Initiation of breastfeeding and prevalence of exclusive breastfeeding at hospital discharge in urban, suburban and rural areas of Zhejiang China

  • Liqian Qiu1, 2,

    Affiliated with

    • Yun Zhao2,

      Affiliated with

      • Colin W Binns2, 3Email author,

        Affiliated with

        • Andy H Lee2 and

          Affiliated with

          • Xing Xie1

            Affiliated with

            Contributed equally
            International Breastfeeding Journal20094:1

            DOI: 10.1186/1746-4358-4-1

            Received: 07 August 2008

            Accepted: 28 January 2009

            Published: 28 January 2009

            Abstract

            Background

            Rates of exclusive breastfeeding in China are relatively low and below national targets. The aim of this study was to document the factors that influence exclusive breastfeeding initiation in Zhejiang, PR China.

            Methods

            A cohort study of infant feeding practices was undertaken in Zhejiang Province, an eastern coastal region of China. A total of 1520 mothers who delivered in four hospitals located in city, suburb and rural areas during late 2004 to 2005 were enrolled in the study. Multivariate logistic regression analysis was used to explore factors related to exclusive breastfeeding initiation.

            Results

            On discharge from hospital, 50.3% of the mothers were exclusively breastfeeding their infants out of 96.9% of the mothers who had earlier initiated breastfeeding. Exclusive breastfeeding was positively related to vaginal birth, baby's first feed being breast milk, mother living in the suburbs or rural areas, younger age of mother, lower maternal education level and family income.

            Conclusion

            The exclusive breastfeeding rate in Zhejiang is only 50.3% on discharge and does not reach Chinese or international targets. A number of behaviours have been identified in the study that could be potentially incorporated into health promotion activities.

            Background

            Breastfeeding has many health and developmental advantages for infants and mothers and is the preferred way of feeding infants to promote optimal infant health and reduced morbidity later in life [13]. In Asian cultures, and perhaps more generally, breastfeeding also protects against early Helicobacter pylori infection [47]. A recent cohort study from Shanghai suggests that breastfeeding may offer a mother some protection against developing Type II diabetes [8]. Breastfeeding has received increased emphasis in China over the past two decades as its importance for child health has become recognized. In order to implement the spirit of the World Summit for Children, the Chinese government issued the "National Programme of Action for Child Development in China in the 1990s" [9]

            A number of cross-sectional and longitudinal studies in China showed that the 'ever breastfed' rate, both in urban and rural areas was over 80% in the 1950s and 1960s. During the 1970s and 80s the use of breast milk substitutes became more popular and the national 'ever breastfed' rate decreased, gradually dropping from about 80% in the 1960s to 42.7% in 1975 and it then fell further to 33.6% in 1985 [10]. The trend was even more marked in the large cities such as Shanghai, where the rate fell to 22.2% in 1982 and again to 13% in 1989 [10, 11].

            The International Baby Friendly Hospital Initiative was introduced with the goal of ensuring that all infants are breastfeeding before their discharge from the hospital and that 80% would be exclusively breastfed for the first six months of life [12]. By 1994, in China a total of 947 hospitals had passed the National Baby Friendly Hospital assessment [13] and since that time the number of BFHI certified hospitals has continued to increase. During the 1990s the Chinese government introduced women and child health protection legislation, society support programs and education programs to support breastfeeding promotion.

            Following the introduction of these programs the breastfeeding initiation rate began to rise again. A survey in one of the largest cities of western China, Chengdu, Sichuan province showed that the 'ever breastfed' rate had risen to 88% in 1993 [14]. A longitudinal study found that the 'full breastfeeding rate' was 78% at six weeks in the east coast city of Zibo, Shandong province in 1996 [15]. A survey of mothers from 105 counties showed that by 1995 the breastfeeding initiation rate was well over 90%, but the exclusive breastfeeding rate was low [16]. In a cohort study from the west of China the any breastfeeding rate on discharge was 92% and 73% were continuing to breastfeed at six months [17]. While the trend in breastfeeding rates is encouraging, many of these studies were cross-sectional surveys and have inherent limitations in the information provided on risk factors that could be used in health promotion programs.

            Factors that are important in the initiation of breastfeeding include a favourable paternal attitude toward breastfeeding, as perceived by the mother [18], whether the mother had an operative delivery, giving prelacteal feeds and ethnicity [19]. The time that the decision to breastfeed is made, maternal age and education and smoking patterns are also important in some societies [20, 21].

            Zhejiang province is located in the mid-east coast region of China and has benefited from economic reforms and for the past three decades has had one of the fastest growing regional economies in the country. The economic improvement has created many new job opportunities for the younger generation in high technology industries and has resulted in a large, well educated middle class in the provincial capital of Hangzhou. The rural areas have not benefited as much from the rapid development and people from rural Zhejiang and other provinces continue to move to the capital city and suburban areas in search of a more prosperous city life. In 2006 the provincial population was 49 million with one of the highest population densities in the country. Hangzhou has a population of six million and advertises itself as the "most beautiful city in China" and the many emperors and government officials who have holidayed there in the past bear testament to this fact.

            Like other big cities in China, the breastfeeding experience of Zhejiang women has changed over time. A cross-sectional survey undertaken in five cities in Zhejiang in 1997 found that the exclusive breastfeeding rate before discharge was 74.4% and this dropped to 43.7% at 10 weeks [22]. This rate was lower than the World Health Organization target for initiation and for exclusive breastfeeding for six months. In China at the present time the initiation rates of breastfeeding are high and the most important issue is the rate of exclusive breastfeeding [23]. A recent review and study of breastfeeding in rural China confirmed the low rate of exclusive breastfeeding and concluded "health care providers need to intensify education and counseling concerning breastfeeding and especially emphasize the importance of exclusive breastfeeding from birth to 4 to 6 months of age" [24] (p.384). A literature search of the English and Chinese language medical literature failed to find any previous longitudinal studies of breastfeeding in Zhejiang Province prior to this cohort study. The differences in breastfeeding rates in rural, suburban and city areas and the first feeds given in Hangzhou, have previously been described [25, 26]. This analysis explores the factors that are important in the initiation of exclusive breastfeeding in Zhejiang Province, PR China.

            Methods

            A cohort study of breastfeeding was undertaken in Zhejiang Province, PR China during the period October 2004 to December 2005. The study was designed as a longitudinal study of infant feeding practices with four interviews over a period of six months. In this paper the results from the first two interviews are used in the analysis. The first interview was held one or two days before discharge from hospital. The exact date of discharge and infant feeding information on infant feeding at discharge was obtained from the second interview one month later. The study included mothers from the capital city, Hangzhou, a suburban area on the outskirts of the metropolitan area, Fu-yang, and a mountainous rural area approximately 300 km to the southwest. A total of 1520 mothers were recruited from hospitals in each location (two in the rural area). Each of these hospitals is typical of the health care facilities in the area they are located. All the mothers in the study were recruited while in hospital and in the larger facilities where there were a number of deliveries on one day, a system of random numbers was used to select the mothers to be included.

            The project was approved by the Zhejiang local research authorities (Zhejiang University, Women's Hospital Ethics Committee) and the Human Research Ethics Committee of Curtin University, Australia. Mothers who agreed to participate in the study signed the consent page attached to the questionnaire and were informed of their rights to withdraw from the follow-up process at anytime without prejudice. They were assured that all of the personal data collected would be kept confidential and identifying data removed from the computer files.

            The first interview was undertaken in person by a nurse or women's health worker before discharge from hospital and follow-up interviews were held at one month, three months and six months post partum. Most of the follow-up interviews (92%) were undertaken by telephone, a testimony to the rapid economic development of this province. In the few instances where mothers could not be reached by telephone, the follow-up interviews were completed at the routine examinations in the community child care clinics.

            The study sample consisted of 1520 mothers who were recruited from the three locations. The inclusion criteria were that the mother had delivered a live child, the mother and neonate did not have serious diseases and that she was resident in the service area of that hospital. Mothers who were not local residents were not included in the study. While in Hangzhou this included almost one half of the deliveries, in the suburban and rural areas almost all mothers were local residents and were eligible to participate. The response rate was high and 98% of mothers (1520 out of 1551) agreed to participate in the study.

            The questionnaire included full details of infant feeding methods and factors likely to influence the initiation and duration of breastfeeding and was based on questionnaires that have been extensively used in breastfeeding cohort studies in China, Australia, Vietnam and Kenya [19, 2730]. The questionnaires were translated and were then tested in focus groups to ensure cultural appropriateness.

            All data analyses were carried out using the Statistical Package for Social Sciences (SPSS), release 14.0 (SPSS Inc., Chicago, IL, USA). Multivariate logistic regression was used to determine factors associated with exclusive breastfeeding at discharge. Backward elimination procedure was applied to remove those variables with non-significant effect.

            Definitions used in this study were from Xu and colleagues [17] and the WHO definition of exclusive breastfeeding [31]:

            'Any breastfeeding'

            The child has received breastmilk (direct from the breast or expressed) with or without other drinks, formula or other infant food.

            'Exclusive breastfeeding'

            Breastfeeding while giving no other food or liquid, not even water, within 24 hours of interview, with the exception of drops or syrups consisting of vitamins, mineral supplements or medicine.

            Results

            The details of the sample are shown in Table 1 with the relationship between demographic factors and exclusive breastfeeding rates. The 'any breastfeeding' rate at discharge from hospital was 96.9%. No significant differences in the 'any breastfeeding' rates were found between the city, suburban and rural areas. The exclusive breastfeeding rate on discharge in Zhejiang was 50.3%, but differed significantly between the three locations: 38% in the city and 63.4% and 61% in the suburban and rural areas [26]. The average hospital stay was 6.4 days and 93% of women were discharged before eight days. The average stay in hospital following a caesarean section was 6.9 days, compared to 5.3 days following vaginal delivery. In the univariate analysis in Table 1 the other significant factors were maternal age and education, having a caesarean section, living with parents, the time the decision to breastfeed was made, parity, attendance at antenatal class, monthly income and whether breast milk was the first feed given to the infant.
            Table 1

            Initiation of breastfeeding and prevalence of exclusive breastfeeding at hospital discharge

               

            Exclusive breastfeeding

              
             

            Total N of women

            %

            n

            %

            Unadjusted Odds Ratio

            95% CI

            Resident

               City

            635

            41.9

            233

            38.0

            1

             

               Suburb

            347

            22.9

            213

            63.4

            2.82

            2.14, 3.72

               Rural

            532

            35.2

            316

            61.0

            2.55

            2.01, 3.24

            Maternal age

               <25

            358

            23.9

            225

            64.8

            1

             

               25–29

            800

            53.5

            379

            48.6

            0.51

            0.39, 0.67

               ≥ 30

            338

            22.6

            148

            45.8

            0.46

            0.34, 0.63

            Caesarean section

               No

            495

            32.7

            282

            58.6

            1

             

               Yes

            1019

            67.3

            480

            48.7

            0.67

            0.54, 0.83

            Maternal education (years)

               ≤ 9 years

            544

            36.0

            330

            62.7

            1

             

               10–12 years

            370

            24.5

            178

            49.4

            0.58

            0.44, 0.76

               > 12 years

            597

            39.5

            251

            43.4

            0.46

            0.36, 0.58

            Baby's gender

               Male

            772

            51.3

            378

            50.5

            1

             

               Female

            732

            48.6

            379

            53.5

            1.13

            0.92, 1.39

            Time breastfeeding decision made

               Before pregnancy

            1089

            72.3

            564

            53.2

            1

             

               During pregnancy

            263

            17.5

            136

            54.2

            1.04

            0.79, 1.37

               After baby born

            154

            10.2

            59

            39.9

            0.58

            0.41, 0.83

            Parity

               Primiparous

            1347

            89.2

            655

            50.2

            1

             

               Multiparous

            163

            10.8

            104

            65.4

            1.87

            1.33, 2.64

            Gestational age (weeks)

               <37

            49

            3.3

            18

            41.9

            1

             

               ≥ 37

            1443

            96.7

            731

            52.1

            1.51

            0.82, 2.80

            Living with parents

               Yes

            742

            49.4

            414

            57.4

            1

             

               No

            759

            50.6

            346

            47.1

            0.66

            0.54, 0.81

            First feed

               Breast milk

            928

            62.5

            499

            53.9

            1

             

               Other

            557

            37.5

            245

            47.7

            0.78

            0.63, 0.97

            Mother's employment

               Laborer

            492

            33.3

            295

            61.3

            1

             

               Office work

            763

            51.7

            330

            44.7

            0.51

            0.40, 0.64

               Not employed

            221

            15.0

            110

            52.4

            0.69

            0.50, 0.96

            Attended antenatal class

               Yes

            949

            63.1

            445

            48.0

            1

             

               No

            555

            36.9

            310

            58.5

            1.53

            1.23, 1.89

            Birth weight

               <2500

            27

            1.8

            14

            58.3

            1

             

               2500–3999

            1382

            91.8

            700

            52.1

            0.78

            0.34, 1.76

               ≥ 4000

            97

            6.4

            42

            45.7

            0.60

            0.24, 1.49

            Admitted to NICU

               Yes

            147

            9.9

            55

            40.4

            1

             

               No

            1333

            90.1

            687

            52.9

            1.66

            1.16, 2.37

            Family monthly income (RMB)*

               ≤ 1500

            215

            14.6

            135

            64.6

            1

             

               1501–3000

            401

            27.2

            236

            59.9

            0.82

            0.58, 1.16

               3001–5000

            451

            30.6

            195

            45.1

            0.45

            0.32, 0.63

               >5000

            407

            27.6

            170

            43.1

            0.42

            0.29, 0.59

            Grandmother breastfed

               Yes

            1408

            96.0

            705

            51.7

            1

             

               No

            58

            4.0

            39

            51.3

            0.98

            0.62, 1.56

            The exchange rate at the time of the study was RMB 7.5. = 1 USD, RMB 10.6 = 1 Euro.

            Differences in the mother's feeding practices and the factors which may influence feeding practices before discharge for city, suburban and rural areas are detailed in Table 2. In this study many mothers, overall 41.4%, believed that their breast milk was insufficient to feed their babies. This perception was worse in the city, where 47.9% of mothers felt they lacked enough breast milk compared to 34.4% in the suburb and 38% in the rural areas respectively.
            Table 2

            The mother's feeding practices in city, suburb and rural areas, Zhejiang (2004–2005)

              

            City

            Suburb

            Rural

            Total

            Variable

             

            n

            %

            N

            %

            n

            %

            n

            %

            First feed

            Breast milk

            472

            74.3

            247

            71.6

            209

            41.4

            928

            62.5

             

            Not breast milk

            163

            25.7

            98

            28.4

            296

            58.6

            557

            37.5

             

            Missing

            3

             

            2

             

            30

             

            35

             

            Time breastfeeding decision made

            Before pregnancy

            482

            75.9

            255

            73.5

            352

            67.2

            1089

            72.3

             

            During pregnancy

            103

            16.2

            73

            21.0

            87

            16.6

            263

            17.5

             

            After baby born

            50

            7.9

            19

            5.5

            85

            16.2

            154

            10.2

             

            Unknown

            3

             

            0

             

            11

             

            14

             

            Mother received gift of formula

            Yes

            246

            38.7

            88

            25.4

            157

            31.8

            491

            33.3

             

            No

            389

            61.3

            258

            74.6

            337

            68.2

            984

            66.7

             

            Unknown

            3

             

            1

             

            41

             

            45

             

            First breastfeed

            ≤ 30 min

            163

            27.0

            178

            53.5

            142

            27.8

            483

            33.4

             

            >30 min

            441

            73.0

            155

            46.5

            369

            72.2

            965

            66.6

             

            Unknown

            34

             

            14

             

            24

             

            72

             

            Colostrum secretion

            ≤ 1 day

            403

            64.1

            164

            47.4

            182

            36.2

            749

            50.7

             

            ≥ 2 days

            226

            35.9

            182

            52.6

            321

            63.8

            729

            49.3

             

            Unknown

            9

             

            1

             

            32

             

            42

             

            Baby admitted to NICU

            Yes

            106

            16.7

            19

            5.5

            22

            4.4

            147

            9.9

             

            No

            528

            83.3

            326

            94.5

            479

            95.6

            1333

            90.1

             

            Unknown

            4

             

            2

             

            34

             

            40

             
            The factors that could be involved in exclusive breastfeeding were incorporated into a multivariate logistic regression model. When adjusted for potential confounding factors, the factors which were related to exclusive breastfeeding are described in Table 3. The factors that significantly contributed to decreasing the likelihood of exclusive breastfeeding included mothers who had a caesarean section (OR = 0.76). Demographic factors that were positively associated with exclusive breastfeeding at discharge were living in the suburb (OR = 2.17) and rural areas (OR = 2.33). Mothers who were older than 24 years (OR = 0.58, OR = 0.51), who did not make the decision to breastfeed until after birth (OR = 0.57) and who didn't give breastmilk as the first feed (OR = 0.56) were less likely to be exclusively breastfeeding on discharge.
            Table 3

            Factors associated with exclusive breastfeeding initiation after adjustment for potential confounders in Zhejiang Province, China, 2004–2005

            Factors

             

            n

            Adjusted Odds Ratio*

            95%CI

            Delivery method

            Vaginal

            407

            1

              
             

            Caesarean

            865

            0.76

            0.59

            0.99

            First feed

            Breast milk

            828

            1

              
             

            Other

            444

            0.56

            0.43

            0.73

            Living place

            City

            599

            1

              
             

            Suburb

            318

            2.17

            1.59

            2.95

             

            Rural

            355

            2.33

            1.69

            3.21

            Maternal age

            <25

            298

            1

              
             

            25–29

            684

            0.58

            0.43

            0.79

             

            ≥ 30

            290

            0.51

            0.34

            0.75

            Breastfeeding decision

            Before pregnancy

            946

            1

              
             

            During pregnancy

            201

            1.03

            0.75

            1.43

             

            After birth

            125

            0.57

            0.38

            0.86

            Parity

            Primiparous

            1142

            1

              
             

            Multiparous

            130

            1.67

            1.08

            2.57

            ∘ All variables of interest were included in the full model in the initial step and then backward elimination procedure was applied to obtain the final model, using 5% critical value of χ2 test for the appropriate degrees of freedom. * -2 log likelihood = 1637.86, d.f = 11

            ∘ Non-significant variables were maternal age, cesarean section, maternal education, infants' gender, when decided feeding method, parity, first feed, gestation week, mothers' job, if mothers attended antenatal classes, infant birth weight, if infants admitted to special care nursery? Living place, family income, maternal grandmother breastfed? Living with other people or only the couple.

            Discussion

            The use of prelacteal feeds were common in all locations (37.5%) and their use in Hangzhou city have been described in more detail [25]. Their use was most common in the rural location where it is traditional not to breastfeed for some time after birth. This is also the case in the far west of China, where delayed first feeds were common, but the use of prelacteal feeds was not as high as in Hangzhou [23]. In Vietnam the use of fluids other than breastmilk as a first feed is also common, but there it is less likely to be infant formula [29]. All of the hospitals in our study are "Baby Friendly Hospital" accredited, as are most Chinese hospitals. In theory all hospitals are required to practice the WHO Ten Steps to Successful Breastfeeding. Practically, the hospitals find that there are some difficulties in following these steps strictly. If a mother (or often her family) feels she does not have enough milk, they can easily get infant formula either from her family or from the hospital.

            In this study there are several factors that could be potentially modified to increase exclusive breastfeeding rates. The length of time to the first feed is an important factor and is used to monitor progress towards the millennium goals for child health [32]. In this study only one third (33.4%) of infants began breastfeeding within 30 minutes of delivery. Delivery room practices need to be modified to make this possible.

            According to Chinese tradition, it is the practice of Chinese friends or relations of postpartum women to visit the mother and they bring gifts which could be consumed or worn by the new baby. In recent times infant formula has become the most popular gift for new mothers. Gifts of infant formula were given to one third of new mothers by friends or relations (see Table 2).

            The time that the decision is made to breastfeed has an important relationship to breastfeeding outcomes in a number of different cultures [18, 33]. This is a function of antenatal preparation and health professionals need to encourage prospective parents to think about the importance of breastfeeding at the earliest opportunity and to continue to discuss this at subsequent contacts. Assisting mothers to make an early decision could also include education of the infant's father and grandmother about the benefits of breastfeeding.

            Exclusive breastfeeding rates were lower in infants who were delivered by caesarean section. This is a common risk factor for not breastfeeding in Asian societies, but not in Australia [29, 34, 35]. In our study population, women having a caesarean section had lower rates of exclusive breastfeeding than with vaginal delivery. After surgery, mothers feel pain in their abdominal incision, movement is limited because of catheterization and intravenous lines, and Chinese mothers worry about the side effects of medicines which may pass to the baby via breast milk. These factors are believed in this culture to influence lactogenesis. Further studies are needed to obtain more details on the reasons for the higher prevalence of caesarean section in this population and the influence on breastfeeding.

            There are several limitations that need to be considered when interpreting the results of this study. The sample was restricted to three locations in Zhejiang Province. While these locations were selected to be representative of Zhejiang and the response rate was high, this should be born in mind when interpreting the results. As economic and health system developments occur in Zhejiang Province it will be important to repeat cohort studies so that breastfeeding is continued to be promoted.

            Conclusion

            In Zhejiang Province the exclusive breastfeeding rate on discharge from hospital was only 50.3%, ranging from a low of 38% in the city to 63% in the suburbs. Risk factors for not exclusively breastfeeding include having a caesarean section, the time at which the decision to breastfeed was made, the place of residence and whether a prelacteal feed was given. Biological factors included maternal age and parity. Some of these factors could be incorporated into trials to increase exclusive breastfeeding rates.

            Notes

            Declarations

            Acknowledgements

            We gratefully acknowledge the willing assistance given by all the mothers in our study, the hospital staff, nurses and health workers in Zhejinag Province. This study could not have been possible without their assistance.

            Authors’ Affiliations

            (1)
            Women's Hospital, School of Medicine, Zhejiang University
            (2)
            School of Public Health, Curtin University
            (3)
            School of Public Health, Curtin University

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            This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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