce the importance of addressing individual and systemic barriers to support mothers in maintaining breastfeeding [2].

We found that family advice and negative breastfeeding experiences were identified as additional factors contributing to early BF cessation. The influence of family and social support on BF decisions is crucial. Interventions promoting positive support and accurate BF information can create an environment conducive to BF success. Our study identified differences in the use of alternative products to replace BF between the exposed and unexposed groups. The unexposed group exhibited a higher prevalence of using breast milk substitutes and other milk alternatives, indicating a potential lack of support for EBF in this group. Notably, porridge emerged as the predominant substitute for EBF at six months, particularly among the unexposed group.

Understanding these factors is crucial for developing targeted interventions to support breastfeeding continuation. By addressing modifiable risk factors and providing adequate support, healthcare providers can help mothers overcome barriers to breastfeeding [32].

The study findings show that there is an urgent need for action to support breastfeeding mothers and improve maternal and child health outcomes. To achieve this, comprehensive PE programs and BF support initiatives should be enhanced. Integrating BF education into routine prenatal care visits is essential, but it’s important to recognize that limited healthcare setting hours and the availability of support groups may present barriers for some women. Additionally, exploring alternative educational settings can further reinforce the importance of BF practice. Lactation consultants and peer support groups should be made readily available to all mothers. Workplace policies should also be implemented to support BF mothers. Policymakers and healthcare providers can promote BF to improve maternal and child health outcomes and the overall well-being of families and communities.

Strengths of the study include its prospective design, a standardized intervention, robust statistical analysis, and inclusion of relevant covariates. These aspects enhance the validity and reliability of the findings.

It is important to note that there are certain limitations to the study. One potential limitation is the presence of selection bias, meaning that the participants who chose to take part in the PE program could be more motivated than others; nevertheless, when searching for potential confounders during modeling it was possible to calculate reliable adjusted estimates of the risk of abandonment, minimizing the risk of selection bias.

Although we classified exposure based on the full completion of the six-session PE program, it is possible that some participants in the unexposed group attended one or two sessions but did not meet the minimum exposure required to be considered fully exposed. In our classification, participants who attended fewer than three sessions were included in the unexposed group. This may have introduced some degree of misclassification, potentially attenuating the measured effect of the PE program. However, we believe this distinction between full and minimal, or no exposure was necessary to evaluate the effect of the complete standardized program, as defined by national policy.

Additionally, the data collected for this study was self-reported, which may also have limitations, but the fact of collecting the information just after birth and corroborating the data by exploring the clinical records reduced the risk of information bias. Although the overall loss to follow-up was low (9.4%), we observed a slightly higher attrition rate in the unexposed group. This difference may be attributed to lower engagement with the health system among women who did not complete the prenatal education program. Participants in the exposed group tended to have more antenatal visits and were more likely to be insured, which may have facilitated contact and follow-up adherence.

This study contributes to growing global evidence that structured, theory-informed, and accessible prenatal education is a critical strategy to improve EBF outcomes. Future research should explore the long-term effects of PE, the cost-effectiveness of scaling up education across diverse populations, and the inclusion of partners, family members, and culturally relevant content. Regular evaluation and adaptation of educational materials should be encouraged to ensure alignment with mothers’ real-life challenges and needs. Alternative delivery formats, such as online or blended sessions, may help reach underserved groups and support continuity of care from pregnancy through postpartum.

Conclusions

This study shows that PE independently and significantly increases the duration of EBF and reduces the risk of early abandonment. These findings highlight the importance of integrating structured and accessible PE programs into routine prenatal care as a key strategy to improve breastfeeding outcomes. While EBF is influenced by multiple factors, including delivery setting, maternal mental health, and family or provider support, PE remains a central intervention to strengthen maternal knowledge, confidence, and commitment. Efforts to improve breastfeeding outcomes should also include adherence to the International Code of Marketing of Breast-milk Substitutes, ensuring that educational messages and health system practices protect, promote, and support breastfeeding. Additionally, lactation support, postpartum depression screening, and workplace policies are essential for fostering a supportive BF environment and improving maternal and child health outcomes.