Breastfeeding is considered one of the most important methods of feeding infants and improving the health of mothers [1, 2]. The World Health Organization (WHO) recommends exclusive breastfeeding of children up to six months of age and emphasizes its benefits in reducing infant morbidity and mortality. In Jordan, the rate of early breastfeeding is 34%, while exclusive breastfeeding within six months is 24% [3]. Additionally, exclusive breastfeeding among children from birth to five months has shown a declining trend from 39% in 1990 to 24% in 2023. Breastfeeding is associated with improved health outcomes in infancy and throughout adulthood, as breast milk contains diverse immune-active factors that influence the development of the infant's immune system [4]. Sustainable Development Goal 3 (SDG 3) aims to ensure health and well-being for all individuals of all ages, and breastfeeding is directly associated with reducing child mortality (Target 3.2) and enhancing maternal health (Target 3.1) [5]. The World Bank asserts that failure to breastfeed leads to high health costs and low productivity [6]. Declining breastfeeding rates in Jordan could lead to increased health care costs, more cases of child illnesses, and possibly other health problems in the future for both mothers and children.

Several interventions to encourage breastfeeding in Jordan, such as the introduction of the Baby-Friendly Hospital Initiative and the International Code of Marketing of Breast-milk Substitutes, have been implemented. Additionally, the Jordanian government, with support from the United States Agency for International Development [7], has put in place educational initiatives and policy reforms. However, these interventions have yet to provide tangible benefits in increasing breastfeeding rates, possibly as they are relatively new or due to insufficient consideration of sociocultural and contextual barriers, which remain inadequately studied in Jordan [8]. For instance, Jordanian pharmacists prioritize breastfeeding support through staff training, prenatal education on breastfeeding benefits, and the implementation of WHO-compliant infant feeding policies; however, these initiatives lag behind current practice [9].

Possible maternal challenges are related to perceived stress, lack of knowledge about the process of breastfeeding, and potential barriers that may prevent mothers from initiating and sustaining breastfeeding. Much of the existing literature describes the interactions among multiple variables that affect the relationship between maternal stress and breastfeeding [10]. High levels of stress have been associated with decreased breastfeeding duration and exclusivity [11,12]. In addition, a link between increased perceived stress levels and decreased attitudes towards breastfeeding has been established [13].

Mothers' decisions and confidence in breastfeeding are largely influenced by their knowledge of breastfeeding practices [14]. Multiple barriers to breastfeeding, such as negative cultural attitudes toward breastfeeding, aggressive corporate marketing of formula, inadequate labor policies for working mothers, and urbanization pressures, have been reported internationally [15]. In addition, healthcare systems that do not properly support breastfeeding practices due to the medicalization of birthing and infant care also contribute to these barriers [15]. A recent study noted that increasing maternal age was associated with increasing negative attitudes towards breastfeeding within the Arab culture [16]. Cesarean delivery, infant hospitalization, and maternal employment are also among the main barriers reported in Jordan [17]. Whereas barriers specific to exclusive breastfeeding in Jordan were mainly infants feeling hungry after breastfeeding, a short period between pregnancies, and breast problems [18].

Although several studies have been conducted to date, there is still a lack of research that seeks to explore the connections between perceived stress, breastfeeding knowledge, and barriers among women who are breastfeeding or have breastfed their children, with little research being conducted in the Arab speaking countries. It is important to fill this gap to identify areas for intervention so that breastfeeding can be better supported. Various interrelated factors may affect the breastfeeding practices: these factors range from the individual level to the societal level. This study aims to understand how individual factors, such as knowledge, stress, and barriers, influence the practice of breastfeeding in the Jordanian context, thereby filling a gap in the current literature on breastfeeding in Arab countries.

The aims of this study are to assess mothers’ knowledge of breastfeeding, perceived barriers to breastfeeding, and perceived stress, and then to determine the relationships among them and with demographic variables. Through the identification of the particular relationships between these variables in Jordan, the research can help in the creation of appropriate culturally specific interventions and support programs, ultimately aiding in the sustainable development goals of global public health.

A total of 350 mothers responded to the online survey. The mean (M) age was 29.8, with an SD of 5.8 years and an age range between 18 and 48 years. A substantial proportion of mothers had completed higher education (n=233, 66.6%), particularly at the bachelor's level (n=129, 36.9%). The majority were unemployed (n=242, 69.1%). Notably, most mothers relied on family members for childcare when employed. The great majority of the participants had multiple previous deliveries (n=238, 68%). Additionally, a considerable proportion had previously breastfed their children (n=287, 82%) (Table 1).

This study assessed the breastfeeding knowledge, perceived barriers, and stress, and explored the relationships between these variables among Jordanian mothers. The findings offer a richer appreciation of how different levels of analysis-individual, interpersonal, and societal- work together to shape breastfeeding behaviors in the specific context of Jordan. Our sample was highly representative of the lower-income segment of Jordanian society [19], as it consisted of relatively well-educated, mainly unemployed, family-oriented women with significant experience in raising children and a frequent reliance on family for childcare arrangements.

The findings regarding breastfeeding knowledge were similar to those obtained in a Lebanese study using the BFK-A [23] indicating the alikeness of the two populations being studied. This possibly reflects shared cultural values, educational systems, and healthcare context across the Middle East. However, it is important to note that this similarity in knowledge does not necessarily translate to similar breastfeeding practices, as practice is influenced by additional factors like workplace support, family dynamics, and healthcare accessibility that may differ between countries. This highlights that knowledge alone is insufficient for achieving optimal breastfeeding outcomes without supportive systems.

Overall, the breastfeeding knowledge assessment showed varying levels of knowledge, with more than half of the mothers having poor to fair knowledge about breastfeeding, indicating the presence of knowledge gaps that can benefit from targeted education. While the results show that most of the women knew the advantages of breastfeeding, there is a need to eliminate misconceptions, especially on milk supply and body changes after giving birth. For example, many new mothers were aware of the benefits of breastfeeding, yet only a few understood that breastfeeding does not affect breast size or shape. Similarly, other misconceptions concerning the adequacy of breast milk and the need for complementary foods were also observed. These findings are in line with those reported in a recent study from southern Jordan, where the belief that breast milk is insufficient was identified as a maternal-related barrier, and mixed feeding (combining breastfeeding with formula feeding) was the most common practice [25]. It is likely that these behaviors and thoughts arise from sociocultural factors, misunderstanding of physiological infant behaviors such as crying, and strong formula marketing.

Education level emerged as a key determinant of breastfeeding knowledge, with mothers who were educated at the bachelor’s level having significantly higher knowledge. This finding aligns with previous Saudi [26] and Ethiopian [27] studies, which found that higher maternal education levels were associated with improved breastfeeding knowledge. Higher education is likely to correlate with greater critical thinking skills, better access to information resources, and potentially greater engagement with healthcare providers. Additionally, educated mothers may have greater confidence in questioning traditional beliefs and seeking evidence-based information. The importance of education in improving knowledge of breastfeeding among primiparas and in delivering focused educational interventions for less educated mothers is highlighted in the literature [28].

Several maternal, infant, and socio-environmental barriers were identified in this study. The most significant reported maternal barriers were ‘Breastfeeding can distort body image’, ‘Overall, I am not good at breastfeeding’, ‘Having previous bad experience with breastfeeding reduces my ability to do that’, ‘I could not practice breastfeeding because of insufficient or no milk’, and ‘I do not have enough skills to practice breastfeeding’. These barriers indicate concerns with either body image or self-efficacy, inherently contributing to the general perception of difficulty in breastfeeding. Furthermore, mothers reported significantly more barriers with increasing parity, which could reflect accumulated negative experiences, greater body awareness after multiple pregnancies, or changing societal expectations about maternal appearance with age. Considering recent evidence indicating that positive body image directly increases breastfeeding self-efficacy [29], it will be important to implement supportive interventions that target body image to improve breastfeeding self-efficacy among mothers.

Infant-related barriers, such as the perception that ‘Breastfeeding doesn’t provide enough nutrition,’ were also common. This finding aligns with earlier findings, which reported that many Jordanian mothers discontinued exclusive breastfeeding due to concerns about infant hunger and inadequate milk production [18]. Similarly, in a recent phenomenological study of mothers' breastfeeding experiences during the pre- and post-COVID-19 periods, many women agreed that vaccination affected their milk and breastfeeding experiences and reported concerns regarding the adequacy of their milk supply [30]. Globally, studies observed misconceptions in which the marketing of formula often played into parents’ anxieties about whether breast milk is enough to meet their babies’ needs [31], which, in turn, affected their confidence in breastfeeding. Therefore, the common perception that breastfeeding does not provide enough nutrition should be interpreted in light of these broader global trends.

The ‘Lack of encouragement from the nurse or midwife’ to breastfeed was identified as the most significant socio-environmental barrier in this study, emphasizing the fact that few mothers receive sufficient help from healthcare professionals. This aligns with previous studies, which found that a minority of Jordanian women received advice on breastfeeding from obstetric providers [32, 33]. This may be due to limited interaction between healthcare providers and patients, heavy workloads, and a limited focus on breastfeeding health education. However, healthcare professionals play an important role in encouraging breastfeeding and addressing maternal worries [34]. These repeated findings highlight serious gaps in professional breastfeeding support in Jordan that need to be addressed.

Interestingly, in this study women did not report discomfort with public breastfeeding to be an important barrier, unlike previous studies, which found that embarrassment about breastfeeding in public was a significant barrier in Jordan [21, 35]. This finding could be related to differences in the demographic or sociocultural characteristics of the study population and environmental factors. Our study participants included a higher proportion of unemployed women who had greater opportunities to breastfeed at home and therefore did not perceive breastfeeding in public as a significant barrier, as they did not need to do so. In contrast, the previous studies focused on working mothers, who are more likely to spend time in urban or professional environments where public breastfeeding may be less socially accepted or practical. Additionally, the availability of breastfeeding-friendly spaces in public areas, such as malls or workplaces, has improved over the last decade, making public breastfeeding less of a concern for mothers. In fact, a recent study reported that workplace breastfeeding support in Jordan was perceived as moderate, which indicates improvements in policies, managerial and co-worker awareness, flexibility for breastfeeding/pumping, and the availability of appropriate physical spaces to facilitate breastfeeding for employed mothers [36].

Almost all women in our sample reported being moderately stressed. Evidence to date suggests that maternal stress may impair lactation and breastfeeding outcomes, but stronger study designs and rigorous assessment methods have been called for [11]. Additionally, the exclusive breastfeeding rates have been shown to be negatively influenced by perceived maternal stress because it affects the hormonal balance of the body and, in consequence, the ability to produce milk [37]. Prenatal anxiety and stress were also shown to be predictors of shorter breastfeeding timelines [10], suggesting the importance of mental health care during the perinatal period.

Stress among breastfeeding mothers can increase oxytocin and cortisol levels, which may affect breast milk supply and quality and, consequently, breastfeeding outcomes [11]. However, this was not perceived as a barrier to breastfeeding in this study. A possible explanation lies in societal and cultural coping mechanisms, which may buffer elevated stress levels in this cohort. Breastfeeding mothers in Jordan tend to perceive high family support, especially from their husbands [32]. Additionally, in Jordanian culture, breastfeeding mothers usually receive guidance and support from their mothers and mothers-in-law [7]. This may act as a buffer against increased stress levels during breastfeeding.

The results show that there is a need for strong breastfeeding support programs to help in dealing with knowledge deficits, barriers, and stress in mothers. Breastfeeding support provided by lactation consultants has been shown to be an effective strategy for improving breastfeeding rates [38]. Educational interventions should be directed towards the misconceptions regarding breast milk sufficiency and body image concerns, especially among less educated women, and should be made relevant to the cultural and socio-economic situation of the population being targeted. Healthcare providers play a crucial role in encouraging breastfeeding, but this study showed that professional support is insufficient. Schools of nursing should integrate comprehensive breastfeeding education into their training modules, equipping future healthcare professionals with the skills and knowledge to effectively support mothers in overcoming breastfeeding challenges. Training in breastfeeding, counselling, and maternal stress management for practicing nurses, midwives, and obstetricians should be improved. Implementing breastfeeding support into routine antenatal and postnatal care can lead to better results. To this end, stress can only be managed through measures such as mental health care, workplace interventions, and community-based breastfeeding support groups. On the other hand, community-based initiatives can also enhance positive breastfeeding environments. Removing obstacles, such as insufficient breastfeeding education and misconceptions, is crucial to improving health outcomes and achieving the targets for the Sustainable Development Goal of Good Health and Well-being (SDG 3) in Jordan and other countries.

This study has several limitations. First, breastfeeding practices and barriers, which were based on self-reported data, may have been subject to recall bias. Additionally, the cross-sectional design of the study cannot be used to establish causal relationships between the variables, namely, knowledge of breastfeeding, barriers, stress, and outcomes. The participants were Jordanian mothers from a low-income area, which limits the generalizability of the findings. Due to the nature of online surveys and the lack of information about nonrespondents, there is a potential for nonresponse bias that may affect the representativeness of the findings. Lastly, while the study identified gaps in professional breastfeeding support, a review of its quality and consistency could have provided further insight. Future work should employ longitudinal designs to examine causal processes, expand the sample to include more diverse participants, and assess the efficacy of specific interventions to remove identified barriers.

The study shows that Jordanian mothers possess fair to good breastfeeding knowledge, yet they continue to hold misconceptions and face barriers such as perceived milk insufficiency and inadequate professional support, which prevent them from achieving optimal breastfeeding practices. To address this, multilevel interventions (integrating education, professional support, and stress management) are recommended, using a socioecological approach, with future work focused on evaluating culturally tailored programs, workplace policies, and community initiatives to establish supportive environments that advance maternal-child health and global sustainability goals.