This study is the first to examine the effect on the exposure to the baby-friendly hospital practices on mothers’ achievement of their planned duration of breastfeeding in a non-Western population. In this study, we identified key maternal characteristics that were strongly related to just over half of the participants who were able to achieve participant’s individual goals. Educated mothers with previous breastfeeding experience and those living in Hong Kong for a shorter period of time were more likely to achieve participant individual goals. The characteristics can be frequently associated with a longer breastfeeding duration in other studies [18, 19]. Although these are non-modifiable characteristics, additional breastfeeding support should be provided to less educated first-time mothers both during the postnatal hospitalization and after hospital discharge to help mothers achieve their individual breastfeeding goals. Also, because breastfeeding duration with a first child is a strong predictor of breastfeeding duration with subsequent children , providing adequate breastfeeding support to first time mothers can be beneficial beyond that pregnancy. In contrast to other studies [21, 22] we found that returning to work was not associated with participants achieving their individual goals. In this study with a high proportion of maternal employment and only 10 weeks of mandated maternity leave in Hong Kong, returning to work has been shown to be strongly associated with overall breastfeeding duration . A local study show that approximately 85% of employed new mothers return to full-time employment before 10 weeks postnatal and 88% work 40 hours per week or more . Therefore, most pregnant women make plans about returning to work before giving birth and their ability to combine breastfeeding and employment is likely reflected in their intended duration of breastfeeding.
Our findings also show that baby-friendly hospital practices were strongly associated with mothers’ achievement of their intended breastfeeding duration. Step 6, giving newborns only breast milk almost doubled a mother’s likelihood of achieving her planned duration of breastfeeding. This finding is consistent with previous studies conducted in the US on the effect of in-hospital exclusive breastfeeding on mothers’ achievement of their individual breastfeeding goals [12, 25]. In this sample however, even among participants who achieved their planned duration of breastfeeding, only 36% exclusively breastfed while in the hospital. Unfortunately, in-hospital formula supplementation of healthy breastfeeding infants is all too common [26, 27] and rarely medically indicated . Numerous studies have shown that early formula supplementation directly undermines the initiation and duration of breastfeeding [19, 26, 29]. In 2006, Hong Kong adopted a policy that all public and private hospitals have to purchase infant formula at market price as a step to becoming more baby-friendly. This significant change differ from US population, that culturally our sample are exposed to Step 6 that no free or low cost supplies of breastmilk substitutes are accepted. This study reinforces previous studies that early supplementation affects the initiation and duration of breastfeeding. Our study extends this finding that it also help mothers achieve their planned duration of breastfeeding in the long term. Early breastfeeding initiation after birth, minimizing separation between mother and baby, and support and advice to minimize maternal anxiety over perceived insufficient milk supply can help to reduce unnecessary formula supplementation during the postnatal hospital stay . Our findings differ from previously published findings in US population that step 10, providing mothers with information on breastfeeding support before hospital discharge was associated with 36% increased odds of participants achieving their planned duration of breastfeeding. Many new mothers report that after going home from the hospital they feel alone and isolated and have to figure out how to breastfeed on their own . Therefore among Chinese population, providing clear information to new mothers about where to find breastfeeding support may help mothers achieve their planned duration of breastfeeding and assist them to find support if needed.
Overall, each of the baby-friendly steps is highly interconnected with the others, structurally and physiologically, and the steps are statistically correlated with each other. Although only two of the six measured baby-friendly practices were individually associated with participants achieving their planned duration of breastfeeding, there was a clear dose-response pattern and exposure to increasing numbers of baby-friendly practices was associated with increasingly higher odds of participants reaching their individual goals. Participants who experienced six baby-friendly hospital practices were four and one-half times more likely to achieve their planned duration of breastfeeding when compared with women who experienced only one practice. Unfortunately, only 19.8% of our participants experienced all six baby-friendly practices. Encouragingly, since our study was conducted, two of our four study hospitals have been officially designated as baby-friendly and the other two are progressing toward baby-friendly status. Full implementation of the BFHI improves hospital practices, reduces unnecessary infant formula supplementation, and improves breastfeeding rates [32, 33].
Strengths of this study were study attrition was minimal, and we had follow-up data on 97.6% of the study sample. Weaknesses of this study were despite the large sample size, participant recruitment was not population based. Therefore, new mothers with more breastfeeding confidence may have been more likely to participate in our study, and we do not have data on eligible mothers who declined to participate. Furthermore, participants self-reported breastfeeding data in this study and therefore it may be subject to recall bias. However, other studies have shown that maternal reports of breastfeeding duration are accurate for many years after women have stopped breastfeeding .