Exclusive breastfeeding intention and associated factors in pregnant women: findings from a population-based study

DOI: https://doi.org/10.21203/rs.3.rs-1856600/v1

Abstract

Background

The benefits of breastfeeding especially exclusive breastfeeding have been well recognized.

Aim

To investigate the prevalence and influencing factors of exclusive breastfeeding intentions for the first six months among pregnant women.

Methods

A self-designed questionnaire was adopted to collect information on maternal intention on exclusive breastfeeding and other related social characteristics. The primary outcome was intention of mother on exclusively breastfeeding which derived by a response to the question “would you be will to breastfeed exclusively for the first 6 months?” Adjusted odds ratio (OR) with 95% confidence intervals were obtained by multiple logistic regression after adjusted by maternal age.

Findings:

A total of 2,479 pregnant women in the third trimester were interviewed. 60.8% of them planned to exclusively breastfeed during the first 6 months. After adjusted by maternal age, intentions to exclusively breastfeed was lower in mothers with a graduate degree (OR,0.70; 0.525–0.987). Mothers who received supports of exclusive breastfeeding from spouses and parents were more likely to intent to exclusively breastfeed than those not. The intention of exclusively breastfeed was higher among mothers (OR = 1.436, 1.199–1.719) who participated in breastfeeding courses during pregnancy were pregnant women independent influencing factors of breastfeeding intention in late pregnant women.

Conclusion

Over half of the pregnancy women showed an intention to exclusive breastfeeding for the first 6 months. Antenatal breastfeeding courses and supportive practices from family need to be enforced to improve mothers' and family members' perception about exclusive breastfeeding, in order to increase the rate and duration of exclusive breastfeeding.

What Is Already Known

What This Paper Adds

Introduction

Breastfeeding offers optimal nutritional and development merits for infants until around six months of age and into adult life. The benefits of breastfeeding particularly exclusive breastfeeding have been well recognized that breastfeeding reduced mortality and morbidity in infants and children(1). Breastfeeding could reduce risk of gastroenteritis, diarrheal disease, necrotizing enterocolitis, sudden infant death syndrome, childhood leukemia, otitis media, and respiratory tract infections (2). It was also reported that breastfeeding was associated with reduced incidence of childhood obesity rate (3), and type 1 and type 2 diabetes(1). Studies have shown that exclusive breastfeeding of low-birth-weight infants reduces the risk of severe intraventricular hemorrhage. For childbearing women, breastfeeding accelerates postpartum recovery, lost weight, and reduced risk of clinical and subclinical cardiovascular disease, type 2 diabetes(4, 5). Breastfeeding was also been linked with a reduced risk of breast, ovarian and rheumatoid arthritis(6). Besides, breastfeeding is important for the formation of an emotional bond between mother and infant. In a word, breastfeeding is important for the physical and psychological health of the mother and child, and is also crucial for maternal and childhood short- and long-term health benefits.

The prevalence of exclusive breastfeeding in China are improving in recent years. A review of changes in breastfeeding in China showed that any breastfeeding at four months has increased from78–83% between 2007–2018(7). According to results of a national Dynamic surveillance study published in 2021, the prevalence of exclusive breastfeeding for at least 5 months has increased rapidly from 16.14–34.9% between 2013–2018(8). The 2019 China Development Research Foundation report shows that the exclusive breastfeeding rate of Chinese infants within 6 months is only 29%, and the rate of exclusive breastfeeding for the second child was only 37.87%(9, 10). However, these rates neither meet the nutrition goals established by WHO, which aims to increase the rate of exclusive breastfeeding in the first six months of life to 50% by 2025(11), nor the new target set in the National Program of Action for Child Development in China from 2011 to 2020 of an rate of over 50% at the sixth month of life(12).

Maternal exclusive breastfeeding intentions strongly determine the subsequent breastfeeding exclusivity behaviors and duration(13, 14). Women with a preference to exclusively breastfeed were likely to initiate exclusive breastfeeding practice. Different factors may influence the maternal exclusive breastfeeding preferences such as age, occupation, family income, spouse and parental support, parities, previous breastfeeding experience, knowledge of breastfeeding benefits, etc. This study aims to examine the intention of exclusive breastfeeding for the first 6 months of life among pregnant women in the third trimester, and identify factors associated with their breastfeeding intentions.

Methods

Study participants

Pregnant women in their third trimester who had received regular obstetric examinations in five obstetric outpatient clinics from January 1 to February 28, 2021 in Xi'an were invited. The inclusion criteria include: a) gestational age ≥ 37 weeks; b) complete the questionnaire independently; c) without any mental disorders. The exclusion criteria include a) with HIV, hepatitis B and other communicable diseases or infectious diseases; b) reside out of Xi'an. A total of 2,671 questionnaires were distributed, and 2,479 (92.8%) valid questionnaires were returned. This study was approved by the Ethics Committee of Northwest Women's and Children's Hospital. Written informed consents were signed and obtained from all participants. In addition, the individual participant’s personal information was anonymized, and authors had no access to information that could identify individual participants during and after data collection.

Procedure

Questionnaire used in this study was self-designed based on proceeding relevant literatures. National breastfeeding consultants, senior maternity nurses and statisticians were involved in the design and revision of the questionnaire. All items in the questionnaire were discussed and determined after several rounds of consultation among experts. The final revision of the questionnaire was completed after a pilot survey which was conducted at Northwest Women's and Children's Hospital. Exclusive breastfeeding is defined as giving an infant no liquid or solid food other than breast milk, no water, tea, or any other liquid other than a drop of vitamins, oral rehydration salts, mineral supplements, or medications.

Basic information on maternal were collected in the questionnaire including maternal age, history of gestation, education level of both parents, annual family income, length of maternity leave, medical insurance pregnancy complications, modes of planned feeding postpartum, feeding advice of husband and other family members, lactation during pregnancy, and so on. The questionnaire was self-administered by pregnant women when they attended maternal check during the third trimester of pregnancy investigators will conduct a preliminary inspection of the contents in the field, and if there is any doubt such as missing items or inappropriate contents, they should be re-examined and verified with the participants. Each field workers had a work manual, and all of them received a unified training. In addition, all the study process will be quality controlled.

Statistical analysis

We used Epidata 3.0 to establish the database and SPSS 22.0 software was used for statistical analysis. Categorical variables were presented as n (%), and maternal age were showed as mean ± standard deviation (SD), as appropriate. Chi-squared test was performed to assess differences in proportions across groups. Univariate analysis was first performed to examined factors that associated with intention to exclusive breastfeeding, and those factors with significance were included into the final mmultivariable logistic regression models to estimate the adjusted odds ratios (ORs) and 95% confident interval (95% CI) between factors and intention to exclusively breastfeeding. All tests are 2-sided and a p value less than 0.05 was considered statistically significant.

Results

A total of 2,479 pregnant women in the third trimester were included in the analysis. The average maternal age was 29.55 ± 3.84, and the educational level of most pregnant women (49.6%) and their husbands (46.6%) was college and below. The majority (85.6%) pregnant women have medical insurance. Multiparous women account for 60.7% of all participants (Table 1).

Table 1

General characteristics of the study population (n = 2,479)

Characteristic

n (%) /Mean ± SD

Maternal age (years)

29.55 ± 3.84

Educational level

 

College and below

1,230 (49.6)

Undergraduate

972 (39.2)

Graduate

277 (11.2)

Education level of Husband

 

College and below

1,155 (46.6)

Undergraduate

989 (39.9)

Graduate

335 (13.5)

Monthly household income (RMB yuan)

 

≤ 5000

539 (21.9)

5001–10000

1,113 (44.9)

≥ 10000

827 (33.4)

Medical insurance

 

Yes

2,121 (85.6)

No

358 (14.4)

Parity

 

1

593 (39.3)

≥ 2

914 (60.7)

Hospital

 

Tertiary

1,868 (75.4)

Secondary

661 (24.6)

Different analysis of the characteristics on the intention of exclusive breastfeeding among pregnant women in the third trimester were showed in Table 2. It showed that both the educational level of pregnant women and husbands, monthly family income, duration of maternity leave, husband and parents support for exclusive breastfeeding, and whether take breastfeeding courses during pregnancy were statistically different on the intention to exclusive breastfeeding.

Table 2

Analysis of different characteristics between intention and no intention to exclusive breastfeeding (n = 2,479)

Characteristics

Intention to exclusive breastfeeding

χ2

P

Yes

n (%)

N = 1,507

No

N (%)

N = 972

Maternal age (years)

   

4.481

0.214

21–24

140 (9.3)

114 (11.7)

   

25–29

776 (51.5)

490 (50.4)

30–34

469 (31.1)

284 (29.2)

≥ 35

122 (8.1)

84 (8.6)

Maternal educational level

   

6.975

0.031

College and below

720 (47.6)

510 (52.5)

   

Undergraduate

622 (41.3)

350 (36.0)

Graduate

165 (10.9)

112 (11.5)

Education level of Husband

   

10.515

0.005

College and below

663 (44.0)

492 (50.6)

   

Undergraduate

628 (41.7)

361 (37.1)

Graduate

216 (14.3)

119 (12.2)

Maternal occupational status

   

0.144

0.704

Employed

939 (62.3)

613 (63.1)

   

Unemployed

568 (37.7)

359 (36.9)

Occupational status of husband

   

0.387

0.534

Employed

977 (64.8)

642 (66.0)

   

Unemployed

530 (35.2)

330 (34.0)

Monthly household income

   

9.047

0.011

≤ 5000

299 (19.8)

240 (24.7)

   

5001–10000

703 (46.6)

410 (42.2)

≥ 10000

505 (33.5)

322 (33.1)

Medical Insurance

   

0.959

0.327

Yes

1281 (85).

840 (86.4)

   

No

226 (15)

132 (13.6)

Parity

   

0.628

0.428

1

593 (39.3)

398 (40.9)

   

≥ 2

914 (60.7)

574 (59.1)

Maternity leave (days)

   

3.842

0.146

≤ 98

315 (64.5)

173 (35.5)

   

99–149

172 (58.6)

123 (41.4)

≥ 150

1018(60.1)

676(39.9)

Gestational complications

   

1.561

0.212

No

919 (61.0)

617 (63.5)

   

Yes

588 (39.0)

355 (36.5)

Husband’s exclusively breastfeed support

   

175.987

< 0.001

Yes

1415 (93.9)

732 (75.3)

   

No

92 (6.1)

240 (24.7)

Parents’ exclusively breastfeed support

   

155.055

< 0.001

Yes

1403 (93.1)

733 (75.4)

   

No

104 (6.9)

239 (24.6)

Lactation during pregnancy

   

3.085

0.079

Yes

556 (36.9)

325 (33.4)

   

No

951 (63.1)

647 (66.6)

Attended breastfeeding class

   

29.401

< 0.001

No

840 (55.7)

648 (66.7)

   

Yes

667 (44.3)

324 (33.3)

Multivariable logistic regression analysis showed that husband's support for exclusive breastfeeding, the family's support for exclusive breastfeeding, and participation in breastfeeding courses during pregnancy were significant associated with pregnant women’ intention to exclusively breastfeed. Compared with women whose husband and family did not support exclusive breastfeeding, women with the support from husband and family to exclusively breastfeed were 2.097 (95%CI: 2.097–4.066) and 2.171 (95%CI: 1,571-3.000) times intention to exclusive breastfeeding. Compared with taking breastfeeding courses, pregnant women who had attended breastfeeding courses during pregnancy had 1.436 times more likely to give exclusive breastfeeding than those who did not take the courses (Table 3).

Table 3

Multivariable logistic regression analysis of factors associated with intention to exclusive breastfeeding

Characteristic

OR

95%CI

p

Maternal educational level

     

College and below

1

   

Undergraduate

0.702

0.492-1.000

0.050

Graduate

0.720

0.525–0.987

0.041

Education level of Husband

     

College and below

1

   

Undergraduate

1.360

0.959–1.928

0.084

Graduate

1.079

0.797–1.460

0.625

Monthly household income

     

≤ 5000

1

   

5001–10000

1.044

0.803–1.355

0.749

≥ 10000

0.872

0.710–1.071

0.192

Husband’s exclusively breastfeed support

     

No

1

   

Yes

2.097

2.097–4.066

< 0.001

Parents’ exclusively breastfeed support

     

No

1

   

Yes

2.171

1,571-3.000

< 0.001

Attended breastfeeding class

     

No

1

   

Yes

1.436

1.199–1.719

< 0.001

Discussion

The present study investigated the rate of intention to exclusive breastfeeding among women in late pregnancy, and analyzed the factors that influenced this intention. Findings showed that 60.8% of pregnant women in the third trimester planned to exclusively breastfeed in the first 6 months. Supports of exclusive breastfeeding from pregnant women’ husband and family were positively associated with intention of exclusive breastfeeding of pregnant women themselves. In addition, women who have attended the breastfeeding courses during pregnancy have higher willingness of exclusive breastfeeding than women who did not attended the courses.

The prevalence of exclusive breastfeeding at six months in China has changed during the past decade. A review paper showed that exclusive breastfeeding rates in the first six months were between 0.50% and 33.45% in 17 cities including Xi’an in China from 2007–2017(7). Another cohort study conducted in 2014 in rural areas from three cities in Shaanxi Province showed that the exclusive breastfeeding rate at six months was 35.04% (15). The fourth national health service survey in 2008 indicated that the rate of exclusive breastfeeding at six months was 27.6%(16), while this rate increased to 58.5% in the fifth survey in 2013(17). Another quasi-experimental study throughout 14 provinces in Western, Eastern and Central China showed that this rate increased significantly from 42.96% in 2012 to 48.84% in 2015(18). Our findings displayed that the intention to exclusive breastfeeding at six months was 60.8%, which is higher than previous literature results. The above increases may be associated with changes in breastfeeding targets set in the National Program of Action for Child Development in China. The recent target of an exclusive breastfeeding rate was ≥ 50% at sixth month of life from 2011–2020(12).

Breastfeeding practices are influenced by various factors including maternal age, education level, family income and so on. A review study of meta-aggregation of qualitative studies showed that maternal perceptions and self-efficacy, family support, social expectations and policy as factors influencing breastfeeding in China(19). The present study found no significant associations between maternal age, mothers’ occupation, and parity and planning for exclusive breastfeeding within 6 months postpartum. It has been suggested that prior breastfeeding experience rather than parity, predicts maternal willingness to exclusively breastfeed(20). Our results indicated that maternal education level was significantly associated with exclusive breastfeeding after adjusted by maternal age. Higher educational level was negatively associated with exclusive breastfeeding preferences and this was consistent with a Saudi study(21). This might be that mothers with high education level were more likely to be employed and had shorter breastfeeding duration(22).

Family member’s infant feeding preferences was strongly predictive of maternal intention to exclusively breastfeed in first six months(23). Previous studies examining factors associated with intention to exclusive breastfeeding found that perceived support from mothers’ social networks was influential(13). The present study found that mothers who received more supports from their husbands and family members were more likely intend to exclusively breastfeed for 6 months. This finding was consistent with studies from Israel, Canada, and the United States, which show that the odds of intending to exclusively breastfeed were higher if the husband and maternal grandmother preferred exclusive breastfeeding (13). Breastfeeding support from women’ partners improved exclusive breastfeeding rates(24), and a preference for infant formula was associated with earlier breastfeeding cessation(25). In addition, the preferences of the mothers’ own mother or their mother-in-low influence maternal exclusive breastfeeding intentions, and this was not surprising given that the strong influence of the mother-in-low in traditional Chinese families. Previous research has shown that most fathers are afraid to offer support because they think they don't know enough about breastfeeding and can't help when breastfeeding is difficult.

Our study found that infants’ mothers who participated in antenatal breastfeeding classes had a higher intention of exclusively breastfeed than those who did not. This was consistent with findings showed that mothers with more breastfeeding knowledge have a more positive attitude towards exclusive breastfeeding and were more willing to exclusively breastfeed after childbirth(26). As the mother's willingness to exclusive breastfeeding is influenced by maternal husband and other family members, it was also necessary to involve infant fathers in the exclusive breastfeeding education program to improve their knowledge and awareness of breastfeeding. Education programs emphasizing the nutritional value and health benefits of breast milk and targeting the important role of the spouse and whole family are needed in achieving breastfeeding success(27). In addition, multifactorial interventions such as direct face-to-face prenatal education in groups, individual counselling, and postpartum telephone follow-up, could also be used in maintaining exclusive breastfeeding rates during the first 6 months postpartum.

This study has some limitations that need to be addressed. Data collected in this study was via interviewing on an individual basis to answer the questionnaire, and pregnant women in late trimester might felt embarrassed to reveal their no intention to exclusive breastfeeding, which might introduce information bias; Besides, husband and family member’s support on exclusive breastfeeding was also reported by mothers themselves, thus there is a bias also. In addition, this study interviewed pregnancy women in five hospitals in the same city, which might limit the generalization of this finding. Last, the cross-sectional study design could not disclose the causal relation between the examined factors and maternal intention to exclusively breastfeed. Strengths of this study include large sample of participated pregnant women in late trimester and standardized application of the questionnaire. We also collected as many the maternal and family characteristics potentially associated with intentions to exclusively breastfeed such as maternal employment, parity, maternal leave duration, health insurance.

Conclusions

There is a high proportion of pregnant women plan to exclusive breastfeeding for 6 months postpartum. Supportive attitude toward exclusive breastfeeding from women’ partners and parents were strongly influence mothers’ intentions of breastfeeding. Benefits and knowledge on benefits of exclusive breastfeeding predicted the intention of exclusive breastfeeding. Prenatal, and postpartum education and supportive interventions should be given to mothers to increase the rate and duration of exclusive breastfeeding in the first 6 months postpartum.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Northwest Women’s and Children’s Hospital. The committee’s reference number is 2021-078. All methods were performed in accordance with the Declarations of Helsinki. Written informed consents were signed and obtained from all participants.

Consent for publication

The informed consents including consent for publication were obtained from all participants.

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available due to patient’s privacy policy but could be available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was supported by research grants from the Key Research and Development Program of Shaanxi Province (No. 2018SF-224, 2022SF-125, 2022SF-436,2021ZDLSF02-14).

Authors’ contributions

JW designed the overall study with contributions from LM. HZ, RG and YM collected the data; HZ and JW analyzed and drafted the manuscript. LM and YM revised the manuscript. JW and HZ interpreted the results and critically revised the manuscript. All authors approved the final version of the manuscript.

Acknowledgments

We thank all the participants in the interview and the nursing staff Department of Obstetrics of Northwest Women’s and Children’s Hospital for their involvement and assistance with the data collection.

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