The current study reveals that the EBF rate in the first six months among the mothers within the maternal health WeChat groups in Jiaxing, China, is 71.3%, which is considerably higher compared to the rates reported by both national and local surveys in China [5–10]. Although there are other factors for this higher EBF rate, we tend to think that the implementation of WeChat group model as a supplement to traditional maternal health care is a main contributing factor.
Health workers have played an important role in breastfeeding initiation and continuation [8–12]. In the traditional model of maternal health care, women are required to attend antenatal and postnatal clinics or classes regularly, and health workers are needed to follow up the mothers by telephone calls or home visits after their hospital discharge. This could decrease the compliance of women and increase the workload of health workers, which in turn diminishes the effectiveness of maternal health care. Considering that WeChat is universally used by almost all women of childbearing age in our area, we adopt the establishment of maternal health WeChat groups as part of routine maternal health care. The advantages of WeChat group include its convenience and timeliness. In this way, health workers can provide regular breastfeeding education for all mothers and individual counseling for those who are experiencing feeding problems. The higher awareness rate (86.1%) of breastfeeding recommendations in this study also reflects the effectiveness of this model of health education. Moreover, the mothers within the group can share their breastfeeding experiences with each other, thereby enhancing their breastfeeding confidence. In addition, this model also provides convenience for health workers to make investigations and gather information on some issues if needed.
We acknowledge, of course, that other factors can also contribute to this higher EBF rate in this study. In particular, most mothers gave birth at the BFHI certificate hospitals which adopted the “Ten Steps to Successful Breastfeeding” launched by WHO . Therefore, it is not surprising that a higher proportion of mothers, even for those with cesarean delivery, had skin-to-skin contact immediately after birth, rooming-in with their infants, breastfeeding initiation within the first hour and EBF during hospitalization in this survey. These interventions have been shown to be strong contributors to establishment and continuation of breastfeeding [11, 17–20].
In line with previous studies [8, 9, 21–23], we found that there were significant differences in maternal age, BMI, employment status, mode of delivery, breastfeeding initiation, EBF during hospitalization and perception of insufficient breast milk between mothers with and without EBF base on the univariate analysis. However, multivariable regression analysis showed that only maternal age, EBF during hospitalization and perception of insufficient breast milk were associated with EBF. Especially, perceived insufficient breast milk significantly decreased, while EBF during hospitalization significantly increased the possibility of EBF within six months. Regarding the association between maternal age and breastfeeding, data in the literatures are conflicting. A number of studies observed that older mothers were associated with lower EBF compared to younger ones [6, 9]; in contrast, other studies showed that older mothers were more likely to have a positive attitude toward breastfeeding and to practice EBF than younger ones [22, 24]. In this study, maternal age was found to be negatively but marginally associated with EBF.
The lack of associations of other variables with EBF within six months may be due to the fact that the majority of surveyed mothers were employed and had breastfeeding initiation within the first hour. As for mode of delivery, previous studies have suggested that women with cesarean delivery were less likely to EBF than those with vaginal delivery [6, 17]. Delayed onset of lactation, disrupted mother-infant interaction, inhibited infant suckling and poor pain relief may mediate the effects of caesarean delivery on breastfeeding . In the current study, although caesarean delivery was less common in EBF mothers than in non-EBF mothers, it was not associated with EBF after adjustment for other confounding variables. This result is consistent with the study by Ruan et al , and suggests that if the mothers receive adequate breastfeeding support, especially during hospitalization, caesarean delivery is not necessarily a barrier to EBF. This may be especially important considering that a relatively higher caesarean delivery rate in China . In addition, we did not found the difference in mothers’ educational level, monthly family incomes, skin-to-skin contact, and room-in between mothers with and without EBF, those have been identified as the factors related to EBF in previous studies [5, 6, 12, 20]. Again, sample characteristics and hospital practices may explain the discrepancy between this study and other studies.
With regard to the reasons for non-EBF, no or insufficient breast milk is the foremost one reported by the non-EBF mothers. This is consistent with the multivariable regression analysis and with other studies [6, 9, 10]. However, in fact, only few mothers have physiological insufficient milk supply and most mothers can produce enough breastmilk to meet their infant’s demand . As such, this result may imply the inadequate education and guidance provided by health workers on this issue. The next main reasons are those work related factors, including inability to breastfeed their infants as needed after return to work and lack of flexible breaks at work. Notably, although fewer mothers (6.8%) stated no breastfeeding room or refrigerator at workplaces as the reason for non-EBF, 72.7% of the employed mothers reported there was no breastfeeding room at their workplaces. Other reasons for non-EBF are various, including infant crying or mother feeling tired or troubled with breastfeeding, nipple and breast problems, the concern about breast milk alone being not sufficient for infant’s needs, and perceived inconveniences or discomfort of breastfeeding in public. Fortunately, most reasons listed above can be amended through education and intervention. For example, health workers can guide mothers how to tell the difference between physiological and perceived insufficient breast milk, prepare mothers for tiredness and fatigue, improve mothers’ ability to soothe their infants, and eliminate their concern about insufficient breast milk nutrition. Returning to work before six months is still the common reason of early weaning breastfeeding for working mothers [9, 11, 13]. Thus, breastfeeding-friendly work policies and environments are needed for improving EBF among those mothers. For example, a relatively long maternity leave can extend breastfeeding duration for working mothers [11, 21, 28]. Hence, government may consider a longer paid maternity leave, guarantee frequent and flexible breaks at work, and encourage the provision of an independent breastfeeding room with a refrigerator at the workplaces. In Jiaxing city, women can now have a paid maternity leave of 128 days for vaginal delivery and 143 days for cesarean delivery.
This study has some limitations. First, due to the nature of cross-sectional design, we cannot establish causal relationships between EBF and associated factors. Second, we used a convenience sampling method and only enrolled the mothers from our maternal health WeChat groups. It is feasible that women who have joined in the WeChat groups are more inclined to breastfeed. Further investigation that includes the whole obstetric population in the same city is warranted to confirm the effect of WeChat group on EBF. Third, the response rate was estimated to be about 75.3%. It is possible that mothers who did not practice EBF were less willing to respond than those who did, which may also lead to overestimation of the EBF rate. Fourth, because the mothers completed the questionnaire six months after their delivery, the recall bias could not be avoided. In addition, the self-report nature of the study may also cause reporting bias. Finally, the questionnaire was designed to be relatively simple in order to increase the participation rate. There were some important factors that failed to be measured, such as mothers’ intention and attitude to breastfeeding, the time when mothers introduce complementary foods and wean breastfeeding, supports of husbands and families, etc. These variables have previously been reported as the factors affecting EBF [7, 11, 28] and may provide more information for future breastfeeding education and interventions.