Disparities between urban and rural areas
Over the past two decades, China has made substantial progress in maternal health , and the gap between urban and rural maternal mortality is closing. In 1991, there were 46 urban vs. 100 rural maternal deaths per 100.000 live births and in 2012, 22 urban vs. 26 rural respectively . However, the National Maternal Mortality Surveillance System in China (NMMSS) reported that between 2001 and 2005 the risk ratio of preventable maternal mortality in rural areas had doubled compared to urban areas (OR 2.38, 95 % CI 2.01, 2.81) . According to the results of this study, some of the disparities in social, demographic and anthropometric status between urban and rural mothers still existed in the study area. On average, urban mothers had significantly higher incomes, were better educated and were about two years older when they conceived than were rural mothers (see Table 1). One study in rural western China indicated that the age of the woman was positively correlated with anemia and that the higher the wealth index of the household, the lower the prevalence of maternal anemia . NMMSS reported that, in remote rural areas, preventable maternal mortality accounted for 97 % of maternal deaths, while the most frequent factors were associated with mothers’ lack of adequate knowledge .
Referring to the mothers’ anthropometric status before pregnancy, in this study, urban mothers were two centimeters taller than rural mothers. Potentially, this may have influence on birth outcomes, the type of delivery, as well as the type of infant feeding, all of which are discussed later in this paper. Most of the mothers in both areas had a pre pregnancy BMI within the normal range. Slightly more mothers tended to be underweight or overweight/obese in rural compared to urban areas. This study found that the proportion of underweight mothers was high in both urban and rural areas (21.9 % urban vs. 22.6 % rural), while the prevalence of overweight/obesity was relatively low in both areas (2.1 % urban vs. 6.5 % rural). This finding is in line with the results from another cross-sectional study in the same region , and with a study conducted in northeastern parts of China by Liu et al. . By contrast, Pei et al. , found a relatively low prevalence of maternal underweight (7.9 %) and a comparably higher prevalence of overweight/obesity (17.9 %) in rural Sichuan province.
With respect to birth outcomes, urban newborns were significantly taller and heavier than rural infants in the study area, which could be explained by the fact that the urban mothers were taller and gained more weight during pregnancy than rural mothers. The prevalence of low birth weight in the study area was 3 %, which was consistent with the Chinese national level , with no significant difference between urban and rural areas. Although the problems of low birth weight and high birth weight infants were not serious in the study area, since pre pregnancy underweight is known to be associated with poor birth outcomes (i.e., premature birth, low birth weight) , more attention needs to be paid to urban and rural underweight women of reproductive age, especially for rural underweight pregnant women as recommended by Gao et al. .
We found nearly all mothers started breastfeeding (98.0 % urban vs. 99.0 % rural) in the Deyang region within the first five days after birth. Similar results were found by Qiu et al., any breastfeeding being practiced substantially in both city (96.5 %) and rural areas (97.4 %) , by Tang et al. (93.5 % rural)  and by Guo et al. (98.3 % in total) . However, with reference to exclusive breastfeeding before discharge, the prevalence of EBF was extremely low in both urban (8.1 %) and rural areas (5.2 %), as compared to a hospital-based study by Qiu et al. (38.0 % urban vs. 61.0 % rural) . Although in this study, no significant difference in infant feeding in urban and rural areas was found on the postnatal wards, the incidence was inadequate in both settings (see Table 5). It is clear, therefore, that there must be other factors impacting mothers’ infant feeding practices, an issue that will be discussed below.
Initiation of breastfeeding
In this study, only 6.6 % of the mothers initiated breastfeeding within one hour of birth. This finding was slightly lower, but similar to the results by Tang et al. (9.1 %)  and Lou et al. (11.1 %)  in the same region of Sichuan province. This is in line with the fact that local people in Sichuan lack the knowledge (only 26.5 % undergraduates agreed) that “breastfeeding should be started within the first hours after birth” . However, when looking at the results of a broader regional study , 6.6 % was far behind the 59.4 % level in central and western China.
“Why did the mothers delay the initiation of breastfeeding?” was a question discussed in the FGDs (see Table 6). A “lack of knowledge about early initiation of breastfeeding” and “Caesarean section” was given as the main reasons. Both quantitative and qualitative results reflected that: (a) there is a need to improve the implementation of the “Ten Steps to Successful Breastfeeding” , both in urban hospitals and rural clinics in the study area and (b) it could be explained by a misunderstanding of what “initiate breastfeeding” means in the local area. In the study area, “initiate breastfeeding” does not have the same meaning as “start sucking”. The mothers insisted they would not start breastfeeding until they felt that they had breast milk or that their breasts felt engorged, even if the baby had started sucking (breastfeeding) several hours or even a few days earlier. This misunderstanding may partly explain why the study results for EBF were so low as well.
Due to the widespread delay in breastfeeding, prelacteal feeding and the use of infant formula as a supplement to breast milk, the prevalence of EBF was only 8 % on postnatal wards. This situation was worse than the results of Chinese regional studies 28.7 % , 24.2 %  and at the national level 28.0 % . Without prelacteal feeding, the prevalence of EBF/AEBF could be up to 42.5 % in this study.
When the newborns’ lengths were shorter than 50 cm, their chances of being breastfed (almost) exclusively were lower compared to those who were ≥ 50 cm. In other words, if the mother had borne a smaller sized baby, her confidence in being able to breastfeed exclusively was reduced. Based on these findings, nurses and midwives should offer more breastfeeding support to the mothers with smaller sized infants, because these infants could benefit very significantly from the higher bioavailability of nutrients in breast milk compared to infant formula [40, 41].
In this study, the time to initiate breastfeeding ≤ two days after delivery was also significantly correlated with EBF/AEBF. The earlier the mothers started breastfeeding, the more likely they were to breastfeed exclusively. Although Caesarean section (CS) was found to be associated with EBF/AEBF, indirectly it was related to the time of initiating breastfeeding. Many other studies noted that CS delays the initiation of breastfeeding [42, 43] and is associated with the use of supplements among newborns  and mothers who had CS experienced more breastfeeding problems [45, 46]. Similar to earlier findings in the same study area , the proportion of CS was over 60 % during the study period and CS could defined as one of the risk factors for not exclusively breastfeeding. Thus, further research to reduce the incidence of CS in China would be important.
Unexpectedly, both the mothers’ educational levels and their knowledge of colostrum were negatively correlated with their feeding practices. Those findings were similar to some study results in other countries [48–50]. In focus group discussions, the mothers’ knowledge of the definition of exclusive breastfeeding was found to be poor. Several mothers had no idea what exclusive breastfeeding meant (Table 7) or knew the optimal time of exclusive breastfeeding. Other quotes included misinformation; “besides breast milk, water is necessary” and “exclusive breastfeeding is good, but difficult to practice”.
The FGDs revealed a common misunderstanding that “there was no/too little breast milk available immediately after childbirth” (Table 7). This perception was reported by mothers, grandparents, peers, and even some of the medical staff; many expectant mothers had purchased a box of infant formula and brought it to the hospital prior to giving birth. This may help to explain why more than 80 % of the infants received infant formula as a prelacteal feed. This misunderstanding was also related to the delay in the initiation of breastfeeding, as the mothers believed that there was nothing in the breasts at the beginning, when the breasts felt soft, and therefore they needed to wait until they were engorged or when they felt they had started to have breast milk. In addition, the belief that “water is essential as the first drink for newborns” was frequently mentioned by mothers in focus group discussions. This misunderstanding needs to be addressed during local breastfeeding promotion/education sessions.
Mothers tried to explain the low prevalence of exclusive breastfeeding in China during the FGDs (Table 7) and the feeling that “the amount of breast milk produced was not enough” was one of the major reasons mentioned. In other studies, “insufficient breast milk syndrome” has also been considered an important barrier to successful breastfeeding [37, 51, 52]. Because mothers usually cannot measure the amount of breast milk a baby has drunk, the mothers in our study often lacked confidence about whether their babies were satisfied or wondered if they were still hungry. In order to match the requirements of the growth charts at the monthly child care examination, these mothers preferred giving additional infant formula to their babies after breastfeeding. In most cases, monitoring the amount and color of the urine in the diaper and the frequency of bowel movements is a more effective indicator than mothers’ feelings . Daily weighing of the infant in the hospital and every couple of days after discharge could reassure the mothers and improve their confidence about exclusive breastfeeding. Due to the fact that most of the mothers delayed the initiation of breastfeeding, prelacteal feedings were widely used. Supplementation was continued after initiating breastfeeding because of the concern of not producing enough milk. During the course of this study, it became obvious that the physiology of breast milk production was not clearly understood. Thus, education on the physiology of breast milk production and secretion and the related importance of frequent suckling should be included in the maternal school curriculum.
Due to the widespread inappropriate advertising for infant formula in China [10, 53], parents believed that many health benefits are linked to formula feeding. Perceptions, such as infant formulas being as nutritious or even superior to breast milk, influenced several mothers to offer these formulas as supplements in addition to breastfeeding. To reduce the impact of the unsubstantiated health claims of the infant formula companies  the Ministry of Health of China issued a ban on aggressive advertising of infant formula in 1995 . However, due to lack of control mechanisms, the ban does not seem to have been effective.
Another barrier to exclusive breastfeeding in China is the shifting attitude about breasts among modern young people. Historically, the main function of breasts was simply ‘feeding’. People now perceive “small and exquisite breasts” as beautiful . According to traditional Chinese culture, small feet not breasts, were the important sexual organs [56–58]. However, in contemporary China, the sexual role of breasts is surpassing their feeding function, just as in other industrialized countries [57, 59, 60]. More and more mothers and their husbands choose infant formulas instead of breastfeeding, because they believe breastfeeding could cause mothers’ breasts to shrivel or sag. To address this increasing problem, mothers need a better understanding of the physical structure and the function of breasts through improved breastfeeding education. The mainstream media could take responsibility for highlighting maternal aspects of breastfeeding rather than focusing only on the erogenous function of breasts.
It is likely that women, who delivered their babies vaginally, without any complications, were discharged earlier and, consequently, were not included in our postnatal assessment which took place during the first week after delivery. Therefore, women who delivered their newborns by Caesarean section may be overrepresented by comparison to those who delivered without any complications and who left the hospital earlier. In addition, the traditionally dominant roles of family members (i.e. father, grandmother) were not adequately considered in this study with regard to infant feeding recommendations and this could have been useful in explaining the breastfeeding situation in the study area.