The economy of Zhejiang Province has grown rapidly in recent years, particularly since the beginning of the 21st century and the per capita GDP in Hangzhou was $6,700 in 2006. The rise in living standards accompanying the economic growth has led to a demand for improved health care and in particular, the application of advanced medical technologies. Infant feeding practices are another part of the culture which has been influenced by economic development. There is now widespread promotion of infant formula and mothers are fascinated by the prospect of a high-technology product which promises much for their infants. On the other hand, cultural beliefs are still strong and most mothers commence breastfeeding, but they tend to combine this with infant formula in the early months of their infants' lives.
Chinese society has changed rapidly and in the "high-tech" city of Hangzhou it is now very common for women to pursue higher education and to marry later in life. The women of Hangzhou are highly educated and in our study 64.1% of the women had post secondary education compared with the rates of 18.2% in the suburban area and 24.0% in the rural area. Almost half of the mothers (45.5%) considered for recruitment into the study were not native residents of the city, compared to the suburban (18.4%) and the rural areas (3.7%). This reflects the dynamic nature of the Hangzhou population resulting from the rapid economic development.
There have been rapid changes in medical practice in the past decades and this is reflected in changes in birthing methods. Overall in the study, two thirds of mothers gave birth by caesarean section. The rates in the city and suburban and rural areas were 75.7%, 74%, and 52.7% respectively. After the Baby Friendly Hospital Initiative (BFHI) was promoted in China in the 1990s, the majority of hospitals in the Province reformed their obstetric practices. The hospital environment became friendly towards babies, as the Ten Steps to Successful Breastfeeding were required in all hospitals and maternal and child health centres. These included 'rooming in', early skin contact, early initiation of breastfeeding and the encouragement of mothers to breastfeed by the doctors and nurses in the obstetric departments. The Bureau of Public Health of Zhejiang Province was responsible for providing a team to regularly evaluate the Baby Friendly hospitals in the Province and to maintain the quality of the BFHI. In this atmosphere of encouragement, breastfeeding initiation rates improved. Almost all mothers understood the benefits of breastfeeding from antenatal classes, from postnatal education or from the media.
In our study more than 96% of mothers were breastfeeding their infants at discharge from hospital. The initiation of breastfeeding has returned to higher levels in the past two decades, and the rates of breastfeeding initiation in Zhejiang are now higher than reported from other provinces in China. A study of infant feeding in Xinjiang Uygur Autonomous China found an 'any breastfeeding' rate of 92.2% at discharge . The 'Beijing and Four Provinces Study' found that the 'ever breastfed' rate was 90.1% in China in 2002 . This rate was similar to an Australia infant feeding study from West Australia where 93.5% of mothers were breastfeeding at discharge from hospital .
The 'any breastfeeding' rate for the city is higher than the rate reported for Shanghai, the closest large city to Hangzhou in the 1980s . This probably reflects a renewed interest in breastfeeding in China. However the situation for 'exclusive breastfeeding' is not as encouraging. The WHO reported the 0–6 months exclusive breastfeeding rate in China to be 51% . Our results for 'exclusive breastfeeding' are far below this figure and may reflect different methodology. The WHO-UNICEF methodology relies on 24 hour recall of no foods or fluids apart from breast milk in the past 24 hours. China is a vast country with a huge population and another reason for the difference may be sample selection. The variation from our study suggests that larger and more widespread studies of breastfeeding are needed and they should preferably use the longitudinal methodology used in this study. Another factor influencing breastfeeding in the city is the economic pressure of the developing economy. In an ethnographic study of women in Beijing, Gottschang summarized the pressures on urban mothers: "global intervention in the form of the WHO-UNICEF sponsored Baby Friendly Hospital Initiative promotes breastfeeding as a women's duty at the same time that market forces counter this message"  (p. 64).
Most mothers had an understanding of the need for breastfeeding at the beginning of their infant's life, but the exclusive breastfeeding rates after discharge from hospital declined rapidly. The exclusive breastfeeding rate was considerably lower than the national target of 80% of babies being exclusively breastfed until four months of age. In our study the exclusive breastfeeding rate at discharge was only one third (38.0%) in the city and even in the suburban and the rural areas, the rates were 63.4% and 61.0% respectively. Prelacteal feeds were common in the initial days after birth, details of which have previously been reported . The exclusive breastfeeding rate in Zhejiang was lower than that in Xinjiang Uygur Autonomous Region, China and in Vietnam, where the rates at discharge were 66.2%  and 83.6% respectively . However the exclusive breastfeeding rate at six months in Xinjiang was similar to the rural area in this study.
At three months, one-half of the mothers were regularly giving their infants some infant formula. A common reason for giving formula or other complementary food is the belief that 'the more or the quicker the baby gained weight, the healthier the baby is'. In the Chinese culture, parents and grandparents are devoted to their children and with the 'one child policy' the centrality of the child in Chinese culture has increased in recent decades. Thus there is always cultural pressure to give the infant supplementary foods.
The breastfeeding rates found in this study are well below international and national targets. If the rates found in this study reflect national trends in China, it would mean that China is falling behind in its quest to meet the Millennium Goals. This suggests that further health promotion programs for breastfeeding and particularly for the extension of the period of exclusive breastfeeding are required. There needs to be continuing monitoring of the implementation of the Baby Friendly Hospital principles in the Province. Further research is needed into ways of increasing community support for breastfeeding and increasing the number of 'Baby Friendly' workplaces.
There are some limitations that need to be considered when interpreting the results of this study. The hospitals used were selected to be representative of their locations, but a larger probability sample would be required to be certain that the selected sample represented Zhejiang Province. A series of focus group discussions and/or in-depth interviews with mothers and the extended families would help in understanding further details about breastfeeding problems and beliefs about infant growth and supplementary feeds.