Breastfeeding experience, challenges and service demands among Chinese mothers: A qualitative study in two cities

Challenges, experiences, and potential supports for East and Southeast Asian mothers in the workforce: a systematic review

OBJECTIVE

To examine the challenges faced by Asian working mothers with a focus on re-entry to the workplace. In addition, we highlight potential supports that retain women in the workforce.

DESIGN

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and registered with PROSPERO database (CRD42022341130).

METHODS

Three independent reviewers were involved in the study selection to screen the search results sequentially by title, abstract, and full text using predefined inclusion and exclusion criteria. The methodological quality of each article was assessed via the Critical Appraisal Skills Programme (CASP) tool.

RESULTS

We analysed a total of 36 studies conducted across different regions: 30 from the East and 6 from Southeast Asia. Among these studies, 20 were quantitative in nature, 15 were qualitative, and one intervention. The 36 studies cover five themes: 1) policies, 2) external support sources, 3) external pressure, 4) breastfeeding and 5) health status. Within each theme the same factor can have a positive or negative impact on the mother depending on her having a pro-career or pro-family mindset. Companies can take various initiatives to support working mothers, such as providing facilities for expressing breast milk at the workplace, educating staff to promote breastfeeding and accommodate childcare needs, and extending maternity leaves. However, there is a lack of literature that directly addresses the barriers and concrete support available to working mothers in Asia, beyond the scope of breastfeeding.

CONCLUSIONS

Our findings underscore several obstacles that can impede a woman's seamless return to work. Pro-family and pro-career mothers have differing needs that cannot be addressed at the same time. There is a lack of comprehensive understanding regarding effective strategies or interventions that can support a positive reintegration into the workforce.

Improving Parental Health Literacy in Primary Caregivers of 0- to 3-Year-Old Children Through a WeChat Official Account: Cluster Randomized Controlled Trial

Background

Parental health literacy is important to children's health and development, especially in the first 3 years. However, few studies have explored effective intervention strategies to improve parental literacy.

Objective

This study aimed to determine the effects of a WeChat official account (WOA)-based intervention on parental health literacy of primary caregivers of children aged 0-3 years.

Methods

This cluster randomized controlled trial enrolled 1332 caregiver-child dyads from all 13 community health centers (CHCs) in Minhang District, Shanghai, China, between April 2020 and April 2021. Participants in intervention CHCs received purposefully designed videos via a WOA, which automatically recorded the times of watching for each participant, supplemented with reading materials from other trusted web-based sources. The contents of the videos were constructed in accordance with the comprehensive parental health literacy model of WHO (World Health Organization)/Europe (WHO/Europe). Participants in control CHCs received printed materials similar to the intervention group. All the participants were followed up for 9 months. Both groups could access routine child health services as usual during follow-up. The primary outcome was parental health literacy measured by a validated instrument, the Chinese Parental Health Literacy Questionnaire (CPHLQ) of children aged 0-3 years. Secondary outcomes included parenting behaviors and children's health outcomes. We used the generalized linear mixed model (GLMM) for data analyses and performed different subgroup analyses. The β coefficient, risk ratio (RR), and their 95% CI were used to assess the intervention's effect.

Results

After the 9-month intervention, 69.4% (518/746) of caregivers had watched at least 1 video. Participants in the intervention group had higher CPHLQ total scores (β=2.51, 95% CI 0.12-4.91) and higher psychological scores (β=1.63, 95% CI 0.16-3.10) than those in the control group. The intervention group also reported a higher rate of exclusive breastfeeding (EBF) at 6 months (38.9% vs 23.44%; RR 1.90, 95% CI 1.07-3.38) and a higher awareness rate of vitamin D supplementation for infants younger than 6 months (76.7% vs 70.5%; RR 1.39, 95% CI 1.06-1.82). No significant effects were detected for the physical score on the CPHLQ, breastfeeding rate, routine checkup rate, and children's health outcomes. Furthermore, despite slight subgroup differences in the intervention's effects on the total CPHLQ score and EBF rate, no interaction effect was observed between these subgroup factors and intervention factors.

Conclusions

Using a WHO literacy model-based health intervention through a WOA has the potential of improving parental health literacy and EBF rates at 6 months. However, innovative strategies and evidence-based content are required to engage more participants and achieve better intervention outcomes.

Returning to work after maternity leave: a systematic literature review

PURPOSE

Working women often experience difficulties associated with balancing family and career, particularly if they choose to have children. This systematic literature review aimed at investigating women's experience in returning to work after maternity leave.

METHODS

The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The literature search led to the identification of 52 articles, which underwent data extraction and qualitative analysis.

RESULTS

Results were organized in 5 categories: (1) Work-life balance; (2) Women's mental and physical health; (3) Job-related wellbeing and working experience; (4) Breastfeeding. Women's both mental and physical health seem connected to a longer maternity leave and a greater coworkers' and supervisors' support. Returning to work seems to constitute one of the most important barriers for exclusive breastfeeding or breastfeeding continuation. A shorter duration of maternity leave, a higher workload and the lack of occupational policies supporting breastfeeding seem to be hindering factors. Partner and family support, and the opportunity for fathers to work under a flextime system after childbirth seem to increase both breastfeeding initiation and duration. Women who continue breastfeeding after returning to work seem to experience more family-to-work conflict and overload.

CONCLUSIONS

This paper show that there are still many understudied aspects in exploring women's experience of returning to work after maternity leave. This represents an important gap in the literature, since returning to work represents a particularly critical time in women's personal and occupational life, in which challenges and barriers may arise, potentially affecting their experience in the immediate future and years to come.

Healthcare providers' perceived barriers to providing breastfeeding support in Northwest rural China

BACKGROUND

Healthcare providers play important roles in supporting breastfeeding. Although there has been insufficient actual breastfeeding support from healthcare providers in China, little research has been conducted to understand Chinese healthcare providers' perceived barriers to providing breastfeeding support, especially in rural China. This study aims to identify these perceived barriers to providing breastfeeding support in Northwestern rural China.

METHODS

This study was conducted during the period from March 2018 to December 2018. Forty-one healthcare providers were recruited through purposive sampling in two rural counties in Northwest China that are in close proximity to each other and share similar demographic features. Participants included obstetrician-gynecologists, midwives, nurses, "village doctors", and township and village maternal and child health workers. Qualitative data were collected through one-on-one in-depth semi-structured interviews and focus group discussions. Transcripts were thematically analyzed.

RESULTS

Analysis of interview data resulted in four themes that the participants perceived as barriers to supporting breastfeeding: (1) lack of medical resources, within which inadequate staffing, and lack of financial incentives were discussed, (2) lack of clear and specific responsibility assignment, within which no one takes the lead, and mutual buck-passing were discussed, (3) healthcare providers' lack of relevant expertise, within which lack of knowledge and skills, and low prestige of village healthcare providers were discussed, (4) difficulties in accessing mothers, within which medical equipment shortages reduce services utilization, mothers' housing situation, mothers' mobility, and cultural barriers were discussed.

CONCLUSIONS

The study identified HCPs perceived barriers to providing breastfeeding support. Unique to China's Tri-Level Healthcare System, challenges like staffing and financial incentives are hard to swiftly tackle. Recommendations include mHealth enhancement and clarified responsibilities with incentives and tailored training. Further research is crucial to evaluate these strategies in rural Northwestern China and comparable underdeveloped areas nationwide.

Investigation of maternal breastfeeding guarantee policy needs and influencing factors: a cross-sectional study in China

Background

The promotion of breastfeeding is an important strategy to prevent neonatal death and improve maternal and infant health. But Chinese efforts to improve breastfeeding practices have not been particularly effective. There is still a long way to go to achieve the national health development goals. We aimed to explore the maternal demand for breastfeeding guarantee policy in China and to determine the impact of a range of socio-demographic and neonatal-related variables on breastfeeding guarantee policy demand.

Methods

The study was carried out in the Obstetrics and Gynecology hospital of Shanghai, one of China's earliest provincial and municipal maternal and child health care institutions. From June to November 2021, 1,292 women were recruited for the cross-sectional study in child health clinic. We collected relevant socio- demographic and neonatal-related data. Maternal breastfeeding needs were measured through a self-designed questionnaire on breastfeeding guarantee policy demands of mothers.

Results

The mean score of breastfeeding guarantee policy demand was 4.42 ± 0.51. There were statistically significant differences in the effects of maternal age, education level, family income per capita (Yuan), medical payment type, baby age, work status, and current feeding methods on the demand for breastfeeding guarantee policies (P < 0.05). Multiple linear regression analyses showed that higher education level (B = 4.437, P < 0.001), baby age (B = 2.150, P = 0.002), and current feeding methods (B = 2.754, P = 0.005) were significantly associated with a higher demand for a breastfeeding guarantee policy, the effect of medical payment type is the most influencing factor (B = -7.369, P < 0.001).

Conclusions

The maternal needs for breastfeeding guarantee policy are multi-faceted and urgent. In the process of improving and implementing policies, the government and relevant departments should take into account the actual needs of women who have different education levels, baby ages, family economics, and feeding methods.

Translation and validation of the Breastfeeding Motivation Scale in China

BACKGROUND

There are several versions of the Breastfeeding Motivation Scale (BMS), which have been shown to measure maternal breastfeeding motivation, but there is not a Chinese version yet. The study aimed to translate the BMS into Chinese and subsequently assess its psychometric properties among Chinese mothers during the postpartum period.

METHODS

The study was composed of two phases. The translation of BMS closely followed the principals of good practices. Phase 1 included a comprehensive translation, back-translation, cross-cultural adaptation, and pretest to develop the Chinese version of the BMS. From 1 December 2021 to 1 July 2022, the Chinese version of the BMS was administered to 206 postnatal mothers in our maternity wards to assess its psychometric properties. Phase 2 involved psychometric property testing, including testing of the internal consistency, test-retest reliability, content validity, construct validity, convergent validity and discriminant validity.

RESULTS

Minor modifications in four items were recommended after translations. The Cronbach's α coefficient of the Chinese version of the BMS was .887, and the intraclass correlation coefficient was .897 (P < 0.001). The model fit was acceptable (χ2/df = 2.40, P < 0.001, RMSEA = 0.08, CFI = 0.91, IFI = 0.92 and TLI = 0.90) according to the confirmatory factor analysis. The composite reliability values corresponding to each latent variable were 0.733 ~ 0.926, and the average variance extracted values were 0.476 ~ 0.653. The correlations among the five measured variables were all lower than .85 and the square roots of average variance extracted from the variable were greater than the interconstruct correlations among the five measured variables in the model.

CONCLUSIONS

The Chinese version of the BMS has good reliability and validity and provides a reliable assessment tool for measuring maternal breastfeeding motivation. It also provides support to develop culturally sensitive interventions for Chinese mothers' who are breastfeeding.

Mediating role of birth at a baby-friendly hospital in the association between parental socioeconomic status and infant exclusive breastfeeding at six months old

BACKGROUND

Current evidence suggests that the exclusive breastfeeding (EBF) rate at six months postpartum in China falls considerably below the targets recommended by the World Health Organization (WHO). Socioeconomic disparities in EBF have been observed in developing countries, with significant heterogeneity across studies. Despite the implementation of the Baby-Friendly Hospital Initiative (BFHI) in China since the 1990s to promote breastfeeding, there has been a lack of assessment concerning infants from different socioeconomic backgrounds. This study sought to investigate the association between socioeconomic status (SES) and EBF and explore the potential impact of giving birth at a Baby-Friendly Hospital (BFH) on this association.

METHODS

We analyzed data from 98,469 mother-child dyads selected from the Maternal and Child Health Management Information System. We used log-binomial models to examine the relationships between SES and EBF, SES and giving birth at a BFH, as well as BFH births and EBF. Additionally, we explored a counterfactual mediation approach to assess the mediating role of BFH births in the SES-EBF association.

FINDINGS

We identified a significant association between SES and EBF (RRMedium vs. Low = 1.47, 95% CI 1.39-1.55; RRHigh vs. Low = 1.40, 95% CI 1.32-1.49). Mothers with higher SES were more likely to give birth at BFHs (RRMedium vs. Low = 1.85, 95% CI 1.81-1.88; RRHigh vs. Low=2.29, 95% CI 2.25-2.33). The significance of the SES-EBF association was attenuated when the type of hospital for childbirth was considered, revealing the significant mediating effect of BFH births in the SES-EBF association.

CONCLUSION

Socioeconomic disparities are linked to infant EBF rates, with giving birth at a BFH mediating this association, especially for cases with low SES in rural areas.

Breastfeeding needs of mothers of preterm infants in China: a qualitative study informed by the behaviour change wheel

BACKGROUND

Although breastfeeding is strongly recommended, the breastfeeding rate of preterm infants in China remains significantly low. In addition to the global structural challenges to breastfeeding and the physiological immaturity of preterm infants, Chinese mothers of preterm infants face unique challenges of maternal-infant separation after birth. Moreover, little is known about Chinese mothers' specific needs in coping with the difficulties posed by these challenges. This study utilized the Behaviour Change Wheel to investigate the breastfeeding needs of Chinese preterm mothers that may facilitate its practice in the future.

METHOD

A qualitative descriptive design was implemented in Wuhan in 2022. Based on purposeful sampling, 13 preterm mothers were recruited from a NICU in a Grade III Class A hospital in Wuhan, China. Face-to-face semi-structured interviews were conducted to collect data using the interview guide developed by the Theoretical Domains Framework. Theoretical Thematic Analysis was used to review the data in 6 steps to identify themes.

RESULTS

Five major themes emerged: (1) capability: ability to interpret infants' cues and identify problems, and need for breastfeeding knowledge and skills training; (2) physical opportunity: cleanliness and quietness in household environment, private lactation spaces and breastfeeding tools in workplaces and hospitals; (3) social opportunity: family support, peer support, and authoritative support from healthcare providers; (4) reflective motivation: information on health impacts of breastfeeding; (5) automatic motivation: maternal-infant bonding, free of aversive stimulus.

CONCLUSION

Preterm mothers' needs to enable breastfeeding were diverse, including increasing their capability, physical and social opportunities, and reflective and automatic motivation. People, resources and environments associated with these needs should be engaged together to stablish a conducive structural environment for breastfeeding. The policy change for "zero separation" and implementation of kangaroo care should also be implemented in Chinese neonatal intensive care units. Future studies are needed to design effective interventions according to mothers' specific needs.

Factors influencing breastfeeding continuation and formula feeding beyond six months in rural and urban households in Indonesia: a qualitative investigation

BACKGROUND

Global and Indonesian guidelines suggest that breastfeeding should continue for at least the first two years of life. While many studies have focused on six-month exclusive breastfeeding practices, little is known about why mothers do not sustain breastfeeding beyond this period. This qualitative study aimed to explore factors influencing breastfeeding continuation and formula feeding beyond six months, regardless of any additional food consumed, focusing on Indonesia's rural and urban areas.

METHODS

We collected the data through 46 in-depth interviews in Pati District and Surakarta City, Central Java, Indonesia. Participants were mothers, grandmothers, health care practitioners, and village kader (frontline female health workers). We used thematic analysis combining deductive and inductive techniques for analysing the data.

RESULTS

Rural mothers practised breastfeeding and intended to breastfeed for a longer duration than urban mothers. Maternal attitude towards breastfeeding, breastfeeding knowledge, previous experiences, and other breastfeeding strategies (e.g., enhancing maternal dietary quality) positively influenced breastfeeding sustainability. In the urban setting, mothers encountered several breastfeeding barriers, such as perceived breast milk insufficiency and child hunger and satiety, child biting, and breastfeeding refusal, causing them to provide formula milk as a breast milk substitute or supplement. In addition, families, communities, health practitioners, and employment influenced maternal decisions in breastfeeding continuation and formula-feeding practices.

CONCLUSIONS

Optimal breastfeeding practices up to two years of age are determined by the individual and setting (i.e., community, healthcare, employment) factors. Providing breastfeeding education covering practical breastfeeding guidance will encourage mothers to breastfeed for longer. Such interventions should involve families, communities, health workers, and the work environment as a breastfeeding support system. Policymakers should develop, enforce, and monitor the implementation of breastfeeding policies to protect, promote, and support breastfeeding in households, communities, health systems, and work settings.

Associations of in-hospital postpartum feeding experiences with exclusive breastfeeding practices among infants in rural Sichuan, China

BACKGROUND

In rural China, exclusive breastfeeding (EBF) prevalence is low and hospitals often fail to attain baby-friendly feeding objectives, such as ≥ 75% of newborns exclusively breastfed from birth to discharge. Empirical evidence for the impact of increased hospital compliance with recommended feeding guidelines on continued EBF in rural China is lacking. We sought to measure and model the association of newborns' in-hospital feeding experiences with EBF practice in infancy to inform policies for EBF promotion.

METHODS

Data were cross-sectional from 785 caregivers of infants < 6 months of age, collected from November to December 2019 in four underdeveloped counties/districts in Sichuan Province. In-hospital feeding practices were determined, and prevalence of current infant feeding practices was calculated from 24-h recall and categorized according to WHO/UNICEF Infant and Young Child Feeding categories as EBF, breastfed with non-milk liquids, mixed feeding, breastfed with solids, and not breastfed. Relative risk ratios were estimated using adjusted multinomial logistic regression to examine risk factors for non-EBF practices compared to EBF, including in-hospital feeding experiences. The regression model was used to investigate change in EBF prevalence under alternative in-hospital experiences.

RESULTS

Only 38.1% of under-six-month-old infants were being exclusively breastfed when data were collected; 61.8% and 77.6% had been fed water and infant formula, respectively, in the hospital. Infants who were fed water or formula before discharge were estimated as 2-3 times as likely to be non-EBF than EBF up to age six months. According to our model, EBF prevalence would have increased to 53.7% (95% confidence interval (CI) 46.1, 61.2) had ≥ 75% of infants been exclusively breastfed and water-based feeds eliminated in-hospital.

CONCLUSIONS

Given the importance of infants' first feeding experiences in the establishment and continuation of EBF, it is imperative that rural Chinese hospitals actively seek to limit infant formula feeds to medically indicated situations and eliminate water-based feeds.

Learning from mothers' success in breastfeeding maintenance: coping strategies and cues to action

This study aimed to gain insight from mothers who were successful in breastfeeding maintenance to develop interventions for promoting breastfeeding maintenance. Following the phenomenological framework, this qualitative study recruited mothers who had maintained breastfeeding for at least 4 months for in-depth interviews. A total of 30 in-depth interviews were completed. We found that almost all participants had experienced an initial adjustment period. During this period, a social support network, personal perseverance in "trying" breastfeeding and "pumping," and adjusting expectations for breastfeeding to relieve themselves from the pressure of exclusive breastfeeding were important coping strategies. All participants then entered a stage of getting more attuned when breastfeeding was easier. During this period, seeking support from the online mother groups, deliberating medication that might affect breastfeeding, adjusting to accommodate breastfeeding and lives, and managing breastfeeding in public were the main strategies. For working mothers, despite workplace and employers' support, proactive adjustment for using the facilities and lactation breaks for breast milk expression was essential for breastfeeding continuation after returning to work. Throughout the whole journey, positive cues identified from their breastfeeding experiences that helped breastfeeding maintenance included enjoying breastfeeding, breastfeeding as a personal achievement, a healthy and thriving child, positive social feedback, bodily response, the convenience of breastfeeding, and breastfeeding as a motherhood commitment. To conclude, while mothers should be mentally prepared for the difficulties of breastfeeding, they should also be encouraged that things will always get easier as they persevere. Adjustments should be made to accommodate lives and other personal needs. Future studies should consider integrating relevant cues into existing psychosocial interventions for promoting breastfeeding maintenance.

The mothers' breastfeeding behaviour within six weeks postpartum: new scale development and psychometric validation study

BACKGROUND

The evaluation of mothers' breastfeeding behaviour within 6 weeks postpartum could help health workers comprehensively identify maternal breastfeeding shortcomings, clarify nursing problems, and provide targeted interventions. However, no prior study was found, therefore this study aimed to develop and validate the reliability and validity of the mothers' breastfeeding behaviour scale within 6 weeks postpartum.

METHODS

A main two-step approach was used: (1) a qualitative pilot study using the purposive sampling method was adopted to test the fitness, simplicity, and clarity of items with 30 mothers; (2) a cross-sectional survey using the convenient sampling method was conducted for item analysis and psychometric validation with 600 mothers.

RESULTS

The final version of the scale consisted of 36 items with seven dimensions, explaining 68.852% of the total variance. The Cronbach's α, split-half, and retest coefficients were 0.958, 0.843, and 0.753, respectively. The validity of the scale: (1) Content validity: content validity index (CVI) range of items was between 0.882 and 1.000. The scale-level-CVI was 0.990. (2) Structure validity: The fitting indices were as follows: χ²/ⅆf =2.239, RMR = 0.049, RMSEA = 0.069, TLI = 0.893, CFI = 0.903, IFI = 0.904, PGFI = 0.674, and PNFI = 0.763. (3) Convergent validity: The composite reliability and average variance extracted (AVE) of the seven dimensions were between 0.876 and 0.920 and between 0.594 and 0.696. (4) Distinguish validity: The correlation coefficients were less than the square root of the AVE, except for self-decision behaviour, self-coping behaviour, and self-control behaviour. However, the fit index of the original three-factor model was better than that of the other new models, with significant differences (P < 0.001). (5) Calibration validity: The area under the curve was 0.860 or 0.898 when the scale was used to predict exclusive or any breastfeeding at 42 days. The correlation coefficients of the maternal breasting feeding evaluation scale, breastfeeding self-efficacy short-form scale, and the scale were 0.569 and 0.674, respectively.

CONCLUSION

The newly developed mothers' breastfeeding behaviour scale within 6 weeks postpartum consists of 36 items belonging to seven dimensions with good reliability and validity and is a reliable and valid instrument to be used in future maternal breastfeeding behaviour assessments and interventions.

Mothers' breastfeeding six weeks postpartum and factors influencing exclusive breastfeeding during the first six months

We aimed to assess the feeding pattern and influencing factors within six weeks postpartum on exclusive breastfeeding duration among Chinese mothers. This study was conducted using 2:1 matched case-control study. Cases and controls were matched for maternal age, parity and mode of birth. A total of 210 women were included. Approximately 67.9% of women stopped exclusive breastfeeding within the first six weeks postpartum. Maternal non-exclusive breastfeeding intention, lower maternal educational level, mother-infant skin to skin contact over one hour, unsatisfied breastfeeding self-evaluation and maternal unhealthy condition within the first six weeks were risk factors for ceasing exclusive breastfeeding early.

Breastfeeding competency and its influencing factors among pregnant women in third trimester pregnancy: a cross-sectional study

Competency is closely related to the occurrence of the behavior. Breastfeeding competence is the mastery of different breastfeeding factors which intervene in breastfeeding behavior. Breastfeeding competence could improve the breastfeeding behavior. However, few studies have paid attention to the status and the influencing factors of breastfeeding competency. The breastfeeding competency of pregnant women in third trimester pregnancy has the greatest impact on breastfeeding behavior after childbirth. Therefore, the objective of this study were to investigate the breastfeeding competency level and independent risk factors for breastfeeding competency among pregnant women in third trimester pregnancy. A cross-sectional survey method and convenience sampling method was used in the study. The general information questionnaire including age, gestational week, educational background, and so on were used to investigate the general information of pregnant women and their husbands. A breastfeeding competency scale (BCS) was used to investigate the breastfeeding competency of pregnant women. The total score of the BCS ranges from 38 to 190, with higher scores indicating greater breastfeeding competency. Lower level, medium level and higher level are 38-89, 90-140 and 141-190 respectively. Type-D Scale-14 (DS14) was used to investigate the type D personality of pregnant women. A multivariable linear regression was used to examine the independent predictors of breastfeeding competency. A total of 550 questionnaires were collected and finally 525 effective questionnaires were collected. The age of 525 pregnant women is (30.24 ± 3.954) years old. The breastfeeding competency score of pregnant women was (134 ± 19.741). Multivariable linear regression analysis showed that higher breastfeeding competency in pregnant women were reported among pregnant women who gestational age ≥ 256 days (37 weeks) (B = 8.494, p < 0.001), the previous breastfeeding experience were exclusive breastfeeding (B = 17.384, p < 0.001) and partial breastfeeding (B = 16.878, p < 0.001), participating in pregnant women school 2-3 times (B = 10.968, p = 0.013) and ≥ 5 times (B = 13.731, p = 0.034). Pregnant women with lower breastfeeding competency were found in women who were judged to have type D personality (B = - 6.358, p < 0.001). The result can explain 25.8% of the variation in the total breastfeeding competency score. This should be considered an important issue by maternal and child health care in the medical system that the moderate level of breastfeeding capacity among pregnant women. Differentiated and targeted breastfeeding support and services for pregnant women should be carried out based on influencing factors of breastfeeding competency.

What are the determinants of low exclusive breastfeeding prevalence in China? A cross‐sectional study

Exclusive breastfeeding (EBF) status is far from the national target in China. To identify the modifiable factors associated with EBF of infants aged under 6 months in China. A cross‐sectional study was conducted in 12 provinces/municipalities across China in 2017–2018. We used multistage stratified cluster sampling and collected data through face‐to‐face interviews with mothers using an electronic questionnaire. Totally, 5287 pairs of mother–infant aged <6 months were investigated. The EBF prevalence was 29.2% (1544/5287). Mothers with correct knowledge of colostrum (adjusted odds ratio [AOR]:1.32, 95% confidence interval [CI]: 1.07, 1.62), EBF (AOR: 1.39, 95% CI: 1.06, 1.81) and the highest scores of perceptions for breastfeeding benefits (AOR: 1.36, 95% CI: 1.14, 1.61) were more likely to exclusively breastfeed. However, mothers with more frequent unwillingness of breastfeeding during the first month postpartum were less likely to practice EBF (AOR: 0.68, 95% CI: 0.52, 0.90). Infants having their first breast milk within 24 h of birth increased the odds of EBF (AOR: 2.41, 95% CI: 1.86, 3.13). Infants were less likely to be exclusively breastfed in the families in which the main caregiver was the grandmothers. Mothers without receiving infant formula feeding suggestions via the health facilities, media, or the Internet (AOR: 1.57, 95% CI: 1.33, 1.85) or without the experience of infant formula feeding in public (AOR: 1.45, 95% CI: 1.23, 1.72) might more likely to practice EBF. To acquire comprehensively correct knowledge and keep a positive attitude of breastfeeding for the mothers are crucial for improving the EBF prevalence. Family supports are potential interventions worth focusing on. Infant formula promotion remains a great barrier for EBF in China.

This is the first study with a large sample size that examined determinants at individual, family, community and social levels potentially affecting EBF practice in China.

In this cross‐sectional study, mothers with completely correct knowledge and positive attitude of breastfeeding, infants having their first breast milk within 24 h of birth, and without exposure to infant formula feeding suggestions or experience might more likely to practice EBF.

Dissemination of comprehensively correct knowledge and operational skills of breastfeeding, initiation of breastfeeding as soon as possible, reducing the influence of infant formula might be effective methods for improving the EBF prevalence in China.

Working mothers' breastfeeding experience: a phenomenology qualitative approach

Background

Breastfeeding practice is influenced by the mother’s attitude toward and knowledge of breastfeeding. Working mothers face many challenges and need support to maintain breastfeeding. This study aimed to explore working mothers’ breastfeeding experiences and challenges that can influenced their practices.

Methods

The qualitative phenomenological approach involving working mothers in Kota Bharu who fulfilled the inclusion criteria and consented to participate in the study were recruited using purposive sampling. Sixteen participants aged 24 to 46 years were interviewed using semi-structured in-depth interviews in the study. All interviews were recorded in digital audio, transcribed verbatim and analyzed using thematic analysis.

Findings

Three main themes emerged from the data analysis: perception of breastfeeding, challenges in breastfeeding, and support for breastfeeding. Two subthemes for perceptions were perception towards breastfeeding and towards infant formula. Challenges had two subthemes too which were related to perceived insufficient milk and breastfeeding difficulty. Where else, two subthemes for support were internal support (spouse and family) and external support (friends, employer, and healthcare staff).

Conclusions

Maintaining breastfeeding after return to work is challenging for working mothers and majority of them need support to continue breastfeeding practice. Support from their spouses and families’ influences working mothers’ decision to breastfeed. Employers play a role in providing a support system and facilities in the workplace for mothers to express and store breast milk. Both internal and external support are essential for mothers to overcome challenges in order to achieve success in breastfeeding.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04304-4.

Breastfeeding Supportive Services in Baby-Friendly Hospitals Positively Influenced Exclusive Breastfeeding Practice at Hospitalization Discharge and Six Months Postpartum

BACKGROUND

Studies have shown that implementing the Ten Steps to Successful Breastfeeding of the Baby-Friendly Hospital Initiative can protect, promote, and support breastfeeding. However, few studies have valuated the quality of breastfeeding supportive services provided by Baby-Friendly Hospitals from the perspective of service users.

METHODS

This was a hospital-based prospective study, conducted at eight Baby-Friendly Hospitals with a total of 707 pregnant women in Shanghai, China between October 2016 and September 2021. Breastfeeding supportive services during hospitalization were assessed at childbirth discharge using a 12-question questionnaire based on the Chinese "Baby-Friendly Hospital Evaluation Standards". Women were followed up on six months postpartum. The impact of breastfeeding supportive services during hospitalization on the exclusive breastfeeding at discharge and six months postpartum were assessed.

RESULTS

Of the 707 mothers who completed the survey at discharge, 526 were followed up on six months after delivery. The overall exclusive breastfeeding rate among participants was 34.4% at discharge and 52.1% at six months postpartum. Mothers who received better breastfeeding supportive services during hospitalization were more likely to practice exclusive breastfeeding at hospitalization discharge compared with mothers who received poorer services (aOR: 3.00; 95% CI: 2.08, 4.35; p < 0.001). Furthermore, they were also more likely to exclusively breastfeed at six months postpartum (aOR: 1.50; 95% CI: 1.03, 2.22; p = 0.033).

CONCLUSION

Better breastfeeding supportive services during hospitalization were significantly associated with higher rate of exclusive breastfeeding at discharge and six months postpartum. More effective measures should be adopted to improve the implementation of the breastfeeding supportive services in Baby-Friendly Hospitals to promote exclusive breastfeeding and better maternal and child health.

Effect of Baby-Led Self-Attachment Breastfeeding Technique in the Postpartum Period on Breastfeeding Rates: A Randomized Study

Objective: To evaluate the effects of a baby-led self-attachment breastfeeding support intervention on the prevalence and duration of exclusive breastfeeding and nipple pain at 3 days, 6 weeks, 3 months, and 6 months postpartum among Chinese mothers. Materials and Methods: A randomized study was conducted with 504 mother-infant dyads allocated to the baby-led self-attachment breastfeeding support intervention (n = 251) and standard postpartum care (n = 253). Data on the prevalence and duration of exclusive breastfeeding and nipple pain were collected at 3 days, 6 weeks, 3 months and 6 months postpartum. Results: Mothers in the intervention group were significantly more likely exclusively breastfeeding at 3 days (mean difference = 12.1%, 95% confidence interval [CI]: 3.9-20.2%, p = 0.004) and 6 months postpartum (mean difference = 17.8%, 95% CI: 8.3-27.4%, p < 0.001). They were less likely to stop breastfeeding over the 6-month period, compared with the control group (Hazard ratio = 0.65; 95% CI: 0.49-0.87). They were also less likely to experience nipple pain at 3 days (mean difference = -8.1%, 95% CI: -15.9 to -0.4%, p = 0.04) and 3 months postpartum (mean difference = -4.9%, 95% CI: -8.7 to -1.2%, p = 0.01). Conclusions: The baby-led self-attachment breastfeeding support is clinically effective in increasing the prevalence and duration of exclusive breastfeeding and reducing nipple pain among Chinese mothers.

Factors influencing breastfeeding practices in China: A meta-aggregation of qualitative studies

The World Health Organization recommends that women exclusively breastfeed until their babies are 6 months old and continue to breastfeed while introducing complementary foods. A meta‐aggregation methodology was used to systematically review and synthesise the qualitative studies on factors influencing breastfeeding practices of healthy Chinese women in Greater China. English and Chinese databases were searched to identify peer‐reviewed qualitative studies (published 2008–2019). Relevant data were extracted, and key themes related to factors influencing breastfeeding practices were identified. Of 7587 articles identified, 22 qualitative studies met inclusion criteria for the review, 10 of which were published in Chinese. A total of 87 themes were extracted from all included studies and classified into 9 subcategories: government enactment of policies, implementation of policies in workplaces, social expectations, social support, medical and health services, services with Chinese characteristics, breastfeeding and pumping facilities, maternal perceptions of breastfeeding and self‐efficacy to breastfeed. The nine subcategories were then grouped into four categories. Potential effect associations among these influence factors of breastfeeding practices emerged from categories and subcategories. Family members' influence on breastfeeding motivation and self‐efficacy suggest a potential benefit of breastfeeding promotion interventions targeting the whole family. The role of primary care should be fully exploited in breastfeeding promotion, including both prenatal education and post‐partum visits. Standardising the training and qualifications of maternity matrons (yuesao) and folk breastfeeding specialists (cuirushi) can promote evidence‐based approaches to facilitating breastfeeding during the confinement period. Increased availability of breastfeeding and pumping facilities in the workplace would facilitate continuing breastfeeding after returning to work.

Breastfeeding Practices among Mothers in Southwest Nigeria

BACKGROUND

This study was conducted to determine the breastfeeding practices among parous antenatal attendees in two teaching hospitals in Southwest Nigeria.

METHODS

A cross-sectional study was carried out on 340 parous antenatal clinic attendees in two teaching hospitals in Ogun State, Nigeria. A structured questionnaire was used to obtain data on breastfeeding practices. Data were analyzed using Statistical Package for Social Sciences (SPSS) windows version 21.0 (IBM Corp., Armonk, NY, USA).

RESULTS

Out of a total of 340 women, 319 (93.8%) breastfed their last babies. The median duration of breastfeeding was 15 months. One hundred and thirty two women (38.8%) initiated breastfeeding within 30 minutes of delivery, and 200 women (58.8%) exclusively breastfed their babies for six months. The majority of the women, 299(87.9%k) did not report any problem associated with breastfeeding. Logistic regression analysis showed that women who had no breastfeeding problems were more likely to exclusively breastfeed their infants for six months compared to those with breastfeeding problems (AOR 3.4; CI 1.6-7.1; P=0.001). Similarly, women who got breastfeeding information from mass media were more likely to practice exclusive breastfeeding for six months compared to those that got breastfeeding information from other sources (AOR42.2; CI 3.1-568.5; P=0.005).

CONCLUSION

Exclusive breastfeeding is suboptimal in Ogun State, Nigeria. Provision of breastfeeding information via mass media will assist in improving breastfeeding practice. Educating mothers on the techniques that help to prevent breastfeeding complications will also be beneficial.

The Patterns and Social Determinants of Breastfeeding in 12 Selected Regions in China: A Population-Based Cross-Sectional Study

BACKGROUND

With rapid industrialization and urbanization, there is a growing need for women to enter the workforce, and affluent people are drawn to the infant formula market. The breastfeeding rates in China are below the optimal level. Large scale quantitative research studying breastfeeding practices after 2015 in China are lacking.

RESEARCH AIM

We aimed to (1) explore the latest patterns and (2) identify the determinants of breastfeeding in China.

METHODS

The study was a population-based, cross-sectional survey. A multi-stage sampling technique was adopted for the selection of participants. We recruited 10,408 mothers with children under 12 months old, in 12 regions of China, and conducted a questionnaire survey about breastfeeding patterns. The associations between social and biophysical determinants and breastfeeding outcomes were analyzed using a logistic regression model.

RESULTS

The exclusive breastfeeding rate was 29.32% (n = 3,052) decreasing from 32.71% (n = 3,404) to 15.83% (n = 1,648) among children aged 0-5 months. Cesarean section had a negative association with early breastfeeding initiation (OR = .33, 95% CI [.30, .36]), exclusive breastfeeding (OR = .78, 95% CI [.69, .89]), and predominant breastfeeding (OR = .73, 95% CI [.65, .83]). Compared to participants with an annual household income lower than 40,000 Yuan ($5,817 USD), those with over 100,000 Yuan ($14,542 USD) had an OR of .78 (95% CI [.67, .90]) in exclusive breastfeeding. Compared with illiterate and unemployed groups, middle/high school education and a current work status, respectively, were associated with a lower likelihood of exclusive breastfeeding (OR = .73, 95% CI [.63, .84]; OR = .58, 95% CI [.37, .89]).

CONCLUSIONS

The prevalence of breastfeeding in 12 selected regions in China was low and interventions focusing on the targeted population should be strengthened.

Exposure to baby-friendly hospital practices and mothers' achievement of their planned duration of breastfeeding

BACKGROUND

Both breastfeeding intentions and exposure to baby-friendly hospital practices were found to be associated with a longer duration of breastfeeding. This study aims to examine the effect of exposure to baby-friendly hospital practices on mothers' achievement of their planned duration of breastfeeding.

METHODS

A total of 1011 mother-newborn pairs from the postnatal units of four public hospitals in Hong Kong were recruited. Sociodemographic data and breastfeeding intention data were collected via self-report questionnaires during the postnatal hospitalization and exposure to Baby-Friendly hospital practices were assessed through hospital records and maternal self-report. Breastfeeding status after hospital discharge was assessed through telephone follow-up for up to 12 months postnatal, or until participants were no longer breastfeeding.

RESULTS

Only 55% (n = 552) of study participants achieved their intended duration of breastfeeding. Participants with higher socioeconomic status, previous breastfeeding experience, and those who had lived in Hong Kong for less than 5 years, were more likely to achieve their planned duration of breastfeeding. Among baby-friendly hospital practices, feeding only breast milk during the hospitalization and providing information about breastfeeding support on discharge were associated with participants' achieving their individual breastfeeding intentions. After adjustment, when compared with women who experienced onebaby-friendly practice, participants who experienced six baby-friendly hospital practices were significantly more likely to achieve their planned duration of breastfeeding (adjusted odds ratio = 8.45, 95% confidence interval 3.03-23.6).

CONCLUSIONS

Nearly half of participants did not achieve their planned breastfeeding duration. Exposure to baby-friendly hospital practices, especially in-hospital exclusive breastfeeding and providing breastfeeding support information upon hospital discharge may help more mothers to achieve their individual breastfeeding goals.

"The sweet and the bitter": mothers' experiences of breastfeeding in the early postpartum period: a qualitative exploratory study in China

Background

In China, the prevalence of exclusive breastfeeding at 6 months was only 20.8%. In promoting breastfeeding for newborns, a number of strategies have been initiated by Chinese government. These actions facilitated a high breastfeeding initiation of 77 to 99.9% in different regions. However, the exclusive breastfeeding rates remained low at 6 months resulting from a high rate of perceived insufficient breast milk and complementary feeding during the early days after childbirth. The aim of this study was to understand the experiences of women in Shenzhen with regard to breastfeeding in the first 6 weeks after giving birth, to identify the facilitators and barriers impacting their breastfeeding decisions and to identify their perceived support needs that might facilitate breastfeeding in the future.

Methods

This was a qualitative exploratory study. Data were collected in November 2018 through semi-structured, face-to-face, in-depth interviews. A purposive sample of early postpartum women was recruited from a postpartum clinic of a tertiary maternal hospital in Shenzhen, China. The dataset was analysed using inductive content analysis.

Results

A total of 22women were interviewed within the first 6 weeks after delivery. Three themes related to breastfeeding were identified from the transcribed interviews: “breastfeeding facilitators,” “breastfeeding barriers,” and “recommendations for breastfeeding promotion.”

Conclusions

Women experienced both joy and suffering in their journey of breastfeeding. Insufficient knowledge of breastfeeding, discomfort, intergenerational disagreements regarding nutritional supplements, and a lack of professional support contributed to difficulties and the threat of discontinuation. A supportive environment for breastfeeding is crucial for women’s decision on exclusive breastfeeding and the psychological wellbeing of breastfeeding women. Interventions that target to promote exclusive breastfeeding should include both new mothers and significant family members. Future studies could test the effectiveness of breastfeeding training for home visit nurses to promote exclusive breastfeeding in the early postpartum.

A Short Message Service Intervention for Improving Infant Feeding Practices in Shanghai, China: Planning, Implementation, and Process Evaluation

BACKGROUND

Although mobile health (mHealth) has been widely applied in health care services, few studies have reported the detailed process of the development and implementation of text messaging (short message service, SMS) interventions.

OBJECTIVE

Our study aims to demonstrate the process and lessons learned from a community-based text messaging (SMS) intervention for improving infant feeding in Shanghai, China.

METHODS

The intervention included planning and development, implementation, and process evaluation. A 3-phase process was adopted during planning and development: (1) a formative study with expectant and new mothers to explore the barriers of appropriate infant feeding practices; (2) a baseline questionnaire survey to understand potential intervention approaches; and (3) development of the text message bank. The text messaging intervention was delivered via a computer-based platform. A message bank was established before the start of the intervention containing information on the benefits of breastfeeding, preparing for breastfeeding, early initiation of breastfeeding, timely introduction of complementary foods, and establishing appropriate feeding practices, etc. An expert advisory committee oversaw the content and quality of the message bank. Process evaluation was conducted through field records and qualitative interviews with participating mothers.

RESULTS

We found that the text messaging intervention was feasible and well received by mothers because of its easy and flexible access. The weekly based message frequency was thought to be appropriate, and the contents were anticipatory and trustworthy. Some mothers had high expectations for timely response to inquiries. Occasionally, the text messages were not delivered due to unstable telecommunication transmission. Mothers suggested that the messages could be more personalized.

CONCLUSIONS

This study demonstrates the feasibility and value of text messaging intervention in filling gaps in delivering health care services and promoting healthy infant feeding practices in settings where personal contact is limited.