Relationship between the Infant Feeding Preferences of Chinese Mothers' Immediate Social Network and Early Breastfeeding Cessation

Building a baby-friendly community: Development, strategy, implementation and evaluation of a BFCI program

AIM

The aim of the study was to investigate the impact of the use of baby-friendly community initiative (BFCI) model on various stakeholders in the community.

DESIGN

Quasi-experimental research design.

METHOD

The study was conducted in public premises and online workshops from April 2019 to September 2022. Participants were followed up for a period of 1 month, except for those employed at public premises. The program involved training based on an accredited BFCI framework to cultivate a breastfeeding-friendly attitude and knowledge. A paired sample t-test was used to examine breastfeeding attitude and knowledge scores before and after BFCI training among staff employed from public premises. An analysis of variance was conducted to examine the breastfeeding self-efficacy and attitude scores, measured repeatedly at different timepoints over 1-month timepoint (T0, T1 and T2) among pregnant and postpartum women.

RESULTS

A total of 2340 perinatal women and 1339 staff from public premises were recruited. For staff, there was an increase in the mean score of breastfeeding knowledge and attitude by 5.8 and 6.1, respectively, at T1. Similarly, for perinatal women, there was an increase in the mean score of breastfeeding self-efficacy and attitude by 6.6 and 3.3, respectively, at T1.

CONCLUSION

In summary, a BFCI model, with active community participation, accreditation and an award system, has been effective in promoting breastfeeding. Adapting the baby-friendly hospital initiative to local contexts and employing a social theory model can enhance breastfeeding promotion and improve infant health outcomes. Prioritizing culturally sensitive breastfeeding education is crucial for successful BFCI implementation.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Healthcare professionals should consider clients' culture and socio-economic backgrounds when providing breastfeeding education to maximize effectiveness. The target audience for breastfeeding education should be expanded to include various community stakeholders beyond families.

IMPACT

What problem did the study address? This study addressed the problem of knowledge gaps among stakeholders in building a breastfeeding-friendly community, particularly in implementing a baby-friendly community initiative (BFCI) as part of a baby-friendly hospital initiative (BFHI). The research filled a service gap by providing effective interventions targeting community stakeholders and assessing the impact of a BFCI program on their knowledge and attitudes towards breastfeeding. What were the main findings? The findings highlighted the effectiveness of a BFCI program in enhancing breastfeeding knowledge and attitudes among frontline staff and increasing breastfeeding confidence among mothers. These findings contribute to the understanding of the program's impact on different stakeholders in the community. Where and on whom will the research have an impact? It impacts on global policymakers by providing insights for developing comprehensive guidelines for future BFCI implementations. It also contributes to the creation of a more baby-friendly community, benefiting breastfeeding families and their infants by promoting and supporting breastfeeding families.

REPORTING METHOD

This study has adhered to relevant EQUATOR guidelines using the TREND reporting guideline.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: This study provides an overview of the establishment of a localized BFCI program. It also opens up a new direction for the community to investigate BFCI strategies for community stakeholders. It also provides evidence to support other countries in following a similar process, as each country approaches becoming breastfeeding-friendly in its own unique way.

TRIAL AND PROTOCOL REGISTRATION

No protocol.

Familial sources of encouragement and breast-feeding practices among women participating in the US Special Supplemental Nutrition Programme for Women, Infants and Children

OBJECTIVE

To explore how sources of familial encouragement are associated with breast-feeding initiation and duration among a national sample participating in the US Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

DESIGN

This study uses the 2013-2015 WIC Infant and Toddler Feeding Practices Study 2 (WIC ITFPS-2) data. Breast-feeding initiation was measured at the first month, while duration was derived from a composite of the first 13 months. The analysis used logistic and linear regression to explore the association between encouragement sources and breast-feeding outcomes.

SETTING

A nationally representative sample of WIC participants in the USA.

PARTICIPANTS

WIC participants who completed the 13-month interview of the WIC ITFPS-2 (n 2807).

RESULTS

Encouragement was significantly associated with both initiation and duration. Each source of encouragement was associated with a 3·2 (95 % CI 2·8, 3·8) increase in odds of initiating breast-feeding in the unadjusted model and 3·0 (95 % CI 2·5, 3·6) increased odds, controlling for age, education, nativity, poverty status, race and ethnicity (<0·0001). When predicting log duration, each percent increase in source of encouragement was associated with an increasing duration on average by 0·003 d (95 % CI 0·2, 0·3, <0·0001). When controls were added, it was associated with an increase of an average of 0·002 d (95 % CI 0·2, 0·3) per percent increase in encouragement source (<0·0001).

CONCLUSIONS

Women who receive encouragement appear to be more likely to breastfeed. Additional work is needed to explore sources of encouragement and how to include them in intervention work.

Infant Feeding Practices and Social Support Networks Among Immigrant Chinese American Mothers With Economic Disadvantage in New York City

BACKGROUND

Maternal social support promotes healthy infant feeding practices, which influence healthy growth and development. Less is known about how the interplay of social support networks and multicultural health beliefs may influence infant feeding practices, particularly among immigrant Chinese American mothers with economic disadvantage and low breastfeeding rates.

RESEARCH AIM

To explore the role of social support networks in the development of infant feeding practices in immigrant Chinese American mothers with infants.

METHODS

This was a prospective, cross-sectional qualitative study where we conducted semi-structured interviews in Mandarin, Cantonese, or English with Chinese American mothers of infants (N = 25) at a federally qualified health center in the Sunset Park neighborhood of Brooklyn, New York. Data were analyzed by a multicultural, multidisciplinary team using qualitative thematic analysis and the constant comparative method to identify and iteratively refine emerging codes.

RESULTS

Three themes emerged describing how broad transnational communities and close family and friends influence maternal-infant feeding practices: (1) Gathering and processing infant feeding information from broad transnational resources (i.e., from both the mother's country of residence and the mother's country of origin); (2) aligning maternal feeding attitudes with cultural health beliefs of local social networks; and (3) gaining confidence with transactional maternal-infant feeding interactions.

CONCLUSIONS

Strategies to promote healthy infant feeding should consider how family supports and culturally-relevant coaching can help align multilevel transnational social networks with healthy infant feeding practices.

The Influence of the Baby-Friendly Hospital Initiative and Maternity Care Practices on Breastfeeding Outcomes

BACKGROUND

The Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 to promote breastfeeding through hospital policy. Researchers have reported breastfeeding improvements after hospitals became "Baby-Friendly." In Hong Kong, the first public hospital was designated as a Baby-Friendly Hospital in 2016.

RESEARCH AIM

To examine the influence of the BFHI on breastfeeding by comparing breastfeeding outcomes in a study cohort recruited before the implementation of the BFHI and a cohort recruited after its implementation.

METHODS

This was a quasi-experimental interrupted time-series design. Two cohorts of mother-infant pairs (N = 2369) were recruited immediately postpartum from four public hospitals in Hong Kong and followed up prospectively. Comparisons were made in five of the BFHI steps experienced in both cohorts and the duration of any and exclusive breastfeeding.

RESULTS

A higher proportion of participants from the post-implementation cohort breastfed and breastfed exclusively at all follow-up periods. Participants in the pre-BFHI cohort, on average experienced 3.10 (SD = 1.42) of the BFHI steps, whereas the participants in the post-BFHI cohort experienced 3.59 (1.09) of the BFHI steps. Half of the participants discontinued any breastfeeding by 13 weeks in the pre-BFHI cohort; more than half in the post-BFHI cohort were still breastfeeding at 6 months postpartum (p < .001). Giving only human milk in the first 48 hr of delivery and not providing pacifiers or bottles were associated with lower risk of not exclusive breastfeeding in both cohorts.

CONCLUSION

Implementation of the BFHI was associated with improvements in breastfeeding practices and outcomes.

The Association Between Breastfeeding Self-Efficacy and Mode of Infant Feeding

Introduction: It is well established that low breastfeeding self-efficacy is associated with early breastfeeding cessation. Over the past several decades, expressed human milk feeding has increased among parents of healthy infants. Researchers have hypothesized an association between maternal breastfeeding confidence and expressed human milk feeding, but it has not been empirically examined. Therefore, the primary objective of this study was to assess the associations between breastfeeding self-efficacy and human milk expression practices. The secondary objective was to assess the effect of breastfeeding self-efficacy on breastfeeding duration and exclusivity. Methods: This study used a prospective cohort design. From 2017 to 2018, we recruited 821 healthy mothers with term births in two public hospitals in Hong Kong. Participants completed a self-administered questionnaire in the immediate postpartum period, which gathered information about sociodemographic characteristics and Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). Participants were followed up for 6 months or until infants were weaned. The proportion and type of infant feeding were assessed at telephone follow-up. Results: The overall mean BSES-SF score in our sample was 46.5 (standard deviation = 10.1). Every one-point increase in the BSES-SF score was associated with 4-5% lower risk of any expressed human milk feeding and 4-7% higher odds of breastfeeding continuation across the first 6 months postpartum. Conclusion: Higher breastfeeding self-efficacy is associated with a lower risk of expressed human milk feeding and a longer duration of any and exclusive breastfeeding. Further studies should explore how improving breastfeeding self-efficacy may affect the mode of human milk feeding.

A mixed-methods study on the association of six-month predominant breastfeeding with socioecological factors and COVID-19 among experienced breastfeeding women in Hong Kong

Background

In the past decade, various breastfeeding policies were implemented in Hong Kong, including changes in perinatal guidelines in public hospitals, adoption of the Baby-Friendly Hospital Initiative (BFHI), provision of guidelines for the marketing of formula milk, penalisation of discrimination towards breastfeeding, and extension of the statutory maternity leave. Meanwhile, the COVID-19 pandemic brought new challenges and opportunities to breastfeeding practices. Infection control measures in public hospitals included the cancellation of antenatal classes, hospital tours, and postnatal classes; suspension of perinatal visiting periods; and compulsory separation of COVID-19 positive mothers from newborns. In addition, work-from-home policies were widely implemented. This study aimed to identify the associated factors of six-month predominant breastfeeding (PBF), and to evaluate the impact of COVID-19 on breastfeeding practice.

Methods

This study was conducted from 1 March 2021 to 7 April 2021 using a mixed-methods approach. An electronic questionnaire was distributed to members of breastfeeding or parenting groups who have had breastfeeding experience in the past 10 yrs. Logistic and linear regression analyses were conducted to identify factors associated with six-month PBF both in general and during the pandemic period. A qualitative content analysis was conducted using an inductive approach.

Results

The study included 793 participants. Giving birth in a public hospital (OR 2.21; 95% CI 1.46, 3.34) and breastfeeding support from family and friends (OR 1.28; 95% CI 1.05, 1.57) were significantly associated with six-month PBF, even during COVID-19. Factors associated with the self-rated impact of COVID-19 on breastfeeding include working from home, the perceived immunological benefits of breastfeeding, and the wish to avoid breastfeeding or expressing breast milk in public premises. Furthermore, breastfeeding practice in public hospitals was more likely to be affected by the busyness of staff, while private hospitals had worse rooming-in practices and staff who had inadequate breastfeeding knowledge.

Conclusions

Giving birth in a public hospital and having breastfeeding support from family and friends were associated with six-month PBF. Furthermore, COVID-19 in Hong Kong had an overall positive impact on six-month PBF. Further studies should investigate the impact of hospital practices and the COVID-19 pandemic on breastfeeding behaviours.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00484-7.

Determinants of breastfeeding self-efficacy among postpartum women in rural China: A cross-sectional study

Background

Breastfeeding self-efficacy is known to positively influence breastfeeding behaviors. While previous research has studied the determinants of breastfeeding self-efficacy in general, these determinants are unstudied among postpartum women in rural China. This study aims to describe the breastfeeding self-efficacy of postpartum women in rural China and identify determinants of breastfeeding self-efficacy using the Dennis breastfeeding self-efficacy framework.

Methods

Using a multi-stage random cluster sampling design, cross-sectional survey data were collected from 787 women within the 0–6 months postpartum period in 80 rural townships. Surveys collected data on breastfeeding self-efficacy, characteristics related to the Dennis breastfeeding self-efficacy framework, and demographic characteristics. Multiple linear regression analysis was used to identify determinants of breastfeeding self-efficacy.

Results

Participants reported a moderate level of breastfeeding self-efficacy, with an item mean score of 3.50. Self-efficacy was lowest for exclusive breastfeeding. Breastfeeding attitudes (β = 0.088, P< 0.001), breastfeeding family support (β = 0.168, P< 0.001), and social support from significant others (β = 0.219, P< 0.001) were positively associated with breastfeeding self-efficacy. Breastfeeding problems, including trouble with latching (β = -0.170, P< 0.001), not producing enough milk (β = -0.148, P< 0.001), and milk taking too long to secrete (β = -0.173, P< 0.001) were negatively associated with breastfeeding self-efficacy.

Conclusion

The findings indicate that positive attitudes, breastfeeding family support and social support contribute to greater breastfeeding self-efficacy in rural China, whereas difficulties with breastfeeding are associated with reduced self-efficacy. Researchers and practitioners should investigate effective strategies to improve social support and family support for breastfeeding, promote positive attitudes towards breastfeeding, and provide women with actionable solutions to breastfeeding problems.

Why do first-time mothers not intend to breastfeed? --A qualitative exploratory study on the decision-making of non-initiation in Jingzhou, China

Background

Although breastfeeding is one of the top priorities for public health in China, the rate of breastfeeding is still low and a large number of women do not initiate breastfeeding due to various reasons. Hence, this study aimed to understand the decision-making of non-initiation and reveal the underlying reasons in order to protect, support, and promote breastfeeding.

Methods

In-depth, exploratory interviews were carried out with 13 new mothers who did not initiate breastfeeding. The collected data were analyzed by inductive content analysis.

Results

Although mothers generally understood the protective effects of breastfeeding, they believed that formula milk is a good alternative to human milk and even better in some aspects. Five core themes related to non-initiation decision-making emerged: (1) expected breastfeeding stress; (2) maladjustment to the maternal role; (3) concerns about physiological issues; (4) the lack of knowledge about the risks of artificial feeding; (5) belief that it is better not to initiate than to interrupt.

Conclusions

The environment for mothers to breastfeed in China is not supportive enough, and the medical staff and families should be held responsible for the non-initiation of breastfeeding. More professionals are needed to support mothers to solve their problems and breastfeeding education should be further expanded.

Factors associated with breast-feeding initiation and continuation in Canadian-born and non-Canadian-born women: a multi-centre study

OBJECTIVE

To identify factors associated with breast-feeding initiation and continuation in Canadian-born and non-Canadian-born women.

DESIGN

Prospective cohort of mothers and infants born from 2008 to 2012: the Canadian Healthy Infant Longitudinal Development (CHILD) Cohort Study.

SETTING

General community setting in four Canadian provinces.

PARTICIPANTS

In total, 3455 pregnant women from Vancouver, Edmonton, Winnipeg and Toronto between 2008 and 2012.

RESULTS

Of 3010 participants included in the current study, the majority were Canadian-born (75·5 %). Breast-feeding initiation rates were high in both non-Canadian-born (95·5 %) and Canadian-born participants (92·7 %). The median breast-feeding duration was 10 months in Canadian-born participants and 11 months in non-Canadian-born participants. Among Canadian-born participants, factors associated with breast-feeding initiation and continuation were older maternal age, higher maternal education, living with their partner and recruitment site. Rooming-in during the hospital stay was also associated with higher rates of breast-feeding initiation, but not continuation at 6-month postpartum. Factors associated with non-initiation of breast-feeding and cessation at 6-month postpartum were maternal smoking, living with a current smoker, caesarean birth and early-term birth. Among non-Canadian-born participants, maternal smoking during pregnancy was associated with lower odds of breast-feeding initiation and lower odds of breast-feeding continuation at 6 months, and older maternal age and recruitment site were associated with breast-feeding continuation at 6 months.

CONCLUSIONS

Although Canadian-born and non-Canadian-born women in the CHILD cohort have similar breast-feeding initiation rates, breast-feeding initiation and continuation are more strongly associated with socio-demographic characteristics in Canadian-born participants. Recruitment site was strongly associated with breast-feeding continuation in both groups and may indicate geographic disparities in breast-feeding rates nationally.

Association between expressed breast milk feeding and breastfeeding duration in Hong Kong mothers

BACKGROUND

Expressed breast milk feeding has increased substantially in the past two decades. Once used primarily for preterm infants, feeding expressed breast milk is now more common in mothers giving birth to healthy term infants. However, the effect of expressed breast milk feeding on breastfeeding duration is unclear.

OBJECTIVES

To assess the association between breast milk expression practices and breastfeeding duration in women giving birth to healthy infants.

METHODS

From 2017 to 2018, we recruited 821 new mothers from two public hospitals in Hong Kong. Participants were followed up at 1.5, 3, and 6 months postpartum or until they stopped breastfeeding. The proportion, type, and mode of all milk feeding were assessed at each follow-up.

RESULTS

At 1.5 months postpartum, 47.9%, 37.7%, and 14.4% of participants were feeding by direct breastfeeding only, mixed-mode feeding, and expressed breast milk only, respectively. Participants feeding expressed breast milk only were more likely to be supplementing with infant formula. When compared with participants who provided only direct breastfeeding, participants who gave only expressed breast milk at 1.5 months had 57% lower odds of breastfeeding continuation at three months postpartum. After stratification by infant formula supplementation, expressed breast milk feeding only at 1.5 months was associated with an increased risk of breastfeeding cessation in participants supplementing with infant formula (adjusted hazard ratio [aHR] = 1.86, 95% CI = 1.17-2.95).

CONCLUSION

In the first six months postpartum, giving only expressed breast milk is associated with early breastfeeding cessation, especially in participants who are also supplementing with infant formula.

Breastfeeding but not Exclusively: Exploration of Chinese American Mothers' Infant Feeding Practices

BACKGROUND

Previous qualitative researchers have shown that Chinese American mothers experienced high rates of suboptimal breastfeeding, especially early introduction of other foods before the recommended 6-month period of exclusive breastfeeding.

RESEARCH AIMS

(1) To explore attitudes that Chinese American mothers have about the meaning and practice of exclusive breastfeeding; (2) to evaluate the extent of family pressure and support to maintain exclusive breastfeeding; and (3) to examine the influence of breastfeeding self-efficacy and the intention to continue exclusive breastfeeding.

METHOD

Guided by the theory of planned behavior, this descriptive cross-sectional prospective online survey was conducted with Chinese American breastfeeding mothers (N = 401). Participants' attitudes, subjective norms, and perceived behavioral control for exclusive breastfeeding behaviors were measured.

RESULTS

The M (SD) age of participants was 29.14 (SD = 6.90). Just over 50% reported receiving family support for exclusive breastfeeding. While participants had positive attitudes about exclusive breastfeeding and the value of colostrum, 64% (n = 257) had already introduced foods other than mother's own milk before their infant was 6-months old. Participants also expressed concern that their infants did not receive enough nutrition from exclusive mother's milk. Participants with more than one child had significantly greater intention to continue exclusive breastfeeding compared to participants with only one child. Perception of approval by others for exclusive breastfeeding and breastfeeding self-efficacy were significantly related to behavioral intention to continue exclusive breastfeeding.

CONCLUSION

Suboptimal infant feeding is a problem for Chinese American women and may also be a problem for mothers in other ethnic groups. We found a lack of adherence with standard recommendations for sustaining 6-months of exclusive breastfeeding.

Effects of a theory of planned behavior-based intervention on breastfeeding behaviors after cesarean section: A randomized controlled trial

Objectives

To examine the efficacy of an intervention based on the theory of planned behavior (TPB) in improving breastfeeding behavior among women with cesarean sections (C-sections).

Methods

This research was a randomized controlled trial. Women with planned elective C-sections were recruited to participate in a randomized controlled trial between June and September 2020. One hundred thirty-two women were divided randomly into the intervention (n = 66) and control group (n = 66) by systematic random sampling. In the intervention group, an intervention project was implemented after the C-section to establish positive breastfeeding attitudes, cultivate supportive subjective norms, enhance perceived behavioral control, and strengthen breastfeeding intention to change behaviors. Those in the control group received routine pre-and post-delivery care. Exclusive breastfeeding rate and breast problem were collected at 5 days, 2 weeks, and 1 month after C-section. The modified Breastfeeding Attrition Prediction Tool (BAPT) on the first day in the hospital, two weeks, and one month after C-section and Numerical Rating Scale (NRS) 24 h postoperatively were used to compare the intervention effect between the two groups.

Results

After the intervention, the intervention group had significantly higher exclusive breastfeeding rates than the control group at five days (86.4% vs. 60.6%), two weeks (77.3% vs. 57.6%), and one month (74.2% vs. 50.0%) after the C-section. Besides, the intervention group was less likely to have sore nipples at five days (6.1% vs. 18.2% in the control group, P < 0.05) and two weeks (9.1% vs. 12.1% in the control group, P < 0.05). After two weeks of intervention, attitude scores (90.64 ± 8.31 vs. 87.20 ± 8.15, P < 0.05), subjective norm scores (88.07 ± 24.65 vs. 79.42 ± 19.47, P < 0.05）and behavior control scores in the intervention group were significantly higher than those in the control group. After one month of intervention, attitude scores (90.34 ± 10.35 vs. 84.22 ± 10.51, P < 0.05) and behavior control scores (43.13 ± 5.02 vs. 39.15 ± 4.69, P < 0.05）in the intervention group were significantly higher than those in the control group, which resulted in the higher breastfeeding intention in the intervention group.

Conclusion

This study indicated that the TPB-based interventions effectively improved women's breastfeeding behaviors after C-sections.

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.

An exploration of the breastfeeding behaviors of women after cesarean section: A qualitative study

Objectives

To explore the factors affecting breastfeeding behaviors in women after cesarean section.

Methods

This is a qualitative study that used a phenomenological approach. This study used individual face-to-face interviews with 19 women who underwent a cesarean section in a Women and Children’s Hospital in China between July to September 2019. Information saturation was used to determine sample size. Data were analyzed using a thematic content analysis method. Themes were developed based on the theory of planned behavior.

Results

Thirteen (68.42%) had a planned cesarean section, and six (31.58%) cesarean sections were unplanned or emergent. Three major themes emerged: ambivalent attitude about breastfeeding, motivation to comply with the traditional cultural norms, and barriers and challenges. The motivating factors for breastfeeding after cesarean sections included perceived benefits of human milk, support from healthcare professionals, and responsibility for breastfeeding. The challenges for breastfeeding after cesarean sections included physical discomfort, knowledge and skills deficit of breastfeeding, lactation deficiency, and lack of knowledge and coping skills in managing their depressive mood after cesarean sections. There were a couple of neutral factors, such as the influences of family and peers. These factors could influence women either positively as facilitators or negatively as barriers.

Conclusions

The findings can offer valuable information for healthcare professionals to help women breastfeed after cesarean sections. To promote women’s breastfeeding behaviors after cesarean sections, it is necessary to change women’s attitudes, belief systems, and the external environments and help them become more confident.

Patterns and predictors of exclusive breastfeeding in Chinese Australian mothers: a cross sectional study

BACKGROUND

While exclusive breastfeeding is recommended to 6 months of age, just 15% of mothers in Australia achieve this. The rate appears to be even lower among mothers born in China, where 90% have introduced infant formula by this time. This study aimed to examine infant feeding patterns in the first 12 months of life and the factors associated with exclusive breastfeeding at 4 months of age and infant formula introduction by 1 month of age among Chinese Australian mothers.

METHODS

Chinese Australian women with a child aged 1 to 4 years born in Australia were recruited through social media and asked to complete an online survey. Chinese ethnicity was defined as the mother or her parents having been born in mainland China, Taiwan or Hong Kong. Infant feeding practices since birth and a range of psychosocial and cultural factors were assessed. A total of 289 Chinese Australian mothers completed the survey. The relationships between exposure variables and exclusive breastfeeding at 4 months or infant formula use by 1 month were examined using multivariable logistic regression.

RESULTS

Almost all (93%) mothers initiated breastfeeding, however by 1 month of age exclusive breastfeeding rates reduced to 44%, with a further decline to 33 and 18% at 4 and 6 months respectively. Concurrently, 7% of parents reported infant formula feeding at birth increasing to 55 and 63% at 1 and 6 months of age respectively. The rates of any breastfeeding were 81% at 6 months and 50% at 12 months of age. Breastfeeding intention, self-efficacy and awareness of the infant feeding guidelines were key factors associated with sustained exclusive breastfeeding to 4 months.

CONCLUSIONS

While Chinese Australian mothers had comparable exclusive breastfeeding rates at 6 months to the general Australian population, twice as many had introduced infant formula by 1 month of age. There is an urgent need to support Chinese Australian mothers in the perinatal period to strengthen their knowledge, intention and confidence to delay early introduction of infant formula and promote exclusive breastfeeding in the early postpartum period.

Promoting Sustained and Exclusive Breastfeeding among Chinese American Pregnant Women

This study investigated prenatal goal setting and breastfeeding attitudes and intentions for 210 Chinese American pregnant women. In addition, this study assessed impact of person-centered versus factual messages on breastfeeding attitudes and intentions. While pregnant women reported receiving information about Baby-Friendly designated hospitals from healthcare providers, most received no breastfeeding information from those same providers. Although women had positive attitudes toward breastfeeding, they showed lack of knowledge about colostrum, general approval for using infant formula, as well as early introduction of complementary foods. By extension, these attitudes suggested they misunderstood the meaning of exclusive breastfeeding. No differences were observed based on parity, trimester of pregnancy, level of education or income. Person-centered and factual messages were judged as equally effective messages, but intention to breastfeed was more affected by the factual message. Reasons for this result are discussed. Healthcare providers are positioned to proactively engage in maternal preparedness for exclusive breastfeeding. These results suggested a missed opportunity for healthcare providers to communicate the value of sustained exclusive breastfeeding for the recommended first 6 months of an infant's life and underscore a need for all antenatal healthcare providers to collaboratively ensure that breastfeeding information is comprehensively provided throughout the span of antenatal care.

Strengthening and weakening factors for breastfeeding from the perspective of the nursing mother and her family

OBJECTIVE

To describe the strengthening and weakening factors for breastfeeding.

METHOD

This is a descriptive multiple case qualitative study, conducted in Curitiba, Parana, with members of 17 families with children between 6 and 12 months old, through semi-structured interview and construction of genograms, analyzed by the strategy of cross case synthesis.

RESULTS

28 people participated in the study. Strengthening factors for breastfeeding were: the desire to breastfeed; child with facility for breastfeeding; mother with time available to the child; previous breastfeeding experience and family history of breastfeeding; the support and encouragement to breastfeed. Weakening factors were: negative expectations; the myth of weak milk; child's disease; maternal illness; negative experiences of the mother; the absence of family history of breastfeeding; lack of a support network.

CONCLUSION

Breastfeeding is a family and social phenomenon. Therefore, practices that go beyond the mother-baby dyad are necessary. The care process should include the social and subjective dimension, strengthening the support network of nursing mothers, in order to obtain more satisfactory professional practices that promote breastfeeding.

"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.

Made to Feel Like Less of a Woman: The Experience of Stigma for Mothers Who Do Not Breastfeed

Background: Breastfeeding has become the recognized standard for good parenting, with social costs for not breastfeeding, but not every mother wants to or is able to breastfeed. Objectives: This study investigated social and personal costs with no breastfeeding. Materials and Methods: An in-depth survey was conducted with 250 mothers with infants who were not breastfeeding. Situated in the Framework Integrating Normative Influences on Stigma model for stigma, the study analyzed internalized stigma and perception of stigma from others, maternal feelings of warmth for the infant, and hiding formula use. Results: Mothers who chose not to breastfeed reported little personal or public stigma. In comparison, mothers who were unable to breastfeed experienced relatively more internalized stigma and perceived that other people saw them as failures. Mothers who experienced more internalized and perceived social network stigma were likely to hide use of infant formula from others and had lower feelings of warmth for their infants. Knowledge about formula use and availability of support resulted in less stigma and more warmth for the infant. Conclusions: These results suggest that public responses causing a mother to feel guilty for using infant formula result in negative feelings of self-worth and dysfunctional maternal behaviors.

The influence of the maternal peer group (partner, friends, mothers' group, family) on mothers' attitudes to obesity-related behaviours of their children

BACKGROUND

Relationships with others can have an impact on the attitudes of new mums to the obesity-related behaviours of their children. The aim of this study was to understand the degree to which other new mums (from their mothers' group), friends, partners, and other family members have an influence on maternal attitudes to child feeding, physical activity and television viewing behaviours in order to more accurately target obesity prevention interventions.

METHODS

In a retrospective cohort study design using data from the InFANT randomized controlled trial, first-time mothers (n = 307) from Melbourne, Australia were asked in 2012-13 how much of an influence their partner, friends, mothers' group and family were on their attitudes to their pre-school aged child's feeding, physical activity and television viewing behaviours. The level of influence was examined using chi-square tests, t-tests, and analysis of variance, stratified by maternal education, age and body weight. We also examined associations between the influence of others on maternal attitudes and actual behaviours including breastfeeding duration, age at introduction of solid food and time their child spent outside.

RESULTS

Mothers rated partners as having the strongest influence on their attitudes toward all obesity-related behaviours. The percentage reporting partners as a major influence were 28.7% (95% CI 23.8,34.0), 33.1% (28.0, 38.6) and 24.2% (19.6, 29.3) for child feeding, physical activity and television viewing, respectively. More highly educated mothers rated social connections as more influential than less educated mothers. The influence of partners on attitudes toward child feeding was associated with longer breastfeeding duration.

CONCLUSIONS

Mothers rated partners as a powerful influence on their attitudes toward the obesity-related behaviours of their pre-school children, suggesting that partners could be an important target of obesity-prevention initiatives. Since less educated mothers reported peers and family as a much weaker influence on their attitudes to obesity-related behaviours than more educated mothers, equity should be taken into consideration when contemplating obesity-prevention interventions that target mothers' groups.

Association between maternal education and breast feeding practices in China: a population-based cross-sectional study

OBJECTIVE

To investigate the association between maternal education and breast feeding in the Chinese population, with a consideration of household income and health-seeking behaviours.

DESIGN

A nationally representative population-based cross-sectional study.

SETTING

77 counties from 12 geographically distinct regions in China.

PARTICIPANTS

10 408 mothers with children from 0 to 12 months of age, aged 15-53 years old (mean: 29.15, SD: 5.11) were classified into primary school or below group (n=781), middle school group (n=3842), high school/vocational school group (n=1990), college or above group (n=3795), according to their highest completed education.

OUTCOMES

Five breastfeeding outcomes, including early initiation of breast feeding (EIB), exclusive breast feeding (EBF) under 6 months, predominant breast feeding under 6 months, current breast feeding and children ever breast fed, were calculated based on the standardised questionnaire from the WHO and Wellstart International's toolkit for monitoring and evaluating breastfeeding activities.

RESULTS

The absolute risk of EIB and EBF in the lowest maternal education level was 64.85% and 26.53%, respectively, whereas the absolute risk of EIB and EBF in the highest maternal education level was 77.21% and 14.06%, respectively. A higher level of maternal education was positively associated with EIB (risk ratio (RR): 1.22; 95% CI: 1.12 to 1.30) and was inversely associated with EBF (RR: 0.59; 95% CI: 0.38 to 0.88). Stratified by household income, a positive association with EIB was observed only in the group with the highest household income and an inverse association with EBF was found in both low household and high household income groups.

CONCLUSIONS

Mothers with a higher education were more likely to initiate early breast feeding when they were also from a high-income household while also being less likely to exclusively breast feed their babies. Routine and successful nursing is crucial for the health of infants and is influenced by maternal education. Future public health interventions to promote breast feeding should consider the issues related to the educational level of mothers.

How do grandparents influence child health and development? A systematic review

Grandparents are often a key source of care provision for their grandchildren, yet they are sidelined in caregiving research and policy decisions. We conducted a global, systematic review of the literature to examine the scope and quality of studies to date (PROSPERO database CRD42019133894). We screened 12,699 abstracts across 7 databases, and identified 206 studies that examined how grandparents influence child health and development. Indicators of grandparent involvement were contact, caregiving behaviors, and financial support. Our review focused on two research questions: how do grandparents influence child health and development outcomes, and what range of child outcomes is reported globally? We examined study design, sample characteristics, key findings, and outcomes pertaining to grandchildren's physical health, socio-emotional and behavioral health, and cognitive and educational development.  Our search captured studies featuring grandparent custodial care (n = 35), multigenerational care (n = 154), and both types of care (n = 17). We found substantial heterogeneity in the data provided on co-residence, caregiving roles, resources invested, outcomes, and mechanisms through which "grandparent effects" are manifested. We identified two important issues, related to operationalizing indicators of grandparent involvement and conceptualizing potential mechanisms, leading to gaps in the evidence base. Currently, our understanding of the pathways through which grandparents exert their influence is constrained by limited data on what grandparents actually do and insufficient attention given to interpersonal and structural contexts. We present a conceptual framework to explicitly measure and theorize pathways of care, with a view to inform research design and policy implementation. We underscore the need for more robust data on three indicators of caregiver involvement-contact, behavior, and support-and for careful description of structural and interpersonal contexts in caregiving research.

Breastfeeding Self-Efficacy Among Parturient Women in Shanghai: A Cross-Sectional Study

BACKGROUND

Breastfeeding self-efficacy has been shown to be a strong predictor of breastfeeding initiation and duration; however, factors associated with breastfeeding self-efficacy in China are unclear.

RESEARCH AIMS

The aims were (a) to describe the breastfeeding self-efficacy of parturient women in Shanghai, China and (b) to identify the sociodemographic factors associated with mothers' breastfeeding self-efficacy.

METHODS

This is a cross-sectional retrospective descriptive study. Through convenience sampling, breastfeeding mothers (N = 801) were recruited to assess breastfeeding self-efficacy before discharge from the hospital. Descriptive statistics were used to analyze the sociodemographic and perinatal characteristics, level of breastfeeding self-efficacy, and correlations between them.

RESULTS

In the process of breastfeeding, 52.2% (n = 418) of participants encountered breastfeeding problems, 37.1% (n = 297) perceived an insufficient milk supply, 82.4% (n = 660) reported attending breastfeeding classes, but only 37.1% (n = 297) chose exclusive breastfeeding. Chinese mothers reported a moderate level of breastfeeding self-efficacy, with an item mean score of 3.67 (score = 1-5). Whether or not encountering breastfeeding problems, infant feeding pattern (fully breastfeeding, partial breastfeeding, no breastfeeding) in the previous 24 hours, whether or not perceiving insufficient milk, and main caregiver's positive attitude toward breastfeeding (ranging from 1 to10, higher score indicating more positive attitude) were correlated with participants' breastfeeding self-efficacy score. (The correlation coefficients were -0.432, 0.377, -0.364, and 0.353, respectively.).

CONCLUSION

The misperception of insufficient milk and main caregiver's attitude toward breastfeeding were important factors for breastfeeding self-efficacy. Greater efforts should be made during breastfeeding education and support.

Breastfeeding Duration and the Theory of Planned Behavior and Breastfeeding Self-Efficacy Framework: A Systematic Review of Observational Studies

Introduction Numerous studies have shown that the constructs of the Theory of Reasoned Action (TRA), Theory of Planned Behavior (TPB) and Breastfeeding Self-Efficacy (BSE) Framework can effectively identify relationships between maternal psychosocial factors and breastfeeding initiation. However, the ability of these theories to predict breastfeeding duration has not been adequately analyzed. The aim of the review was to examine the utility of the constructs of TRA/TPB and BSE to predict breastfeeding duration. Methods We conducted a literature search using Pubmed (1980-May 2015), Medline (1966-May 2015), CINAHL (1980-May 2015), EMBASE (1980-May 2015) and PsycINFO (1980-May 2015). We selected studies that were observational studies without randomization or blinding, using TRA, TPB or BSE as the framework for analysis. Only studies reporting on breastfeeding duration were included. Results Thirty studies were selected, which include four using TRA, 10 using TPB, 15 using BSE and one using a combination of TPB and BSE. Maternal intention and breastfeeding self-efficacy were found to be important predictors of breastfeeding duration. Inconsistent findings were found in assessing the relationship between maternal attitudes, subjective norms, perceived behavior control and breastfeeding duration. Discussion The inadequacy of these constructs in explaining breastfeeding duration indicates a need to further explore the role of maternal self-determination in breastfeeding behavior.

Breastfeeding outcomes among early-term and full-term infants

BACKGROUND

When compared with full-term birth (39 to <42 weeks), early-term birth (37 to <39 weeks) is associated with adverse neonatal outcomes that may impede breastfeeding. Breastfeeding provides numerous benefits to infants and could potentially offset the effects of early-term birth. However, the effect of early-term birth on any and exclusive breastfeeding duration among healthy normal weight infants is unclear.

OBJECTIVES

The objective of this study was to examine the association between early-term birth and breastfeeding duration and exclusivity among healthy term infants.

METHODS

Two prospective cohorts of 2704 healthy mother-infant pairs were recruited in Hong Kong in 2006-07 and 2011-12. Participants were followed prospectively for 12 months or until they stopped breastfeeding.

RESULTS

Approximately one-third (32.8%) of the infants were born early-term. More than one-half of all participants had stopped breastfeeding by three months postpartum and approximately one-half of the infants were not being exclusively breastfed by two weeks postpartum. There was no significant difference in the odds of any (adjusted odds ratio [aOR] = 1.05; 95% 0.85, 1.31) or exclusive (aOR = 0.89; 95% 0.73, 1.08) breastfeeding at one-month postpartum between infants born early-term and at full-term. There was also no significant difference in the duration of any (adjusted hazard ratio [aHR] = 1.0; 95% 0.91, 1.10) or exclusive (aHR = 1.0; 95% 0.91, 1.09) breastfeeding between early-term and full-term infants.

CONCLUSION

In this cohort, early-term birth was not associated with breastfeeding duration and exclusivity. This suggests that, in the absence of neonatal complications, early-term birth itself may not lead to a shorter duration of any or exclusive breastfeeding.

The impact of immigration on the breastfeeding practices of Mainland Chinese immigrants in Hong Kong

BACKGROUND

Researchers have found breastfeeding disparities between immigrant and native-born women in many countries. However, most studies on immigration and breastfeeding practices have been in Western countries. The aim of this study was to examine the effect of length of time since immigration on the breastfeeding practices of Mainland Chinese immigrants living in Hong Kong.

METHODS

We recruited 2704 mother-infant pairs from the postnatal wards of four public hospitals in Hong Kong. We examined the effect of migration status on the duration of any and exclusive breastfeeding.

RESULTS

Breastfeeding duration was progressively shorter as the time since immigration increased. When compared with mothers who had lived in Hong Kong for <5 years, Hong Kong-born participants had a 30% higher risk of stopping any breastfeeding (hazard ratio [HR] 1.34 [95% confidence interval {CI} 1.10-1.63]) and exclusive breastfeeding (HR 1.33 [95% CI 1.11-1.58]). In both Hong Kong-born and immigrant participants, breastfeeding cessation was associated with return to work postpartum and the husband's preference for infant formula or mixed feeding. Intention to exclusively breastfeed and to breastfeed for >6 months, and previous breastfeeding experience substantially reduced the risk of breastfeeding cessation for both Hong Kong-born and immigrant participants.

CONCLUSIONS

Health care professionals should consider immigration history in their assessment of pregnant women and provide culturally adapted breastfeeding support and encouragement to this population.

The Association Between Pregnancy Intention and Breastfeeding

BACKGROUND

Although breastfeeding is associated with proven benefits to both mother and child, there are many factors that influence a mother's decision to breastfeed. Pregnancy intentionality at the time of conception is associated with postpartum maternal behavior including breastfeeding. Research aim: We sought to understand how maternal and paternal pregnancy intentions were associated with breastfeeding initiation and duration in a nationally representative sample.

METHODS

We used a cross-sectional, retrospective study of the CDC National Survey of Family Growth data to examine the link between pregnancy intentionality and breastfeeding initiation and duration among women ages 15 to 44 years.

RESULTS

We found that whereas the mother's intention to have a child was a factor in how long she breastfed, the paternal intention to have a child predicted whether the mother breastfed at all. Additionally, Hispanic mothers were most likely to breastfeed and breastfed the longest of any other group. Age and education were also positive predictors of ever breastfeeding.

CONCLUSION

Understanding the father's and mother's attitudes toward the pregnancy and influence on breastfeeding intention is important for intervention planning.

Effect of Secondary Cigarette Smoke from Household Members on Breastfeeding Duration: A Prospective Cohort Study

OBJECTIVE

Maternal smoking and exposure to tobacco smoke is one modifiable risk factor that affects breastfeeding initiation and duration. We prospectively examine the effects of maternal and paternal smoking and other family members' smoking status on the duration of breastfeeding.

MATERIALS AND METHODS

A cohort of 1,277 mother-infant pairs admitted to the postpartum units of four major public hospitals in Hong Kong. Demographic data, maternal, paternal and household smoking habits, and other potential confounding variables were collected via self-reported questionnaires during the postnatal hospitalization. Breastfeeding status after hospital discharge was assessed through telephone follow-up up to 12 months postpartum, or until participants were no longer breastfeeding. If the participant had weaned during that follow-up interval, she was asked to report the total duration (in weeks) of both any and exclusive breastfeeding.

RESULTS

A total of 1,240 (97%) mother-infant pairs completed followed up, 2.5% were smokers, 29.2% of their partners smoked, and 11.3% had another smoker living in their home. Maternal and other family members' smoking predicted breastfeeding cessation. When compared with mothers in nonsmoking family, those exposed to two or more family members who smoked had approximately a 30% increased risk of breastfeeding cessation (adjusted hazard ratio [aHR] = 1.31; 95% CI 1.01-1.68).

CONCLUSION

Mothers who were exposed to two or more smokers in the household had a significantly shorter duration of any breastfeeding at 12-month follow-up.

Family members' infant feeding preferences, maternal breastfeeding exposures and exclusive breastfeeding intentions

BACKGROUND

Maternal breastfeeding intentions are strongly associated with breastfeeding exclusivity and duration. Factors that affect new mothers' exclusive breastfeeding intentions have not been adequately examined.

OBJECTIVE

The purpose of this study was to examine the association between family member's infant feeding preferences, breastfeeding exposures, and womens' exclusive breastfeeding intentions.

METHODS

1277 breastfeeding mother-infant pairs were recruited from four public hospitals in Hong Kong. We used multiple logistic and linear regression models to explore the impact of the family members' infant feeding preferences and breastfeeding exposures on exclusive breastfeeding intentions.

RESULTS

78.1% mothers reported an intention to exclusively breastfeed, and the median intended duration of exclusive breastfeeding was 26 weeks. The husband's preference for breastfeeding (aOR = 1.67; 95% CI 1.20-2.31), previous breastfeeding experience (aOR = 1.56; 95% CI 1.10-2.23) and attendance at an antenatal breastfeeding class (aOR = 2.09; 95% CI 1.45-3.02) were all strongly associated with higher maternal intention to exclusively breastfeed. For every additional family member who preferred breastfeeding, the odds of intending to exclusively breastfeed increased by 32% (aOR1.32; 95% CI, 1.13-1.55). Similarly, the proportion of participants intending to exclusively breastfeed increased progressively with more breastfeeding exposures.

CONCLUSIONS

Including fathers and other significant family members in antenatal breastfeeding education can help to maximize breastfeeding support for the new mother and encourage new mothers to exclusively breastfeed.