Low exclusive breastfeeding rate in 6 months
According to the China Development Outcome of Child (2011–2020), the percentage of babies aged 0 to 6 months who are exclusively breastfed would reach 50% or higher . In this study, the exclusive breastfeeding rate of preterm infants was 19.0% in the first month, 17.2% in the third month and only 10.4% in the sixth month after discharge from the hospital. The exclusive breastfeeding rate for preterm children rapidly fell after discharge and was significantly lower than the 36.18% exclusive breastfeeding rate for full-term infants in the first 6 months of life . Preterm children may be born with severe respiratory distress, hypoglycemia and hypothermia as a result of immature physiological development, leading in maternal-infant separation and delayed breastfeeding initiation .Second, sucking-swallowing-respiratory function does not become gradually coordinated until around 37 weeks . In addition, preterm newborns may be unable to create appropriate negative pressure while sucking due to underdevelopment of the cheek fat bed . During maternal-infant separation, maternal frequent hand pumping is required to ensure that the ducts are unblocked and a lack of adequate breastfeeding knowledge and skilled lactation can result in breast swelling and acute mastitis, the mothers have to stop breastfeeding after medication, directly leading to breastfeeding failure after the preterm infant is discharged. Breastfeeding success after preterm infant discharge is inextricably linked to frequent sucking, skin-to-skin contact, early perception of the infant’s physiological state and effective response adjustment. Exclusive breastfeeding following preterm infant discharge is currently unfavorable and healthcare providers should keep this in mind when investigating the causes of exclusive breastfeeding failure.
Analysis of the time-varying covariates of maternal breastfeeding knowledge, self-efficacy, postpartum depression and family support
Within 6 months following delivery, the mean scores for maternal breastfeeding knowledge varied from (12.37 ± 4.37) to (13.63 ± 2.93), which was lower than the survey by Layal Hamze et al. . Inadequate breastfeeding education and support after discharge may be linked to low maternal breastfeeding knowledge.
After discharge, the mother’s breastfeeding self-efficacy improved steadily, the baby’s continual interaction with her increased the mother’s breastfeeding self-efficacy and the mother’s increasing willingness to breastfeed made it simpler for her to keep to breastfeeding. Breastfeeding self-efficacy is regarded to be a factor of breastfeeding duration and is changing . Creating strategic plans and setting targets to assist women who are separated from their infants in enhancing their nursing self-efficacy is crucial.
Postpartum depression (PPD) is a perinatal form of major depressive disorder (MDD) and affects approximately 500,000 women annually in the US (prevalence 10–15%) , while in China, the prevalence were about 23.5% . In the research, maternal PPD levels increased significantly during mother-infant separation, but steadily decreased when the preterm infant was discharged from the NICU. Our findings were much higher than the prevalence reported in the literature, maybe due to premature births and maternal and infant separation. The physical health of a premature infant will have a substantial impact on the mother’s emotional health.
The level of maternal family support was modest in the study. Having maternal support from family, friends and health care providers can help you establish successful breastfeeding . A mother’s decision to breastfeed her infant is influenced by her family . Family support for breastfeeding should be strengthened in women who have separated their infants from their mothers and in preterm neonates. Because most Chinese families only have one child due to the country’s family planning policy, the child naturally becomes the family’s focal point. The majority of family members’ preparation for a baby’s birth is material and lacks information. After the premature baby is discharged from the hospital, family members’ lack of knowledge about breastfeeding will impede mother breastfeeding.
Factors associated with exclusive breastfeeding rate at 6 month
Smaller gestational age was found to be an unfavorable factor in the exclusive breastfeeding rate of preterm infants 6 months after discharge from the hospital, which was consistent with Perrella’s research . Because most preterm infants need to be transported to the NICU right after birth and are separated from their mothers, delayed breastfeeding initiation occurs  and the younger the gestational age, the longer the hospital stay. In addition, preterm infants less than 34 weeks of gestational age cannot establish effective swallowing and sucking, necessitating nasal feeding. In certain cases, preterm infants are discharged with indwelling nasal feeding tubes, despite their inability to attain complete oral feeding. Mothers must express their breast milk by hand or use a breast pump to maintain lactation during this time and perceived inadequate milk supply (PIMS) is one of the leading causes of breastfeeding discontinuation . In this cohort study, maternal-infant separation was found to be most common in late preterm newborns (LPT)(34+ 0–36+ 6), who had a low exclusive breastfeeding rate after discharge from the hospital, only 45 of 359 (12.5%) late premature infants were exclusively breastfed 6 months after discharge from the hospital, far below the WHO target of 50% exclusive breastfeeding rate at 6 months . Several studies have revealed lower rates of breastfeeding initiation and shorter breastfeeding duration in LPT newborns when compared to term infants [37, 38], despite the recognized short- and long-term effects of LPT births, as well as the mother and baby health benefits of breastfeeding . These differences in breastfeeding could be due to a variety of factors, including maternal medical difficulties, delayed lactogenesis and infant clinical abnormalities. Better breastfeeding success for LPT infants in the NICU could be explained by more support and systematic breastfeeding education in the NICU [37, 39]. Medical personnel should pay special attention to preterm newborns, teach women to monitor daily lactation, keep lactation diaries and intervene as needed to optimize maternal lactation and promote nursing for infants of lower gestational ages.
In the research, type of delivery also influenced the exclusive breastfeeding rate of preterm infants for 6 months after discharge. Compared to cesarean delivery, preterm infants vaginal delivery had a higher exclusive breastfeeding rate after discharge from the hospital(44.2%vs55.8%).Incision pain, postural limitations and delayed lactation following a cesarean section all make these preterm infants breastfeeding more challenging, resulting in a low breastfeeding success rate among cesarean section moms . In addition, women who had a cesarean section showed a lower readiness to breastfeed and experienced more feeding issues and obstacles than women who had a vaginal delivery . Another factor that may have contributed to the high cesarean section rate was a new birth policy enacted in 2013 to encourage families to have two children, which resulted in an increase in the number of older pregnant women who underwent cesarean surgery for a variety of reasons .
Factors associated with exclusive breastfeeding duration
In the research, that exclusive breastfeeding duration was decided by maternal planned pregnancy, maternal and family action (delivery of the breast milk to the infants separated from their mothers during hospitalization), medical intervention (artificial feeding of premature infants in the NICU) and family support. The psychological status of the mothers before pregnancy also had a great impact on the breastfeeding duration. Therefore, the maternal psychological state of preparation for pregnancy should be paid greater attention to . The more psychological preparation for pregnancy a mother had, the lower the risk of weaning in the future. Meanwhile, they were also more aware of the benefits of breastfeeding and were empowered to decide whether to breast feed or not .
The delivery of breast milk by mothers and their families was linked to a higher exclusive breastfeeding rate and longer exclusive breastfeeding duration. According to studies, the lower the premature infant’s birth weight, the longer it takes for them to adjust to direct breastfeeding following discharge. Early breastfeeding termination was usually linked to shorter pregnancy duration and a lower birth weight . The organ system of sucking in preterm newborns became less mature as the gestational week progressed, resulting in poor swallowing and aspiration coordination, necessitating nasal feeding . Premature newborns will be able to start breastfeeding as soon as feasible if breast milk is delivered early to the NICU.
Artificial feeding of premature infants in the NICU has also been established as a factor linked to exclusive breastfeeding duration after discharge, according to our findings. The risk of breastfeeding cessation was raised when neonates were fed formula. Mothers of infants who were breastfed during hospitalization were more likely to continue to direct breastfeed following discharge. In a national study on preterm infant breastfeeding in Denmark, it was discovered that allowing mothers to visit the NICU to care for preterm newborns via cup-feeding or spoon-feeding could lead to premature infants accepting direct nursing sooner after discharge . In China, the traditional NICU was designed as a multi-person room with many warming boxes in a large open space to allow a medical staff to observe multiple infants at the same time and reduce walking distances. Because of the NICU’s closed environment in China, parents are not permitted to visit their children. Premature newborns are typically fed formula, which presents a challenge for mothers who wish to continue breastfeeding their babies after they are discharged from the hospital. Participants reported a sense of intimacy with their preterm infants when feeding, holding and engaging with them. Participants recognized intimate physical contact between the parent and the infant as an important aspect of intimacy in all of these actions. The NICU is more than simply a treatment facility for children; it is also a living environment for them and their families, with a focus on family-centered care. The most recent NICU arrangement in the United States is more equipped to gather the necessities of families in the family room (Single-Family Room, SFR). According to a study , SFRs invigorate breastfeeding because of the advancement of breastfeeding training provided to families by clinical professionals, allowing moms to acquire enough expert aid. SFR allowed mothers to be directly identified with truly focusing on their infants. They were also likely to have maternal assurance as a result of it, which aided in the early establishment and maintenance of breastfeeding. Therefore, they were also more likely to gain maternal confidence as a result of it, making it easier to initiate and maintain breastfeeding early on. As a result, it is recommended that the NICU be opened twice or three times a week to increase the contact time between the mother and the preterm infants. In the meantime, mothers should be encouraged to express milk on the cot side, which can relieve the mother’s anxiety and increase the exclusive breastfeeding rate.
Factors associated with exclusive breastfeeding rate and duration
This study pointed out that maternal family support not only affected the exclusive breastfeeding rate but also the duration. Breastfeeding success is dependent on a supportive family setting. However, the results of this survey revealed that family support for breastfeeding is low, particularly in terms of psychological support. The score of family support during hospitalization was only (2.79 ± 0.37), whereas the score of behavioral support was slightly higher. For example, when asked if “my family believes formula may substitute breast milk,” the overall consensus was that formula could be given instead of breast milk when breast milk was insufficient. It was shown that family members lacked breastfeeding knowledge and they wanted to help mothers in their own way. Therefore, the establishment of a supportive environment was essential to improving breastfeeding outcomes for most families.
The high rate of lost to follow up would probably influence the results. Therefore, every effort was made to reduce the number of lost to follow ups. There were reminders about the follow-up. Defaulted mothers were contacted and given a different date. To overcome the inaccuracy caused by lost to follow ups, we conducted a longitudinal analysis on lost to follow up rates. In the implementation of clinical research, the lost to follow up rate of no more than 20% is generally guaranteed . In this study, which was a longitudinal survey of breastfeeding and maternal related conditions of preterm infants at 1 month, 3 months and 6 months after discharge, the lost to follow up rate was 11.4%, which was within the acceptable range. The socio-demographic features of lost to follow ups were compared to those of preterm infants who completed the follow-up and found no significant differences. In this study we only calculated the minimum sample size based on the cohort study formula, in the future as our sample size increases and our uncertainty decreases, we will have greater precision for breastfeeding follow-up results.
Our study also had some limitations. First, exclusive breastfeeding duration was reported by mothers or their husbands, so there was some room for information bias as some women could have shared information according to social desires more than according to their actual practice. Second, although the sample size was only 500 mother-infant dyads, some categories in the analysis had fewer participants, which made some confidence intervals excessively wide. Finally, due to human and time restrictions, this study only followed women for 6 months after giving birth. In addition, according to the WHO recommendation of exclusive breastfeeding for 6 months after delivery . In future investigations, the duration of longitudinal follow-up could be prolonged. In the Ericson study  it was noted that 21% preterm infants (n = 49) partially breastfed at 12 months, the overall breastfeeding prevalence would be lower if moms who were not breastfeeding at discharge had been included. This conclusion was consistent with our study. The main strength of our study was that women and preterm infants were prospectively followed homogeneously in a single center committed to breastfeeding practices.