This is the first study to describe prevalence of breastfeeding practices among rural-to-urban migrants and examine the association between them. Based on a large, population-based sampling survey, the findings in this article are highly reliable and meaningful. In the present study, the prevalence of breastfeeding practices was not optimal to meet the goal by 2020. The rural-to-urban migration was only inversely related to EBF among those with high education level, living in metropolis and being minority, after adjusting for other covariates.
Association between breastfeeding practices and rural-to-urban migration
In the present study, we found that prevalence of the four breastfeeding practices (ever BF, EBF, predominant BF and age-appropriate BF) in rural-to-urban migrants was slightly, but not significantly lower than that of local population. This is more optimal than our expectations. Rural-to-urban migrants are more vulnerable to health-related issues because most health services and policies are registration-related in China, making those migrants inconvenient to have access to them. However, breastfeeding is different from those traditional health issues. It also takes consideration of self-efficacy and social environment. Some studies concluded that maternal education was a strong indicator for breastfeeding practices(22). We found no difference in maternal education between the two group of participants, which could reduce the difference in breastfeeding practices between them. Baby-friendly hospital practices may also help the establishment of breastfeeding(23), particularly giving only breast milk in the hospital(24). As the new Medicare Reform involved more registration-inconsistent people, rural-to-urban migrants can have similar, even the same access to hospital services like local citizens, resulting in similar prevalence of breastfeeding practices in the two groups.
After adjusting for other confounding variables, rural-to-urban migrant status was solely, significantly and robustly associated with EBF. This indicates the association between rural-to-urban migrant status and EBF may be modified by other variates. In another study conducted in 2013 in China, they examined the association between maternal migrant status and EBF and found it not significant(6). However, the definition of maternal migrant status was not described in the study and no further multivariate analysis was conducted between them. We found no other study discussing the association between rural-to-urban migrant status and breastfeeding practices in China.
Stratified by different social-demographic characteristics, we noticed some special, vulnerable groups which should be paid more attention to about EBF. Migrants with high education level gave less exclusive breastfeeding to their children than local mothers with the same diploma. However, such difference was not found within those with low education level. Overall, mothers with higher education level exclusively breastfed their children more than those who were educated less. According to the systematic review of Boccolini et al., the low education level was associated with the interruption of EBF(25). However, another systematic review of Zhao J et al. found that in the Chinese culture and employment environment, mother with higher education level were less likely to breastfeed their babies compared to those who were less educated(22). We presumed that in our study, mothers with higher education level are more likely to attend antenatal childbirth and breastfeeding classes and get right attitude towards infant formula milk(16). Among higher educated mothers, rural-to-urban migrant status became a risk factor for EBF and we presumed that it was caused by their working status and living places. Migrants are more likely to rent a house, rather than buying one, without enough space for breastfeeding, especially in suburb areas. Higher educated migrant mothers may have better jobs, equivalent to their diploma, in central areas and hire babysitters to looking after their children. As migrants, they may face more pressure than local citizens and have to work hard to avoid being fired and earn enough money for rental and baby caring. Thus, they may pay less attention to their children and don’t share enough time with them. The long distance between their rent house and working place also reduced their time for breastfeeding. Migrants with lower education level may just find jobs near their living place for convenience and most of them may be informal employed, which means they have less traffic time and face less pressure than higher educated ones. The low EBF rate of lower educated participants itself may also lighten the influence of rural-to-urban migration on EBF.
Place of residence is another factor that affects the association between rural-to-urban migration and EBF. Overall, living in metropolis rather than middle or small cities can promote EBF. Super cities, like capitals, can provide more health-related services, prenatal lessons and peer education to highlight the importance of EBF(26). In the subgroup of participants living in metropolis, rural-to-urban migrant children are less likely to be exclusively breastfed than local ones. The expense of living in metropolis is much higher for migrants and they are more common to have mental health problems than natives(27). When local citizens are surrounded by plenty resources of postpartum and neonatal caring, the migrants may be facing heavy working load or traffic jam, resulting in less time for breastfeeding. High prevalence of postpartum mental health problems in migrants can also deter the execution of EBF(28). However, the difference of EBF rate between rural-to-urban migrants and local people living in middle or small cities is slight but not significant. The scale of the cities is not as big as metropolis and the traffic congestion is not so severe, so these migrants waste less time in commuting and have enough time for breastfeeding. Also, migrants living in middle or small cities face less stress of living and working than those in big cities and they are less vulnerable to postpartum mental health problems.
The lower prevalence of EBF in rural-to-urban migrants was solely apparent in those ethnic minorities. This result is consistent with previous findings. Aguilar Ortega et al.(14) found that Chinese born immigrant women showed lower prevalence of EBF (36.4%) compared to native Spanish women (80%). Another study conducted in Hong Kong concluded that breastfeeding duration was progressively shorter when the immigrant time increased(16). Acculturation to the dominant Han culture of not favoring breastfeeding, which happened among migrants, might reduce the prevalence of EBF. We postulated that migrants were likely to abandon their traditional breastfeeding practice and adopt Han’s disfavor of breastfeeding. Local minority citizens are more likely to live in ethnic communities and maintain their traditional breastfeeding habits. However, it might be hard for minority migrants to fit into such ethnic communities, resulting in loss of their traditional breastfeeding practices.
There are still some limitations in our study. First, we didn’t consider the original registration place for floating population specifically. Where they are from may largely affect their employment status, then make difference to their practice of breastfeeding. Second, causal effect between rural-to-urban migrant status and EBF was difficult to examine because of the nature of cross-sectional study. Further perspective study is needed to clarify the causal relationship. Third, the prevalence of breastfeeding practices was calculated based on a “24-hour recall method”, which could overestimate the prevalence and cause recall bias.