Updated algorithms for direct and indirect mapping of WHOQOL-BREF to EQ-5D-5L utility scores using data from a multi-provincial Thai general population sample.

Breastfeeding is recognized as the optimal source of infant nutrition and a cornerstone of child survival. Breast milk contains antibodies, hormones and immune factors to protect the baby against common infections [, ]. World Health Organization (WHO) and UNICEF emphasize its benefits for both child and mother, as it reduces risks of infant mortality and later obesity or diabetes in breastfed children, and lower breast and ovarian cancer risks in mothers [, ]. However, globally, fewer than half of infants aged < 6 months are exclusively breastfed [, ] and about 46% begin breastfeeding within an hour of birth. The WHO recommend that newborns be placed skin-to-skin and put to the breast within the first hour of life, be fed only breast milk for 6 months, and continue breastfeeding up to ≥ 2 years with complementary foods introduced after 6 months []. Evidence-based campaigns and policies have been adopted in many countries to support this; however, international surveys show that uptake of these recommendations remains suboptimal, as only about half of women worldwide adhere to exclusive breastfeeding for the full 6 months. While exclusive breastfeeding rates have risen by about 10% over the past decade, reaching ~ 48% globally []. In 2023, UNICEF and WHO reported that exclusive breastfeeding rates have only reached ~ 48% worldwide, still just shy of the WHO’s 2025 target of 50% []. Many regions, including the Middle East still report exclusive breastfeeding well below targets. In Iraq, infant nutrition indicators are concerning, as ~ 20% of children aged < 5 years are stunted, reflecting chronic malnutrition, and UNICEF reports that only 19.6% of infants are exclusively breastfed immediately after birth. Continuation of breastfeeding is also poor in Iraq, as 33% of newborns were breastfed within the first hour of life, 25% were exclusively breastfed for 6 months, and 22.7% breastfed for one year. These low rates occur in a context of ongoing conflict and displacement, which UNICEF notes further jeopardize child feeding and nutrition []. The Kurdistan Region of Iraq shares many of these challenges with low adherence of mothers to optimal breastfeeding in the first 6 months, as reported in Sulaimaniyah (46.5%) [] and Duhok (8%) []. These figures are below WHO targets and the modest national average. Kurdish mothers often receive breastfeeding-related information from elder female relatives, particularly grandmothers and mothers-in-law, whose traditional beliefs may influence maternal feeding decisions. Informal advice from relatives may sometimes override professional healthcare recommendations. The Kurdish sociocultural environment differs from many neighboring regions because maternal and infant care practices are frequently shaped by extended family systems, cultural expectations, and traditional postpartum practices. These contextual factors may influence breastfeeding knowledge, attitudes, and continuation. Significant gaps and barriers persist, especially in low and middle-income regions. Thus, despite strong guidelines, compliance with breastfeeding recommendations in developing countries is low [, ]. Although breastfeeding practices have been investigated in some Iraqi settings, comprehensive evidence regarding breastfeeding knowledge and attitudes among Kurdish mothers remains limited. Understanding these factors within the unique sociocultural and post-conflict healthcare context of the Kurdistan Region is important for developing culturally appropriate maternal and child health interventions. Consequently, in this locality, no comprehensive cross-sectional data exist on this aspect. To address this literature gap, this study addresses the following fundamental research questions: What is the current level of breastfeeding knowledge and attitudes among Kurdish mothers in Iraq? and what are the primary sociodemographic and cultural factors that predict these outcomes? By answering this question, this study aimed to assess Kurdish women’s knowledge and attitudes toward breastfeeding and their predictors. This quantitative, descriptive, cross-sectional study was conducted on 412 mothers from December 2024 to February 2025, in public and private maternity hospitals and primary healthcare centers in different areas of Iraqi Kurdistan Region, including Erbil, Sulaymaniyah, Halabja, Koya, Rania and Qaladze to ensure comprehensive representation of urban, semi-urban, and peripheral populations.