Breastfeeding practices and associated factors at the individual, family, health facility and environmental levels in China

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.

Estimating carbon and water footprints associated with commercial milk formula production and use: development and implications of the Green Feeding Climate Action Tool

Carbon offset frameworks like the UN Clean Development Mechanism (CDM) have largely overlooked interventions involving food, health, and care systems, including breastfeeding. The innovative Green Feeding Climate Action Tool (GFT) assesses the environmental impact of commercial milk formula (CMF) use, and advocates for breastfeeding support interventions as legitimate carbon offsets. This paper provides an overview of the GFT's development, key features, and potential uses. The offline and online GFT were developed using the DMADV methodology (Define, Measure, Analyze, Design, Verify). The GFT reveals that the production and use of CMF by infants under 6 months results in annual global greenhouse gas (GHG) emissions of between 5.9 and 7.5 billion kg CO2 eq. and consumes 2,562.5 billion liters of water. As a national example, in India, one of the world's most populous countries, CMF consumption requires 250.6 billion liters of water and results in GHG emissions ranging from 579 to 737 million kg CO2 eq. annually, despite the country's high breastfeeding prevalence among infants under 6 months. The GFT mainly draws on data for low- and middle-income countries (LMICs), as many high-income countries (HICs) do not collect suitable data for such calculations. Despite poor official data on breastfeeding practices in HICs, GFT users can input their own data from smaller-scale surveys or their best estimates. The GFT also offers the capability to estimate and compare baseline with counterfactual scenarios, such as for interventions or policy changes that improve breastfeeding practices. In conclusion, the GFT is an important innovation to quantify CMF's environmental impact and highlight the significance of breastfeeding for planetary as well as human health. Women's contributions to environmental preservation through breastfeeding should be recognized, and breastfeeding interventions and policies should be funded as legitimate carbon offsets. The GFT quantifies CMF's carbon and water footprints and facilitates financing breastfeeding support as a carbon offset initiative under CDM funding facilities.

Effective breastfeeding techniques and associated factors among lactating women: a community-based study, north east Ethiopia

Background

Effective breastfeeding techniques, which include proper attachment, positioning, and suckling, offer a range of benefits for both the mother and the infant. These techniques ensure efficient milk transfer, reduce the risk of infections, support optimal infant weight gain, enhance maternal comfort, and foster a strong emotional bond. This study aimed to identify the magnitude and factors associated with effective breastfeeding techniques among lactating women in the Legambo district of South Wollo, Ethiopia, in 2022.

Methods

A community-based cross-sectional study was conducted from September to November 2022. Samples were selected using a multi-stage sampling method from 18 wards (kebele). Data were collected using an interviewer-administered structured questionnaire and an observational checklist. The collected data were entered into Epi-Data and then exported to SPSS version 25.0 for analysis. Descriptive statistics and bivariate and multivariable logistic regression analyses were performed to identify the magnitude and associated factors. Variables with a p-value less than 0.05 on multivariable analysis were considered independent factors associated with the outcome variable.

Results

Six hundred and ten lactating women were included for observation and interviewed, resulting in a 96.2% response rate. The magnitude of effective breastfeeding technique practice was found to be 25.9% (95% CI: 22.47-29.57%). Factors associated with effective breastfeeding technique practice included being a working woman (AOR = 1.70; 95%CI: 1.07-2.72), age between 26 and 30 years (AOR = 0.37; 95%CI: 0.16-0.84), urban residence (AOR = 1.59; 95%CI: 1.06-2.39), initiating breastfeeding 1 to 2 h after birth (AOR = 0.27; 95%CI: 0.16-0.43), and initiating breastfeeding after 2 h of birth (AOR = 0.34; 95%CI: 0.17-0.67). Additionally, not receiving breastfeeding education (AOR = 0.46; 95%CI: 0.30-0.72) and experiencing current breast problems (AOR = 0.28; 95%CI: 0.28-0.75) were also found to have a significant association with effective breastfeeding technique practice.

Conclusion

Only one in four women demonstrated effective breastfeeding techniques, indicating that their practice was below the WHO's recommendations. Therefore, it is crucial to consider the identified variables to improve the practice of effective breastfeeding techniques.

Factors associated with high exclusive breastfeeding rates among preterm infants under 34 weeks of gestation in Da Nang, Vietnam: A retrospective cohort study

Background

Preterm infants have higher mortality than full-term infants. While breastfeeding dramatically reduces preterm death, it is limited by biological and practice barriers, particularly for babies born before 34 weeks gestational age. Da Nang Hospital for Women and Children developed a quality improvement approach to improve breastfeeding of preterm infants by strengthening feeding support, non-separation, and kangaroo mother care (KMC).

Methods

To determine breastfeeding outcomes following discharge and explore factors associated with improved feeding, mothers of infants under 34 weeks gestational age born October 2021 to March 2022 and discharged alive were interviewed at six months and their medical records were reviewed.

Results

Out of 104 preterm infants included, all were exclusively breastfed at discharge and one month, 86.5% at three months, and 63.5% at six months; 47.1% received immediate skin-to-skin contact, 31.7% immediate and continuous KMC, and the remaining 68.3% continuous KMC beginning at a median of three days. Exclusive breastfeeding at six months was associated with the mother antenatally seeking breastfeeding information (odds ratio (OR) = 14.5; 95% confidence interval (CI) = 1.2-173.6), avoiding bottle-feeding at home (OR = 7.7; 95% CI = 1.7-33.7) and reduced with each day delay between birth and full breastfeeding (OR = 0.8; 95% CI = 0.6-0.9).

Conclusions

Hospital environments that limit mother-baby separations and feeding delays, including rooming-in of mothers and infants, KMC, and breastfeeding support from birth, enabled 100% of preterm infants born before 34 weeks gestational age to breastfeed exclusively with continued rates higher than previously reported. Addressing antenatal and post-natal factors limiting practice can further improve longer-term breastfeeding outcomes. The approach can be adapted to achieve high exclusive breastfeeding rates, regardless of gestational age.

Law matters - assessment of country-level code implementation and sales of breastmilk substitutes in South Asia

Objectives

This study examines the status of implementation of the International Code of Marketing of Breast-milk Substitutes of eight countries in the South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka), and describes the sales value and volume of commercial milk formula (CMF) marketed as breastmilk substitutes (BMS) and baby food in four countries (Bangladesh, India, Pakistan, and Sri Lanka).

Design

A mix of descriptive methods is used to assess national status of Code implementation, including a desk review of the 2022 WHO/UNICEF/IBFAN Code Status Report, systematic content analysis of national Code measures, and insights generated from the participation of key government and UNICEF/WHO actors in a regional workshop that aimed to identify each country's barriers, gaps, and the status of Code implementation. Data on the sales value and volume of CMF and baby food between 2007 to 2021 and with the prediction to 2026 in Bangladesh, India, Pakistan, and Sri Lanka were obtained from Global Data.

Findings

There are major gaps in Code implementation in countries even with legal measures considered substantially aligned with the Code, such as the inadequate age range of CMF covered in the scope, insufficient safeguards against conflicts of interest in the health system, lack of warning of risks of intrinsic contamination of powdered milk formula, and an absence of effective monitoring and enforcement mechanisms. Data on CMF sales shows health facilities and pharmacies sustain the highest sales. Lower sales volume of infant formula (including special formula), compared to other CMF such as follow-up formula and growing-up milk, has been observed in three of the four countries (Bangladesh, India, and Sri Lanka). Overall, GUM, followed by baby cereals, accounted for a large portion of CMF and baby foods sales in the same three countries.

Recommended actions include

(1) Closing the gaps between national measures and the Code, (2) Ensuring effective monitoring and enforcement mechanisms, (3) Strengthening conflicts of interest safeguards in the health system, (4) Tackling digital marketing, and (5) Galvanizing political support and support from in-country public health and women's rights jurist networks.

Breastfeeding and infant care as 'sexed' care work: reconsideration of the three Rs to enable women's rights, economic empowerment, nutrition and health

Women's lifelong health and nutrition status is intricately related to their reproductive history, including the number and spacing of their pregnancies and births, and for how long and how intensively they breastfeed their children. In turn, women's reproductive biology is closely linked to their social roles and situation, including regarding economic disadvantage and disproportionate unpaid work. Recognizing, as well as reducing and redistributing women's care and domestic work (known as the 'Three Rs'), is an established framework for addressing women's inequitable unpaid care work. However, the care work of breastfeeding presents a dilemma, and is even a divisive issue, for advocates of women's empowerment, because reducing breastfeeding and replacing it with commercial milk formula risks harming women's and children's health. It is therefore necessary for the interaction between women's reproductive biology and infant care role to be recognized in order to support women's human rights and enable governments to implement economic, employment and other policies to empower women. In this paper, we argue that breastfeeding-like childbirth-is reproductive work that should not be reduced and cannot sensibly be directly redistributed to fathers or others. Rather, we contend that the Three Rs agenda should be reconceptualized to isolate breastfeeding as 'sexed' care work that should be supported rather than reduced with action taken to avoid undermining breastfeeding. This means that initiatives toward gender equality should be assessed against their impact on women's ability to breastfeed. With this reconceptualization, adjustments are also needed to key global economic institutions and national statistical systems to appropriately recognize the value of this work. Additional structural supports such as maternity protection and childcare are needed to ensure that childbearing and breastfeeding do not disadvantage women amidst efforts to reduce gender pay gaps and gender economic inequality. Distinct policy interventions are also required to facilitate fathers' engagement in enabling and supporting breastfeeding through sharing the other unpaid care work associated with parents' time-consuming care responsibilities, for both infants and young children and related household work.

The health consequences of informal employment among female workers and their children: a systematic review

BACKGROUND

Informal employment is unprotected and unregistered and it is often characterized by precarious working arrangements. Although being a global phenomenon and the most common type of employment worldwide, scholarly attention to its health effects has only recently accelerated. While there is still some debate, informal employment is generally understood to be detrimental to workers' health. However, because women are more vulnerable to informality than men, attention is required to the health consequences of female workers specifically. We conducted a systematic review with the objective to examine the global evidence on the consequences of informal employment, compared to formal employment, on the health of female workers and their children.

METHODS

We searched peer-reviewed literature in Embase, Medline, PsychInfo, Scopus and Web of Science up until November 11, 2022. No restrictions were applied in terms of year, language or country. Individual-level quantitative studies that compared women of reproductive age in informal and formal employment, or their children (≤ 5 years), were eligible for inclusion. If studies reported outcomes per subgroup level, these were included. Study quality was assessed using the Joanna Briggs Institute checklist and a narrative synthesis of the results were conducted.

RESULTS

13 articles were included in the review, looking at breastfeeding outcomes (n = 4), child nutritional status and low birthweight (n = 4), antenatal health (n = 3), and general health outcomes for women (n = 2). The overall evidence from the included studies was that compared to formal employment, there was an association between informal employment and worse health outcomes, especially on child nutritional status and antenatal health. The evidence for breastfeeding outcomes was mixed and showed that informal employment may be both protective and damaging to health.

CONCLUSION

This review showed that informal employment is a potential risk factor for health among female workers and their children. Further research on the pathways between informal employment and health is needed to strengthen the understanding of the health consequences of informal employment.

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.

Breastfeeding practices in Northeast China in 2008 and 2018: cross-sectional surveys to explore determinants over a decade

BACKGROUND

This study was conducted to investigate the prevalence and determinants of breastfeeding in 2008 and 2018, respectively, in Northeast China, where health service efficiency is at the lowest national level and regional data on breastfeeding are lacking. The influence of early initiation of breastfeeding on later feeding practices was specifically explored.

METHODS

Data from the China National Health Service Survey in Jilin Province in 2008 (n = 490) and 2018 (n = 491) were analysed. Multistage stratified random cluster sampling procedures were used to recruit the participants. Data collection was conducted in the selected villages and communities in Jilin. Early initiation of breastfeeding was defined as the proportion of children born in the last 24 months who were put to the breast within one hour after birth in both the 2008 and 2018 surveys. Exclusive breastfeeding was defined as the proportion of infants 0-5 months of age who were fed exclusively with breast milk in the 2008 survey; while defined as the proportion of infants 6-60 months of age who had been fed exclusively with breast milk within the first six months of life in the 2018 survey.

RESULTS

The prevalence of early initiation of breastfeeding (27.6% in 2008 and 26.1% in 2018) and exclusive breastfeeding during the first six months (< 50%) were low in two surveys. Logistic regression revealed that exclusively breastfeeding at six months was positively associated with early initiation of breastfeeding (OR 2.65; 95% confidence interval (CI) 1.65, 4.26) and negatively associated with caesarean section (OR 0.65; 95% CI 0.43, 0.98) in 2018. Continued breastfeeding at one year and timely introduction of complementary foods were associated with maternal residence and place of delivery, respectively, in 2018. Early initiation of breastfeeding was associated with mode and place of delivery in 2018 but residence in 2008.

CONCLUSION

Breastfeeding practices in Northeast China are far from optimal. The negative effect of caesarean section and positive effect of early initiation of breastfeeding on exclusive breastfeeding suggest that an institution-based approach should not be substituted by the community-based one in the formulation of breastfeeding strategies in China.

Birth and newborn care policies and practices limit breastfeeding at maternity facilities in Vietnam

The prevalence of early and exclusive breastfeeding in Vietnam remains sub-optimal. The objective of this study was to determine factors associated with early initiation of breastfeeding (EIBF) and exclusive breastfeeding for the first 3 days after birth (EBF3D). We conducted a population-based, cross-sectional survey of 726 mothers with children aged 0-11 months in two provinces and one municipality from May to July 2020. Multinomial logistic regression was used to examine factors associated with EIBF and EBF3D. The prevalence of EIBF was 39.7% and EBF3D 18.0%. The EIBF prevalence is positively associated with immediate and uninterrupted skin-to-skin contact (SSC) for 10-29 min (aOR: 2.55; 95% CI: 1.49, 4.37), 30-59 min (aOR: 4.15; 95% CI: 2.08, 8.27), 60-80 min (aOR: 4.35; 95% CI: 1.50, 12.6), or ≥90 min (aOR: 5.87; 95% CI: 3.14, 10.98). EIBF was negatively associated with cesarean birth (aOR: 0.24; 95% CI: 0.11, 0.51), bringing infant formula to the birth facility (aOR: 0.49; 95% CI: 0.30, 0.78), purchased it after arrival (aOR: 0.37; 95% CI: 0.24, 0.60), or did both (aOR: 0.43; 95% CI: 0.21, 0.89). EBF3D was negatively associated with cesarean section birth (aOR: 0.15; 95% CI: 0.06, 0.39), vaginal birth with episiotomy (aOR: 0.40; 95% CI: 0.18, 0.88), bringing formula to the maternity facility (aOR: 0.03; 95% CI: 0.01, 0.07), purchased it after arrival (aOR: 0.02; 95% CI: 0.01, 0.06) or did both (aOR: 0.04; 95% CI: 0.02, 0.10). Receiving counseling from any source was not significantly associated with early breastfeeding practices. Policy and health service delivery interventions should be directed at eliminating infant formula from birthing environments, reducing unnecessary cesarean sections and episiotomies, providing immediate and uninterrupted SSC for all births, and improving breastfeeding counseling and support.

Breastfeeding Practices and Associated Factors in Shanghai: A Cross-Sectional Study

The status of breastfeeding practices remains unsatisfactory across China, but regional differences persist. However, disaggregated data for specific provinces are limited. This representative survey determined the status of breastfeeding and factors associated with breastfeeding practices in Shanghai. The questionnaire was designed in compliance with indicators for assessing infant and young child-feeding practices defined by the World Health Organization and the United Nations Children's Fund (UNICEF). A total of 2665 children aged two years and younger (0-730 days) were investigated, among whom 1677 were aged under six months. The early initiation of breastfeeding (EIBF) rate was 60.3%. Among children aged under six months, 43.4% were exclusively breastfed (EBF). The univariate regression analysis showed that the EBF rate was influenced by multiple factors, including individual, socioeconomic, workplace and employment, and health system. The subsequent multivariate analysis suggested that mothers with a higher rate of EBF shared the following characteristics: intention to breastfeed during pregnancy, breastfeeding knowledge, and higher satisfaction with support through the healthcare system after delivery. The rate of EBF in Shanghai is over 40%, and supporting breastfeeding requires measures at multiple levels, including individual attributes, women's work and employment conditions, breastfeeding knowledge, and health services.

Timing of Breastfeeding Initiation Mediates the Association between Delivery Mode, Source of Breastfeeding Education, and Postpartum Depression Symptoms

Background: Emergency cesarean section (EMCS) and breastfeeding difficulties increase the risk of postpartum depressive (PPD) symptoms. Early initiation of breastfeeding (EIBF) may not only alleviate PPD symptoms but also facilitate subsequent breastfeeding success. EMCS is a risk factor for not practicing EIBF. Therefore, it is important to understand the relationship between EMCS, EIBF, and PPD symptoms. Methods: We conducted a prospective cohort study in three areas of China. At baseline, a total of 965 mothers completed electronic questionnaires within 72 h postpartum. Women were screened for PPD symptoms using the Edinburgh Postpartum Depression Scale (EPDS). Multivariate logistic regression was used to identify the determinants of PPD symptoms. Mediation analysis was used to determine if EIBF mediated the relationship between delivery mode or breastfeeding education source and PPD symptoms. Results: The prevalence of EIBF was 40.6%; 14% of 965 mothers experienced EMCS, and 20.4% had PPD symptoms. The risk factors for developing PPD symptoms were excessive gestational weight gain (adjusted odds ratio [aOR] = 1.55, confidence interval [95% CI]: 1.03−2.33, p = 0.037) and EMCS (aOR = 2.05, 95% CI: 1.30−3.25, p = 0.002). The protective factors for developing PPD symptoms were monthly household income over CNY 10000 (aOR = 0.68, 95% CI: 0.47−0.97, p = 0.034), EIBF (aOR = 0.49, 95% CI: 0.34−0.72, p < 0.001), and prenatal breastfeeding education from nurses (aOR = 0.46, 95% CI: 0.29−0.73, p = 0.001). EIBF indirectly affected PPD symptoms in patients who had undergone EMCS (percentage mediated [PM] = 16.69, 95% CI: 7.85−25.25, p < 0.001). The source of breastfeeding education through EIBF also affected PPD symptoms (PM = 17.29, 95% CI: 3.80−30.78, p = 0.012). Conclusion: The association between EMCS on PPD symptoms was mediated by EIBF. By providing breastfeeding education, nurses could also help alleviate PPD symptoms.

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.

Exclusive Breastfeeding Experiences of Thai Mothers in Metropolitan Bangkok

Introduction

In 2019, only 14% of mothers in Thailand performed six-month exclusive breastfeeding. This study sought to understand the pathways that mothers in Bangkok Metropolitan took to achieve successful six-month exclusive breastfeeding.

Methods

A total of 50 mothers living in Bangkok with children aged 6–12 months, who achieved and not achieved 6-month exclusive breastfeeding, were recruited for in-depth interviews during February to July 2020. Inductive thematic analysis of participants’ viewpoints was applied for data analysis and interpretation.

Results

Four themes that contributed to six-month exclusive breastfeeding were i)  maternal breastfeeding self-efficacy;  ii)  support provided by family members;  iii)  engagement with and support from healthcare professionals; and iv)  employers’ support and workplace environments. Mothers with strong breastfeeding intentions and “perceived capability” to succeed at breastfeeding tended to prioritize breastfeeding and overcome and cope well with unforeseen breastfeeding challenges. Supportive family members, who were convinced of the benefits of breastfeeding, engaged in maternal decision-making, and provided optimal support, contributed to successful exclusive breastfeeding. Health professionals were key in supporting mothers throughout pregnancy until the postpartum period. Lactating-mother-friendly working conditions, flexible working hours and enabling workplace environments, including the provision of breastfeeding breaks and a dedicate space for breast milk expression, were enabling factors for successful exclusive breastfeeding among working mothers.

Conclusion

We recommend that all mothers and their family members are fully informed and convinced of the benefit from breastfeeding and trained with practical skill during their visit to antenatal care clinics. These interventions aim to develop mothers’ self-efficacy for breastfeeding and to prepare them to manage common breastfeeding challenges. Health professionals should provide regular follow-up and counseling sessions on breastfeeding practices to mothers and families throughout the lactating period, especially working mothers for breastfeeding continuation after resume to work. Enhanced societal collective actions such as breastfeeding-friendly policy in workplace, including breastfeeding break-time and corner, can create enabling environments for successful exclusive breastfeeding.

Infant and young child feeding during natural disasters: A systematic integrative literature review

BACKGROUND

As climate change worsens, the frequency and intensity of natural disasters continues to increase. These extreme weather events particularly affect the physical and mental health of vulnerable groups such as mothers and infants. From low-income to high income countries, poorly organised disaster response can negatively impact infant and young child feeding practices.

AIM

To examine challenges and supportive strategies for infant and young child feeding during natural disasters to inform further research and guide disaster recommendations and practice.

METHODS

A comprehensive search strategy explored the electronic databases PubMed, CINAHL and Cochrane Library. Screening, data extraction and analysis were conducted using Covidence. Quality assessment was conducted using the Mixed Methods Appraisal Tool (MMAT). Studies were analysed using thematic analysis.

FINDINGS

This review included 13 studies (4 mixed methods, 1 critical ethnography, 2 quasi-experimental studies, 4 descriptive studies, 1 qualitative study, 1 evidence gap map analysis). Breastfeeding facilitators during natural disaster contexts are privacy for breastfeeding, community and family support, adaptation of professional breastfeeding support to the local context and pre-existing breastfeeding practice. Breastfeeding challenges during natural disasters include decreased breastfeeding self-efficacy, lack of knowledge and resources and over-reliance on formula baby milks. Formula baby milk feeding challenges during natural disasters are the lack of access to resources required for hygienic formula baby milk preparation as well as the lack of availability of formula baby milk in some contexts.

CONCLUSION

This systematic integrative review demonstrates that interventions which facilitate optimal infant and young child feeding in natural disaster contexts must be culturally and socially appropriate; increasing women's knowledge of optimal breastfeeding and safe formula baby milk feeding practices as well as breastfeeding self-efficacy.

Factors associated with exclusive breastfeeding practice among mothers in nine community health centres in Nanning city, China: a cross-sectional study

BACKGROUND

The prevalence of exclusive breastfeeding (EBF) is suboptimal in China. There is limited evidence of effective interventions to increase EBF in China. Therefore, it is urgent to explore the potential factors that may be effective in promoting exclusive breastfeeding. Previous studies have mainly focused on socio-demographic factors and the Han ethnic group. This study explores more modifiable influencing factors of EBF in the Guangxi Zhuang Autonomous Region of China.

METHODS

The cross-sectional data used in this study were collected to provide baseline information on EBF prevalence for a breastfeeding promotion project. A total of 494 mothers of infants aged 0-5 months were recruited from nine community health centres in Nanning, China, in October 2019. Data were collected through face-to-face interviews using structured questionnaires. Infant feeding was measured by 24-h recall. The Chinese version of the Breastfeeding Self-Efficacy Scale-Short Form was used to examine the maternal breastfeeding self-efficacy. Univariate and multivariate logistic regressions were used to examine the factors associated with EBF practices.

RESULTS

In the present study, the prevalence of exclusive breastfeeding was 37.0%. Higher breastfeeding self-efficacy scores (adjusted odds ratio [AOR] 1.93; 95% confidence interval [CI] 1.25, 2.98), a college degree or above (AOR 2.15; 95% CI 1.24, 3.71), and early initiation of breastfeeding (AOR 2.06; 95% CI 1.29, 3.29) were positively associated with EBF practice. However, the preparation for infant formula before childbirth (AOR 0.30; 95% CI 0.17, 0.52) and premature birth (AOR 0.30; 95% CI 0.10, 0.87) were negatively associated with EBF practice.

CONCLUSIONS

Exclusive breastfeeding practice was suboptimal and associated with various factors in the study area. The prevalence of EBF was positively associated with higher breastfeeding self-efficacy, education level of mothers, and early initiation of breastfeeding, whereas premature birth and preparation for infant formula before childbirth were barriers to exclusive breastfeeding. Future intervention projects should target mothers with premature babies, lower levels of education, and breastfeeding self-efficacy. Breastfeeding-friendly practices, such as the early initiation of breastfeeding and regulations on breastmilk substitutes, should also be encouraged.

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.

A multi-center longitudinal study on responsive breastfeeding in China from the perspective of health equity: research protocol

Background

Socio-economic inequities can strongly influence suboptimal infant feeding outcomes. Factors such as lack of knowledge about breastfeeding, low family income, low educational attainment, social and economic status, cultural norms and ethnicity may negatively affect success with offering breastfeeding following a responsive feeding approach (ie. responsive breastfeeding). Such inequities can indeed shorten breastfeeding duration, and negatively affect behavioral and cognitive infant outcomes. In China, there is a dearth of studies focusing on breastfeeding from the responsive and health equity perspective.

Objective

The aim of this article is to present a protocol of an ongoing longitudinal cohort study investigating factors associated with responsive breastfeeding behaviors, and the child’s behavioral and cognitive development from birth to12 months post-partum in five centers in China. The study seeks to identify breastfeeding barriers and facilitators from a health equity perspective.

Methods

We are enrolling 700 women and their singleton full term infants in Chongqing, Huizhou and Guangzhou urban and rural areas. The study questionnaires will be administrated within 72 h, 30 days, 3, 6, 9, and 12 months post-partum during the baby’s vaccination visits. We will investigate the difference between urban and rural areas sociodemographic characteristics, breastfeeding knowledge, attitudes and practice, postnatal depression, maternal emotion regulation and parenting stress, and anthropometric and cognitive development indicators of the infants at each time-point.

Conclusion

Our article illustrates how a cohort study can be designed to understand the barriers and facilitators of responsive breastfeeding taking equity principles into account to help promote infants’ growth and development in China.

Advice to use infant formula and free samples are common in both urban and rural areas in China: a cross-sectional survey

Objective:

To examine the association between the place of residence and receiving free samples and advice to feed the baby with infant formula.

Design:

A cross-sectional study.

Setting:

The current study covered twelve counties/districts in China.

Participants:

5112 mothers with infants aged 0–5·9 months.

Results:

About 16 % of the mothers received free samples of infant formula. During pregnancy, this likelihood was higher among mothers in small and medium cities (OR: 1·96; 95 % CI 1·14, 3·38) and non-poor rural counties (OR: 4·65; 95 % CI 1·65, 13·14) compared with mothers in big cities. During the hospital stay, it was lower in big cities. After discharge, it was lower in poor rural counties (OR: 0·14; 95 % CI 0·05, 0·41). About 26 % of the mothers were advised to feed their infants with infant formula. The likelihood of receiving advice to feed the baby with infant formula from hospitals was lower in non-poor (OR: 0·37; 95 % CI 0·21, 0·66) and poor rural counties (OR: 0·35; 95 % CI 0·13, 0·91) than in big cities. Mothers in non-poor rural counties were less likely to receive advice from traditional mass media (OR: 0·17; 95 % CI 0·06, 0·48), while mothers in small and medium cities were more likely to receive advice from modern mass media (OR: 1·84; 95 % CI 1·20, 2·80) compared with mothers in big cities.

Conclusions:

The promotion strategy of infant formula varies from different places of residence in China. The study suggests the need to strengthen enforcement of relevant regulations, especially within health facilities and through modern mass media.

Assessing the Effectiveness of Policies Relating to Breastfeeding Promotion, Protection, and Support in Southeast Asia: Protocol for a Mixed Methods Study

BACKGROUND

Despite its well-known benefits, breastfeeding practices remain suboptimal worldwide, including in Southeast Asia. Many countries in the region have thus enacted policies, such as maternity protection and the World Health Assembly International Code of Marketing of Breast-milk Substitutes (the Code), that protect, promote, and support breastfeeding. Yet the impact of such national legislation on breastfeeding practices is not well understood.

OBJECTIVE

This study aims to review the content, implementation, and potential impact of policies relating to maternity protection and the Code in Myanmar, the Philippines, Thailand, and Vietnam.

METHODS

This mixed methods study includes a desk review, trend and secondary data analyses, and quantitative and qualitative data collection. Desk reviews will examine and compare the contents, implementation strategies, coverage, monitoring, and enforcement of national policies focusing on maternity protection and the Code in each country with global standards. Trend and secondary data analyses will examine the potential impact of these policies on relevant variables such as breast milk substitute (BMS) sales and women's workforce participation. Quantitative data collection and analysis will be conducted to examine relevant stakeholders' and beneficiaries' perceptions about these policies. In each country, we will conduct up to 24 in-depth interviews (IDI) with stakeholders at national and provincial levels and 12 employers or 12 health workers. Per country, we will survey approximately 930 women who are pregnant or have a child aged 0-11 months, of whom approximately 36 will be invited for an IDI; 12 partners of the interviewed mothers or fathers of children from 0-11 months will also be interviewed.

RESULTS

This study, funded in June 2018, was approved by the Institutional Review Boards of the relevant organizations (FHI 360: April 16, 2019 and May 18, 2020; and Hanoi University of Public Health: December 6, 2019). The dates of data collection are as follows: Vietnam: November and December 2019, May and June 2020; the Philippines: projected August 2020; Myanmar and Thailand: pending based on permissions and funding. Results are expected to be published in January 2021. As of July 2020, we had enrolled 1150 participants. We will present a comparison of key contents of the policies across countries and against international standards and recommendations and a comparison of implementation strategies, coverage, monitoring, and enforcement across countries. We will also present findings from secondary data and trend data analyses to propose the potential impact of a new or amended policy. For the surveys with women, we will present associations between exposure to maternity protection or BMS promotion on infant and young child feeding practices and their determinants. Findings from IDIs will highlight relevant stakeholders' and beneficiaries' perceptions.

CONCLUSIONS

This study will increase the understanding of the effectiveness of policy interventions to improve breastfeeding, which will be used to advocate for stronger policy adoption and enforcement in study countries and beyond.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21286.

Predictors of exclusive breastfeeding practice among migrant and non-migrant mothers in urban China: results from a cross-sectional survey

OBJECTIVE

To explore and compare the predictors for exclusive breast feeding (EBF) among migrant and non-migrant mothers in China.

DESIGN

A large-scale cross-sectional study.

SETTING

12 counties/districts were covered in China.

PARTICIPANTS

A total number of 10 408 mothers were recruited, of whom 3571 mothers of infants aged 0-5 months in urban China were used for analysis.

OUTCOME

The practice of EBF was calculated based on the foods and drinks consumed in the last 24 hours, as recommended by WHO.

RESULTS

Around 30% of Chinese mothers with infants aged 0-5 months practised EBF in urban areas, with no significant difference between migrant and non-migrant mothers (p=0.433). Among the migrant mothers, factors associated with EBF included residence in big cities (adjusted OR, AOR 1.68 (95% CI 1.20 to 2.34)), premature birth (AOR 0.27 (95% CI 0.09 to 0.81)), knowledge about EBF (AOR 2.00 (95% CI 1.51 to 2.65)), low intention of breast feeding in the first month postpartum (AOR 0.59 (95% CI 0.36 to 0.97)) and mothers working in agriculture-related fields or as casual workers (AOR 1.77 (95% CI 1.18 to 2.64)). Among non-migrant mothers, in addition to similar predictors including residence in big cities (AOR 1.40 (95% CI 1.13 to 1.73)), knowledge about EBF (AOR 1.25 (95% CI 1.02 to 1.53)) and low intention of breast feeding in the first month post partum (AOR 0.46 (95% CI 0.31 to 0.70)], early initiation of breast feeding (EIBF) (AOR 1.78 (95% CI 1.35 to 2.33)) and caesarean delivery (AOR 0.74 (95% CI 0.60 to 0.89)) were also factors associated with EBF.

CONCLUSIONS

There was no significant difference in the prevalence of EBF between migrant and non-migrant mothers in urban China. Premature birth and maternal occupation in agriculture-related fields or casual work were distinctive factors associated with EBF for migrants, while EIBF and caesarean delivery were unique predictors for non-migrants.

TRIAL REGISTRATION NUMBER

ChiCTR-ROC-17014148; Pre-results.

Triple trouble: Understanding the burden of child undernutrition, micronutrient deficiencies, and overweight in East Asia and the Pacific

Young children in the East Asia and the Pacific region¹ are failing to thrive, in large numbers, as indicated by stagnation in the decline of stunting, wasting, and micronutrient deficiencies and the fastest growing rates of overweight in the world. Eliminating the triple burden of malnutrition is essential to ensure that, as a matter of right, all children reach their full physical growth and development potential and actively contribute to equitable prosperity and the sustainable development of their communities and nations. Ending all forms of malnutrition will only be achieved through the implementation of effective policies and programmes soundly based on an understanding of the leading contextual drivers of child malnutrition. To address the lack of data on these drivers in the region, the UNICEF regional office for East Asia and the Pacific commissioned a series of papers in 2017–2019 to fill gaps in the current body of evidence on the triple burden of maternal and child malnutrition. This series includes analyses of the determinants of child malnutrition including maternal nutrition status, dietary quality of children, inequity, and poverty. Additionally, policy and programmatic actions associated with improved coverage and quality of nutrition interventions are reviewed. This overview paper summarizes the findings of these analyses and presents recommendations for the direction of future advocacy, policy, and programmatic actions to address the triple burden of malnutrition in East Asia and the Pacific.

Breastfeeding practices and associated factors at the individual, family, health facility and environmental levels in China

We examined the association between breastfeeding practices and associated factors using cross-sectional data from face-to-face interviews with 9,745 mother-child dyads in China. The study collected information on breastfeeding practices and potential associated factors at the individual, family, health facility and environmental levels in China. We used survey commands in Stata to consider sampling weight and survey design effects. Although breastfeeding was the norm (97.4% ever breastfed), the prevalence of early initiation of breastfeeding (EIBF) in 0-11 months old was 8.2%, exclusive breastfeeding (EBF) in 0-5 months old was 27.8% and breastfeeding on the previous day in 6-11 months old was 77.5%. The prevalence of EIBF was lower for caesarean delivery and among mothers belonging to ethnic minority groups. The prevalence of EBF was higher among mothers who practiced EIBF, received information that encouraged breastfeeding and knew that a baby should be breastfed on demand and exclusively. By contrast, the prevalence of EBF was lower in mothers who received infant formula advice or felt uneasy breastfeeding in public places. The prevalence of breastfeeding on the previous day was higher among mothers whose partners supported breastfeeding and who knew about timing of colostrum production, EBF for 6 months, and to nurse more to stimulate milk production. The prevalence of breastfeeding on the previous day was lower in mothers who received infant formula advice or felt uneasy breastfeeding in public places. In conclusion, we found that the prevalence of EIBF and EBF practices in China was low and associated with factors at individual, family, health facility and environmental levels.