Demographic characteristics of the participants
From 1st August to 31st October 2020, 2233 mothers completed the questionnaire. All participants were married. At the time of survey completion, mean maternal age was 31.4 ± 4.1 years, and mean infant age 8.2 ± 4.0 months (range 1–18 months). The background characteristics are shown in Table 1. There were 992 (44.4%) and 1241 (55.6%) mothers who gave birth during the lockdown (DL) and before the lockdown (BL), respectively. Maternal education and infant gestation did not differ between the BL and DL groups. Infant age was higher as expected in BL (10.8 ± 3.1 months) than in DL (5.0 ± 2.3 months). The BL group contained more male infants (52.5%) than the DL group (48.2%). Mothers in the BL group were also older than those in the DL group (31.7 ± 4.1 years vs. 31.2 ± 4.0 years) and more were in the lowest category for education and household income compared to the DL group.
Table 1
Background characteristics of mothers who completed the survey (mean ± SD / n(%)).
| | Baby born before lockdown | Baby born during lockdown |
| | (n = 1241) | (n = 992) |
Maternal age (years) * | | 31.7 ± 4.1 | 31.2 ± 4.0 |
Total years of maternal full-time education * | | 15.32 ± 2.6 | 15.58 ± 2.5 |
Maternal education | | | |
| Diploma or under | 533 (43.4) | 394 (40.3) |
| Bachelor’s degree | 507 (41.3) | 422 (43.1) |
| Master’s degree | 169 (13.8) | 149 (15.2) |
| PhD/professional qualification | 18 (1.5) | 13 (1.3) |
Household income in CNY * | | | |
| < 20,000 | 433(35.1) | 305 (31.1) |
| < 30,000 | 267 (21.7) | 272 (27.7) |
| < 40,000 | 168 (13.6) | 123 (12.5) |
| < 50,000 | 67 (5.4) | 37 (3.8) |
| > 50,000 | 33 (2.7) | 34 (3.5) |
| Other | 18 (1.5) | 4 (0.4) |
| Prefer not to say | 246 (20) | 206 (21) |
Maternal social class * | | | |
| IV & V | 364 (30.9) | 248 (26.3) |
| III | 377 (32.0) | 351 (37.3) |
| I & II | 436 (37.0) | 343 (36.4) |
Infant age (months) * | | 10.8 ± 3.1 | 5.0 ± 2.3 |
Infant gestation (weeks) | | 38.8 ± 1.5 | 38.8 ± 1.4 |
Infant gender * | | | |
| Male | 651 (52.5) | 477 (48.2) |
| Female | 588 (47.5) | 513 (51.8) |
Other children in household | | 456 (37.0) | 387 (39.4) |
Living status during the lockdown * | | | |
| With husband | 410 (33.5) | 390 (40.4) |
| With husband & parents | 315 (25.7) | 247 (25.5) |
| With husband & parents-in-law | 485 (39.6) | 320 (33.1) |
| Alone | 9 (0.7) | 8 (0.8) |
| Other | 5 (0.4) | 2 (0.2) |
Current accommodation * | | | |
| Bungalow | 5 (0.5) | 14 (1.5) |
| T-apartment without gardena | 112 (10.1) | 174 (18.7) |
| T-apartment with garden | 259 (23.4) | 218 (23.4) |
| B-apartment without gardenb | 164 (14.8) | 113 (12.2) |
| B-apartment with garden | 542 (48.9) | 397 (42.7) |
| Villa | 26 (2.3) | 14 (1.5) |
Notes: * P < 0.05. SD = standard deviation |
a T-apartment is a type of apartment building with around ten residents living on each floor. |
b B-apartment is a type of apartment with less than three residents living on each floor. |
Birth experiences and daily life
For DL and BL mothers, 64.3% and 60.4% were vaginally delivered and the post-birth skin-to-skin contact was 97.1% and 96.3% respectively; with no significant differences between groups. Over 90% of the women delivered at a national hospital, although 13.2% of DL mums reported the delivery place had been altered. Notably, over half of women in the DL group considered COVID-19 to have had a moderate-to-high impact on their household income (53.9%) and on the convenience of purchasing daily necessities (50.7%), compared to 50% and 44.1% in the BL group (Table 2).
Table 2
Birth experience and daily life during lockdown of women who completed the survey, according to whether they delivered before or during the lockdown (n (%))
| | Baby born before lockdown | Baby born during lockdown |
| | n = 1241 | n = 992 |
Mode of delivery | | | |
| Vaginal | 746 (60.4) | 637 (64.3) |
| Vaginal induced | 38 (3.1) | 41 (4.1) |
| Planned caesarean | 304 (24.6) | 215 (21.7) |
| Emergency caesarean | 148 (12.0) | 98 (9.9) |
Birth location | | | |
| National hospital | 1186 (95.6) | 938 (94.7) |
| Private hospital | 50 (4.0) | 53 (5.3) |
| Oversea hospital | 3 (0.2) | 0 (0) |
| Home | 1 (0.1) | 0 (0) |
COVID impact on birth location * | | | |
| Yes | 58 (4.7) | 128 (13.2) |
| No | 1171 (95.3) | 845 (86.8) |
Skin-to-skin contact after delivery | | 1194 (96.3) | 960 (97.1) |
COVID impact on household income * | | | |
| Great | 146 (11.8) | 140 (14.3) |
| Moderate | 471 (38.2) | 389 (39.6) |
| Little | 299 (24.2) | 224 (22.8) |
| No | 318 (25.8) | 229 (23.3) |
COVID impact on purchasing daily necessities * | | | |
| Great | 107 (8.7) | 126 (12.8) |
| Moderate | 435 (35.4) | 372 (37.9) |
| Little | 379 (30.8) | 275 (28.0) |
| No | 309 (25.1) | 209 (21.3) |
Note: * P < 0.05 |
Infant feeding during the lockdown
Infant feeding intentions did not differ between DL and BL groups (Table 3). Among DL women, 32.6% reported a moderate-to-high impact of COVID-19 on their infant feeding practice, compared to 24.2% in the BL group (, Table 3). Besides, 25.9% of mothers in the BL group with a feeding goal of EBF before delivery had changed to formula or mixed feeding after birth, compared to 17.8% in DL mothers (Fig. 1). In the DL group, significantly more mothers reported 6-month MBF compared to the BL mothers (71.6% vs. 60.6%). As expected, given the younger age of the infants of DL mothers, a significantly higher proportion were MBF (52.8%) or fed a combination of breast milk and infant formula (11.5%) at the time of completing the questionnaire, while a greater proportion of older infants born BL also consumed solid foods (Table 3).
Table 3
Infant feeding practice of women who completed the survey, according to whether they delivered before or during the lockdown (n (%)).
| | Baby born before lockdown | Baby born during lockdown |
| | n = 1241 | n = 992 |
Feeding intention before delivery | | | |
| Exclusive breastfeeding | 1020 (82.7) | 851 (85.8) |
| Formula feeding | 32 (2.6) | 22 (2.2) |
| Mixed feeding | 122 (9.9) | 76 (7.7) |
| No plans | 60 (4.9) | 43 (4.3) |
Infant feeding at 6-month * | | | |
| Mostly breastfeeding | 748 (60.6) | 708 (71.6) |
| Formula feeding | 81 (6.6) | 53 (5.4) |
| Mixed feeding | 405 (32.8) | 228 (23.1) |
Change in feeding intention and actual feeding at 6-month * | | | |
| 1 Yes, change | 372 (30.0) | 212 (21.4) |
| 0 No change | 868 (70.0) | 780 (78.6) |
Current infant feeding * | | | |
| Mostly breastfeeding | 88 (7.1) | 523 (52.8) |
| Breastfeeding + solids | 399 (32.2) | 156 (15.7) |
| Formula feeding | 38 (3.1) | 32 (3.2) |
| Formula feeding plus solid | 266 (21.5) | 46 (4.6) |
| Mixed milk feeding | 46 (3.7) | 114 (11.5) |
| Mixed feeding plus solids | 403 (32.5) | 120 (12.1) |
COVID impact on infant feeding * | | | |
| Great | 66 (5.3) | 77 (7.9) |
| Moderate | 233 (18.9) | 242 (24.7) |
| Little | 248 (20.1) | 165 (16.9) |
| No | 688 (55.7) | 495 (50.6) |
Note: *P < 0.05 |
Infant feeding support during the lockdown
The main reported sources of infant feeding support (‘Where do you get support with infant feeding?’) were the partner (66.2%), followed by parents (55.1%), and parents-in-law (45.7%), health professionals (41.9%), breastfeeding support groups (30.9%), friends and family (25.8%), and online support (16.3%). A significantly higher proportion of DL mothers reported having received support from their partner compared to the BL group, whilst a larger proportion of BL mothers received support from health professional, friends and relatives, online support sources or reported no support during the pandemic (Table 4).
Table 4
Sources of infant feeding support of women who completed the survey, according to whether they delivered before or during the lockdown (n (%))
| | Baby born before lockdown | Baby born during lockdown |
| | n = 1241 | n = 992 |
Who supports infant feeding? (multiple choices allowed) | | | |
| Partner * | 782 (63.7) | 697 (70.8) |
| Parent | 696 (56.7) | 534 (54.3) |
| Parent In-laws | 560 (45.6) | 461 (46.8) |
| Health professional * | 558 (45.4) | 377 (38.3) |
| Friend/relative * | 362 (29.5) | 213 (21.6) |
| Breastfeeding group | 389 (31.7) | 302 (30.7) |
| Online support * | 244 (19.9) | 121 (12.3) |
| Other | 14 (1.1) | 4 (0.4) |
| No support * | 39 (3.2) | 17 (1.7) |
Contact with a health professional (per week) * | | | |
| Never | 761 (62.2) | 569 (58.0) |
| 1–3 times | 374 (30.6) | 325 (33.1) |
| 4–5 times | 30 (2.5) | 51 (5.2) |
| Daily or more | 58 (4.7) | 36 (3.7) |
Chat in a breastfeeding support group (per week) | | | |
| Never | 545 (44.5) | 395 (40.2) |
| 1–3 times | 478 (39.1) | 416 (42.3) |
| 4–5 times | 93 (7.6) | 75 (7.6) |
| Daily or more | 108 (8.8) | 97 (9.9) |
Received enough help with BF from professionals * | | | |
| Yes | 1180 (95.3) | 965 (97.7) |
| No | 58 (4.7) | 23 (2.3) |
Received enough help with BF from family * | | | |
| Yes | 1174 (94.8) | 960 (97.2) |
| No | 64 (5.2) | 28 (2.8) |
Enough support with own health | | | |
| Yes | 1057 (90.5) | 863 (92.4) |
| No | 111 (9.5) | 71 (7.6) |
Notes: * P < 0.05. For multiple choices question, we compared each choice for DL & BL using the Chi-square. For single choice question we used the Chi-square and Mann-Whitney test for all categories. |
No difference was found between BL and DL mothers regarding the frequency of participating in a breastfeeding support group. Significantly more DL women reported having contacted health professionals more than four times a week (8.9%), compared to those from the BL group (7.2%). Of the mothers who had contacted health professionals, 97.7% thought they had obtained enough help with breastfeeding in the DL group, which was significantly higher than BL mothers (95.3%). Moreover, more mothers in the DL group reported receiving sufficient help from family, compared to BL mothers (97.2% vs. 94.8%), suggesting that mothers who had given birth during the pandemic may have received more support than those who had given birth before.
Predictors of infant feeding during the first 6-months
Logistic regression was performed based on the DAG (EFigure 1), including 1231 BL and 576 DL mothers who were feeding an infant ≥ 6 months at the time of completion of the questionnaire. MBF during the first 6 months was positively predicted by delivery DL versus BL (OR1.42, 95%CI 1.06, 1.90). Positive predictors of MBF (Table 5) also included younger maternal age, infant feeding discussion in a support group more than four times a week, and receiving support from friends or relatives. Moreover, relative to those little affected by COVID, those who were much affected were less likely to MBF.
Table 5
Multivariable logistic regression for determinants of whether or not MBF for the first 6 months (subgroup those infant age 6 + months)
| | N = 1807 (DL = 1231, BL = 576) |
| | Nagelkerke R = 0.079 |
| | | | 95% CI |
| | Sig. | OR | Lower | Upper |
Infant born before/during lockdown? | | | | | |
| born before lockdown | ref | ref | ref | ref |
| born during lockdown | 0.017 | 1.42 | 1.06 | 1.90 |
Maternal age (years) | | 0.003 | 0.95 | 0.92 | 0.98 |
Total years of maternal full-time education | | 0.612 | 1.02 | 0.96 | 1.08 |
Household annual income in CNY | | | | | |
| < 200,000 | ref | ref | ref | ref |
| 200,000-300,000 | 0.715 | 0.94 | 0.68 | 1.30 |
| > 300,000 | 0.076 | 1.39 | 0.97 | 1.99 |
Maternal social class a | | | | | |
| IV & V | ref | ref | ref | ref |
| III | 0.609 | 1.10 | 0.77 | 1.56 |
| I & II | 0.13 | 0.77 | 0.55 | 1.08 |
Infant gender | | | | | |
| boy | ref | ref | ref | ref |
| girl | 0.444 | 1.11 | 0.85 | 1.43 |
Infant gestation (weeks) | | 0.283 | 1.05 | 0.96 | 1.14 |
No. of children in the household | | | | | |
| more than one child | ref | ref | ref | ref |
| only one child | 0.212 | 0.83 | 0.63 | 1.11 |
Co-habitation with family members | | | | | |
| alone/with husband | ref | ref | ref | ref |
| living with husband & (in-law) parents | 0.543 | 0.92 | 0.70 | 1.21 |
Building living | | | | | |
| T apartment without garden | ref | ref | ref | ref |
| T apartment with garden b | 0.23 | 1.33 | 0.84 | 2.10 |
| B apartment no garden c | 0.955 | 0.99 | 0.61 | 1.60 |
| B apartment with garden | 0.164 | 0.75 | 0.50 | 1.12 |
| Villa with garden | 0.974 | 0.98 | 0.33 | 2.90 |
Mode of delivery | | | | | |
| Vaginal | ref | ref | ref | ref |
| Caesarean | 0.247 | 0.85 | 0.64 | 1.12 |
Contact with a health professional (per week) | | | | | |
| Never | ref | ref | ref | ref |
| 1–3 times/week | 0.803 | 1.04 | 0.76 | 1.42 |
| 4 + times/week | 0.596 | 1.16 | 0.66 | 2.04 |
Discuss health issues in mothers' group online | | | | | |
| Never | ref | ref | ref | ref |
| 1–3 times/week | 0.178 | 1.24 | 0.91 | 1.69 |
| 4 + times/week | 0.032 | 1.60 | 1.04 | 2.46 |
Enough support with own health? | | | | | |
| not enough | ref | ref | ref | ref |
| enough | 0.208 | 1.35 | 0.85 | 2.15 |
Enough infant feeding support? | | | | | |
| not enough | ref | ref | ref | ref |
| enough | 0.207 | 1.64 | 0.76 | 3.54 |
whether had support from families/friends after birth | | | | | |
| No | ref | ref | ref | ref |
| Yes | 0.036 | 1.95 | 1.04 | 3.65 |
whether COVID impacted birth | | | | | |
| Moderate-great impact | ref | ref | ref | ref |
| Little or no impact | 0.04 | 1.80 | 1.03 | 3.16 |
COVID impact on purchasing daily necessities | | | | | |
| Moderate-great impact | ref | ref | ref | ref |
| Little or no impact | 0.07 | 0.78 | 0.59 | 1.02 |
Notes: MBF = Mostly breastfeeding; CI = confidence interval; DL = mothers who delivered during the lockdown; BL = mothers who delivered before the lockdown. Factors controlled for included maternal socio-economic status (education, income, social class), living conditions, cohabitation with family members (“Who did you live with during the lockdown?”), gestational age, health advice-seeking behaviour (“Frequency of discussing with health professionals/chatting in breastfeeding support group”), support (“Did you receive enough support from health professionals/family members?”), and the impact of the COVID-19 lockdown on maternal daily life. |
a Class IV&V mainly refer to manual labor jobs which don't require high education experience; Jobs in class III & II require certain training, certifications, licenses and degree to qualify; Jobs in class I involve professional careers which require advanced degree, high-end skills or expertise. |
b T-apartment is a type of apartment building with around ten residents live in each floor. |
c B-apartment is a type of apartment with less than three residents live in each floor. |
Comments
Summary of the results
Our findings show that, despite the difficulties imposed by the pandemic, hospital facilities in Beijing continued to implement measures based on WHO guidelines [8, 16, 17]. Current evidence and clinical experience confirms the safety of breastfeeding for mothers with confirmed or suspected COVID-19 [18–20] and the CDC of China have modified the relevant guidelines from initially not recommending breastfeeding for women with suspected or confirmed COVID-19 to currently recommending that breast-feeding mothers in isolation for COVID-19 can continue breastfeeding if they follow protective measure to reduce the risk of droplet transmission [11]
Infant feeding practice and support
60.6% and 71.6% mothers in the BL and DL group chose EBF for the question “what is the source of milk you used for feeding for the first six months after birth?”, which is significantly higher than the EBF rate reported in previous studies in China [21]. This may reflect differences in the definition of EBF used in different studies. We did not provide a specific definition of EBF and, whilst nurses were available to help mothers if they had any queries, some mothers may not have asked for clarification. Furthermore, the question in the survey referred to milk feeding but did not specifically ask about the use of complementary foods before 6 months. For these reasons, we renamed the EBF variable as ‘mostly breastfeeding (MBF)’ – to reflect the infant’s main source of milk during the first 6 months. The high rate for MBF during the first 6 months is also likely to reflect the inclusion criteria for the study which specified that participants must have breastfed their infant during the lockdown. Rates of EBF vary across provinces and cities in China. According to the data published in 2013, the EBF rate for 14539 children from 30 provinces in China was 20.8% [22], whilst a large cohort study conducted in Zhejiang province involving 42,550 children reported a 3-to 5 month EBF rate of 51.3% for girls and 46.8% for boys [21]. However, in that cohort, EBF ≥ 6 months was defined as self-reported EBF at each of the 3 clinical visits (1, 3, and 6 months), thus the EBF rate may have been over-estimated. In another cohort study in Zhejiang in 2005, 74% of 1520 mothers reported “any breastfeeding” defined as the infant has received breastmilk (direct from the breast or expressed) with or without other drinks, formula, or infant food at 6 months. Zhejiang is an eastern coastal province in China, where health care facilities and baby-friendly hospitals are well-developed, and, compared to Zhejiang, the development of baby-friendly hospitals is even better in Beijing. As reported by Beijing Municipal Health Commission [23], in 2019, there were 114 baby-friendly hospitals in Beijing, where most of our participants were recruited. A Chinese review showed that after the baby friendly hospital initiative became established in 1992, the 4-month EBF rate (EBF was not defined in the methodology) increased from 28–40% [24]; a retrospective study reported the same trend with an increase in the 4-month EBF rate in Beijing from 16.77% in 1991–1994 to 58.77% in 1995–1998 [25]. While more recent data are need to confirm this finding, it supports the importance of baby friendly hospitals in supporting EBF.
Interestingly, the findings show that a significantly lower proportion of DL mothers changed their initial feeding goal from EBF to formula/mixed feeding compared to BL mothers (18% vs. 26%), suggesting that the lockdown measures may have indirectly promoted breastfeeding, perhaps by allowing mothers to spend more time with their babies, or feeling less pressure due to fewer visitors during the lockdown [26]. A similar finding was reported in the COVID-19 New Mum Study in the UK [27], where 13% of women reported changes to feeding method due to the lockdown; a higher frequency and longer duration of breastfeeding was observed in 30% and 17% women who were breastfeeding during the pandemic, reflecting more time spent at home as well as a greater contribution to childcare from themselves and partners during the lockdown period. However, as suggested by the researchers, the effects of the pandemic on infant feeding may differ depending on access to support and special circumstances experienced by individual mothers. Indeed, our results suggest that DL mothers received significantly more infant feeding support than BL mothers. As suggested by the literature, both peer and professional support are important for the success of breastfeeding [28].
Research on breastfeeding support has consistently identified the husband or partner as an important source of support for women, with influence on four aspects in particular: breastfeeding decisions, assistance at first feeding, assistance during breastfeeding, and risk factors for bottle feeding [29]. Our study found that women from both groups considered their partner as the greatest source of support for infant feeding, consistent with the UK New Mum study [27]. Compared to BL mothers, DL mothers received even more support from their partners, possibly reflecting the “work from home” measures in place during the lockdown, which increased the time husbands could spend with their wives. As suggested by Vazquez et al [27], husbands who contribute more to childcare during this exceptional period may represent a valuable source of support for women, especially for those with limited access to friends or relatives who would provide this support under normal circumstances.
According to Chinese tradition, mothers normally adhere to a month long “confinement period” after birth. Although an increasing number of mothers use a confinement centre where they can receive care and professional support, most centres were closed during the lockdown period; this may have led to differences in the confinement experience for mothers in the DL and BL groups. However, a recent study found that the 1- and 6-month EBF rate did not differ between mothers who chose a confinement centre and mothers who stayed at home (37% vs. 42%, p = 0.5) [30]. Whilst more studies are needed to confirm this finding, we suggest that mothers in the DL group may have received more support from their partner, so the total support received by the DL and BL mothers might have been the same.
Predictors of infant feeding during the lockdown
Mothers who delivered during the lockdown were more likely to mostly breastfeed their infant during the first six months. This may reflect the increased time available for both mothers and their partners to spend with the infant and the breastfeeding support provided during the lockdown. Higher rates of MBF were also observed among mothers who delivered at a younger age. This result is consistent with a previous study in Zhejiang, China, which indicated that EBF was positively related to younger maternal age [31]. However, this contrasts with studies in many high-income countries which indicated that older maternal age was associated with a higher rate of breastfeeding initiation and the duration of EBF [32–34]. This may reflect social and cultural factors, and emphasizes the importance of considering these factors when developing health policy to promote breastfeeding. In recent years, EBF has become a “new fashion” in several modern cities in China, including Beijing, Shanghai, and some large cities in Zhejiang province, possibly reflecting the increasing number of Chinese female celebrities sharing their EBF experiences and healthy mother-infant relationships through vlogs or posts. Young women from these cities are keen to follow this new fashion and are very proud of themselves if they successfully EBF to 6 months. Additionally, our results suggest that discussing infant feeding in a feeding support group more than four times a week, getting support from friends or relatives, and considering that the COVID-19 pandemic had little or no impact on their planned birth location positively predicted MBF in the first 6-months, reflecting the vital role of infant feeding support and the normal operation of health care facilities in promoting breastfeeding for mothers.
Strengths and Limitations
To our knowledge, this is the first cross-sectional study investigating infant feeding practices and potential predictors of infant feeding during the COVID-19 pandemic in China. Using an adapted version of questionnaire that has been used in the COVID-19 New Mum Study [14, 27] in the UK makes the results comparable between countries. However, the study has some limitations. Firstly, although Beijing is a metropolitan city with 20 million residents from different regions of China [35], study participants are not representative of all new mothers in China; since the significant higher gross domestic product per capita in Beijing results in a higher level of family income and education of the population [36], which may partly explain the higher MBF rate in this study[37]. However, considering the duration of lockdown and the type of lockdown measures varied between provinces and cities in China, it was difficult to compare the infant feeding outcomes between cities even in a national survey. Secondly, there may be recall bias since at the time of survey completion lockdown measures had just ended in Beijing. Last but not least, we did not clearly define EBF in our questionnaire so; consequently, we relabeled this variable as ‘mostly breastfeeding’.