A total of 707 (89.7%) women completed the discharge survey. The age range was from 17 to 42 years with the mean age of 29.8 years. About half of the mothers’ household registration was non-Shanghai (50.5%). The majority of the mothers were Han ethnicity (97.3%) and without religious belief (93.9%). Nearly 25% of participants were unemployed. About 50% of women planned to return to work within 6 months postpartum. More than 80% of mothers didn’t consume alcohol during pregnancy. Nearly 60% of the participants had maternity insurance. More than three-fifths (64.4%) of mothers attended the maternity school provided by the hospitals. About three quarters of mothers were primiparous (71.1%). Around 75% of the children's primary caregivers during hospitalization were their fathers and grandparents. The mean score of BF supportive services received by mothers during hospitalization was 8.4, ranging from 2 to 12. (Table 1).
Table 1 Characteristics of participants and the associations with EBF at hospital discharge (n=707)
Characteristic
|
n (%)
|
EBF at hospital discharge
|
c2
|
P value
|
Yes, n(%)
|
No, n(%)
|
Age (years)
|
≤ 30
|
435(61.5)
|
142(32.6)
|
293(67.4)
|
1.49
|
0.22a
|
>30
|
272(38.5)
|
101(37.1)
|
171(62.9)
|
|
|
Education level
|
Junior middle school
|
104(14.7)
|
34(32.7)
|
70(67.3)
|
0.19
|
0.91#
|
Senior middle school
|
127(18.0)
|
45(35.4)
|
82(64.6)
|
|
|
College and above
|
476(67.3)
|
164(34.5)
|
312(65.5)
|
|
|
Intended time returning back to work
|
≤ 6 months
|
350(49.5)
|
115(32.9)
|
235(67.1)
|
0.70
|
0.43a
|
> 6 months
|
357(50.5)
|
128(35.9)
|
229(64.1)
|
|
|
Alcohol intake during pregnancy
|
No
|
578(81.8)
|
199(34.4)
|
379(65.6)
|
0.01
|
1.00a
|
Yes
|
129(18.2)
|
44(34.1)
|
85(65.9)
|
|
|
Family monthly income per capita
|
≤10,000 RMB
|
495(70.0)
|
171(34.5)
|
324(65.5)
|
0.02
|
0.93a
|
>10,000 RMB
|
212(30.0)
|
72(34.0)
|
140(66.0)
|
|
|
Maternityinsurance
|
|
|
|
|
|
No
|
253(35.8)
|
77(30.4)
|
176(69.6)
|
2.88
|
0.24#
|
Yes
|
418(59.1)
|
154(36.8)
|
264(63.2)
|
|
|
Others
|
36(5.1)
|
12(33.3)
|
24(66.7)
|
|
|
Family structure
|
|
|
|
|
|
Nuclear family
|
350(49.5)
|
115(32.9)
|
235(67.1)
|
0.70
|
0.43a
|
Non-nuclear family
|
357(50.5)
|
128(35.9)
|
229(64.1)
|
|
|
Receiving specific BF guidance (such as feeding posture and expressing) in the maternity school
|
Yes
|
353(49.9)
|
122(34.6)
|
231(65.4)
|
0.011
|
0.915a
|
No
|
354(50.1)
|
121(34.2)
|
233(65.8)
|
|
|
Mode of delivery
|
Vaginal delivery
|
331(46.8)
|
112(33.8)
|
219(66.2)
|
0.079
|
0.961#
|
Forceps delivery
|
11(1.6)
|
4(36.4)
|
7(63.6)
|
|
|
Cesarean section delivery
|
363(51.3)
|
126(34.7)
|
237(65.3)
|
|
|
Primiparity*
|
Yes
|
502(71.3)
|
159(31.7)
|
343(68.3)
|
5.091
|
0.028a
|
No
|
202(28.7)
|
82(40.6)
|
120(59.4)
|
|
|
Newborn sex
|
|
|
|
|
|
Boy
|
383(54.2)
|
134(35.0)
|
249(65.0)
|
0.141
|
0.751a
|
Girl
|
324(45.8)
|
109(33.6)
|
215(66.4)
|
|
|
Primary caregiver during hospitalization
|
Husband
|
166(23.5)
|
60(36.1)
|
106(63.9)
|
0.760
|
0.684#
|
The husband and grandparents
|
532(75.2)
|
179(33.6)
|
353(66.4)
|
|
|
Yuesao or others
|
9(1.3)
|
4(44.4)
|
5(55.6)
|
|
|
Types of delivery hospital*
|
Maternal and Child Health (MCH) hospital
|
350(49.5)
|
140(40.0)
|
210(60.0)
|
97.38
|
0.002#
|
General hospital
|
357(50.5)
|
103(28.9)
|
254(71.1)
|
|
|
Breast or nipple pain
|
Yes
|
180(25.4)
|
71(39.4)
|
109(60.6)
|
2.756
|
0.102a
|
No
|
527(74.5)
|
172(32.6)
|
355(67.4)
|
|
|
Started breastfeeding on*
|
On parturition day
|
210 (29.7)
|
122(58.1)
|
88(41.9)
|
85.373
|
<0.001#
|
First day after birth
|
103(14.6)
|
32(31.1)
|
71(68.9)
|
|
|
Second day after birth
|
76(10.7)
|
26(34.2)
|
50(65.8)
|
|
|
Third day after birth
|
104(14.7)
|
27(26.0)
|
77(74.0)
|
|
|
Food feeding before BF*
|
No food
|
221(31.4)
|
128(57.9)
|
93(42.1)
|
79.031
|
<0.001a
|
Milk powder and other food
|
482(68.6)
|
115(23.7)
|
371(76.3)
|
|
|
Nipple status
|
Normal
|
612(86.6)
|
219(35.8)
|
393(64.2)
|
4.273
|
0.118#
|
Flat
|
59(8.3)
|
16(27.1)
|
43(72.9)
|
|
|
Sunk
|
36(5.1)
|
8(22.2)
|
28(77.8)
|
|
|
Maternal mood after delivery
|
Calm
|
664(93.9)
|
229(34.5)
|
435(65.5)
|
0.809
|
0.667#
|
Anxious
|
30(4.2)
|
11(36.7)
|
19(63.3)
|
|
|
Irritable
|
13(1.8)
|
3(23.1)
|
10(76.9)
|
|
|
Admission to infant intensive care
|
No
|
577(81.6)
|
189(32.8)
|
388(67.2)
|
3.628
|
0.057a
|
Yes
|
130(18.4)
|
54(41.5)
|
76(58.5)
|
|
|
Score of BF supportive services received during hospitalization*
|
<8 scores
|
271(38.3)
|
57(21.0)
|
214(79.0)
|
34.654
|
<0.001a
|
≥ 8 scores
|
436(61.7)
|
186(42.7)
|
250(57.3)
|
|
|
aBy Pearson’s c2 test. #By Mantel–Haenszel c2 test. * Significant difference.
Table 1 showed the factors associated with EBF at hospital discharge. Using the Chi-square (χ2) test, it was found that primiparous mothers, childbirth in MCH hospitals, earlier lactation time, not feeding of liquid or milk formula before BF initiation, and higher score of BF supportive services during hospitalization were significantly associated with a higher incidence of EBF at hospital discharge.
Table 2 presented status of postnatal BF supportive services provided by hospitals. Only 24.5% of mothers had early sucking and 43.1% of mothers had SSC within 1 hour after birth. Among the 12 BF service items, four supportive services, including rooming-in, providing BF information by doctors, providing BF information by nurses, and no recommendation of infant formula achieved above 90% coverage. The Chi-square (χ2) test showed significant difference between MCH hospitals and general hospitals on BF supportive services. MCH hospitals consistently performed better in early sucking and SSC within 1 hour after birth, no bottle use before BF initiation, rooming-in practice, information provision on BF, restriction on the use of breast milk substitute during hospitalization, encouragement of BF on demand, recommendation of infant formula, BF guidance and human milk as the primary food after birth (p < 0.05).
Table 2 The twelve BF supportive services provided by Maternal and Child Health Hospitals and general hospitals
Items
|
MCH hospital
|
General hospital
|
Total, n(%)
|
c2
|
P value
|
1. Early sucking within 1 hour after delivery*
|
Yes
|
105(30.0)
|
68(19.0)
|
173(24.5)
|
11.47
|
0.001a
|
No
|
245(70.0)
|
289(81.0)
|
534(75.5)
|
|
|
2. Skin-to-skin contact (SSC) within 1 hour after delivery*
|
Yes
|
190(54.3)
|
115(32.2)
|
305(43.1)
|
35.10
|
<0.001a
|
No
|
160(45.7)
|
242(67.8)
|
402(56.9)
|
|
|
3. Limitation of bottle use before BF initiation*
|
Yes
|
302(86.3)
|
244(68.3)
|
546(77.2)
|
32.33
|
<0.001a
|
No
|
48(13.7)
|
113(31.7)
|
161(22.8)
|
|
|
4. Rooming-in*
|
Yes
|
332(94.9)
|
322(90.2)
|
654(92.5)
|
5.53
|
0.022a
|
No
|
18(5.1)
|
35(9.8)
|
53(7.5)
|
|
|
5. Information provision about BF by doctors
|
Yes
|
321(91.7)
|
325(91.0)
|
646(91.4)
|
0.103
|
0.79a
|
No
|
29(8.3)
|
32(9.0)
|
61(8.6)
|
|
|
6. Information provision about BF by nurses*
|
Yes
|
333(95.1)
|
324(90.8)
|
657(92.9)
|
5.17
|
0.027a
|
No
|
17(4.9)
|
33(9.2)
|
50(7.1)
|
|
|
7. Advice on no use of bottle by health staff
|
Yes
|
213(60.9)
|
192(53.8)
|
405(57.3)
|
3.62
|
0.58a
|
No
|
137(39.1)
|
165(46.2)
|
302(42.7)
|
|
|
8. No use of breast milk substitute during hospitalization*
|
Yes
|
199(56.9)
|
174(48.7)
|
373(52.8)
|
4.67
|
0.035a
|
No
|
151(43.1)
|
183(51.3)
|
334(47.2)
|
|
|
9. No food or fluids other than breast milk, unless medically indicated*.
|
Yes
|
253(72.3)
|
108(30.3)
|
361(51.1)
|
124.95
|
<0.001a
|
No
|
97(27.7)
|
249(69.7)
|
346(48.9)
|
|
|
10. No recommendation of infant formula*
|
Yes
|
347(99.1)
|
333(93.3)
|
680(96.2)
|
16.55
|
<0.001a
|
No
|
3(0.9)
|
24(6.7)
|
27(3.8)
|
|
|
11. Encouragement of breastfeed on demand*
|
Yes
|
210(60)
|
243(68.3)
|
453(64.2)
|
5.24
|
0.023a
|
No
|
140(40)
|
113(31.7)
|
253(35.8)
|
|
|
12. Specific BF guidance (such as feeding posture and expressing) *
|
Yes
|
288(82.3)
|
237(66.4)
|
525(74.3)
|
12.37
|
<0.001a
|
No
|
62(17.7)
|
120(33.6)
|
182(25.7)
|
|
|
Score of 12 BF supportive services during hospitalization*
|
< 8 scores
|
98(36.2)
|
173(63.8)
|
271(38.3)
|
31.30
|
<0.001a
|
≥ 8 scores
|
252(57.8)
|
184(42.2)
|
436(61.7)
|
|
|
aBy Pearson’s c2 test. #By Mantel–Haenszel c2 test. * Significant difference.
After controlling for confounding factors of mother’s age and education, family monthly income per capita, intended time returning back to work, alcohol intake, maternity insurance, family structure, receiving specific BF guidance (such as feeding posture and expressing) in the maternity school, mode of delivery, parity, gender of the newborn, newborns’ primary caregiver during hospitalization, maternal nipple status, maternal mood, and admission to infant intensive care, the multiple binary logistic regression analysis showed that BF supportive services provided by hospitals had significantly positive association with EBF at discharge (Table 3). Mothers who received more BF supportive services (≥8 score) during hospitalization were three times more likely to have EBF practice at the time of discharge, compared with mothers who received less BF supportive services (<8 score) during hospitalization (aOR: 3.00; 95% CI: 2.08, 4.35; p<0.001).
Table 3 The multiple binary logistic regression of association between BF supportive services during hospitalization and EBF at hospital discharge
Variable
|
Crude OR
|
Adjusted ORa
|
95%CI
|
P value
|
Score of BF supportive services received during hospitalization
|
Higher (≥8)
|
2.79
|
3.00
|
2.08-4.35
|
<0.001#
|
Lower (˂8)
|
1
|
1
|
|
|
# Significant difference. aAdjusted for confounding factors of mother’s age and education, family monthly income per capita, intended time returning back to work, alcohol consumption, maternity insurance, family structure, receiving specific BF guidance (such as feeding posture and expressing) in the maternity school, mode of delivery, parity, gender of the offspring, offspring’s primary caregiver during hospitalization, maternal nipple status, maternal mood, and admission to infant intensive care.