868156

research-article2019
JHLXXX10.1177/0890334419868156Journal of Human LactationFang et al.

Original Research
Journal of Human Lactation

The Patterns and Social Determinants

1­–12
© The Author(s) 2019
Article reuse guidelines:
of Breastfeeding in 12 Selected Regions sagepub.com/journals-permissions
DOI: 10.1177/0890334419868156
https://doi.org/10.1177/0890334419868156

in China: A Population-Based Cross- journals.sagepub.com/home/jhl

Sectional Study

Zhe Fang, BM1,4, Yuning Liu, MSc2, Hanyu Wang, BA3,

and Kun Tang, PhD4

Abstract
Background: With rapid industrialization and urbanization, there is a growing need for women to enter the workforce, and
affluent people are drawn to the infant formula market. The breastfeeding rates in China are below the optimal level. Large
scale quantitative research studying breastfeeding practices after 2015 in China are lacking.
Research aim: We aimed to (1) explore the latest patterns and (2) identify the determinants of breastfeeding in China.
Methods: The study was a population-based, cross-sectional survey. A multi-stage sampling technique was adopted for
the selection of participants. We recruited 10,408 mothers with children under 12 months old, in 12 regions of China, and
conducted a questionnaire survey about breastfeeding patterns. The associations between social and biophysical determinants
and breastfeeding outcomes were analyzed using a logistic regression model.
Results: The exclusive breastfeeding rate was 29.32% (n = 3,052) decreasing from 32.71% (n = 3,404) to 15.83% (n = 1,648)
among children aged 0–5 months. Cesarean section had a negative association with early breastfeeding initiation (OR = .33,
95% CI [.30, .36]), exclusive breastfeeding (OR = .78, 95% CI [.69, .89]), and predominant breastfeeding (OR = .73, 95% CI
[.65, .83]). Compared to participants with an annual household income lower than 40,000 Yuan ($5,817 USD), those with
over 100,000 Yuan ($14,542 USD) had an OR of .78 (95% CI [.67, .90]) in exclusive breastfeeding. Compared with illiterate
and unemployed groups, middle/high school education and a current work status, respectively, were associated with a lower
likelihood of exclusive breastfeeding (OR = .73, 95% CI [.63, .84]; OR = .58, 95% CI [.37, .89]).
Conclusions: The prevalence of breastfeeding in 12 selected regions in China was low and interventions focusing on the
targeted population should be strengthened.

Keywords
breastfeeding, breastfeeding practices, complementary feeding, feeding patterns

Background
Researchers have demonstrated diverse and compelling
advantages of breastfeeding for infants, mothers, families,
and society (Victora et al., 2016). Multilevel programs and
interventions have been put into action to improve breast-
feeding practices. Despite the initiatives, breastfeeding rates
are still far below the international target (World Health
Organizaton [WHO], 2017). Researchers previously esti-
mated that in low-income and middle-income countries, only
37% of children under 6 months were exclusively breastfed,
and the breastfeeding duration in more affluent countries was
generally shorter than in poor countries (Victora, et al.,
2016). The prevalence of breastfeeding in the industrialized
East Asia region was demonstrated to be below optimal
level. Researchers found that in Korea the exclusive breast-
feeding rate was only 11.4% (Chung, Kim, Choi, & Bae,
2013), and in Japan it was 55.9% (Patel, Bansal et al., 2015).
In a population-based survey in Hong Kong, the prevalence
of early initiation was 67.0% (Wang, Lau, Chow, & Chan,
2014). In the relatively poor South Asia region, there were
1
School of Public Health, Peking University Health Science Centre, Beijing,
China
2
Department of Global Health and Population, Harvard T. H. Chan School
of Public Health, Harvard University, Boston, MA, USA
3
Institute for Medical Humanities, Peking University Health Science
Centre, Beijing, China
4
Research Center for Public Health, Tsinghua University, Beijing, China
Date submitted: October 29, 2018; Date accepted: July 17, 2019.
Corresponding Author:
Kun Tang, PhD, Research Center for Public Health, Tsinghua University,
Haidian District, Beijing 100191, China.
Email: tangk@mail.tsinghua.edu.cn
2 Journal of Human Lactation 00(0)
positive trends in breastfeeding practices but disparities
existed in different countries and socioeconomic groups
(Benedict, Craig, Torlesse, & Stoltzfus, 2018). In a cross-
sectional study conducted in 55 counties of 30 provinces in
China, ever breastfeeding prevalence was 79.6%, and only
20.8% of 14,539 children surveyed were exclusively breast-
fed for 6 months (Yang et al., 2016).
Except for very few with severely limiting medical disor-
ders, almost all women are biologically capable of breast-
feeding (American Academy of Pediatrics, 2018). However,
breastfeeding practices are not merely biological issues, but
are influenced by multifactorial determinants, including his-
torical, socioeconomic, cultural, and individual factors (Lou
et al., 2014; Zhou, Yu, & Qian, 2018). In China, breastfeed-
ing practices face unique challenges, due to the country’s
enormous population, political system, and historical con-
cepts regarding breastfeeding. Regulations and legislation
targeting infant formula are not well-formed in China, which
is also a challenge for breastfeeding practices (Kent, 2015).
Researchers who have conducted population-based
studies in China have mainly focused on rates of breast-
feeding, use of infant formula, and the nutrition status of
infants (Duan et al., 2018; Yang et al., 2016). Studies
regarding social determinants of breastfeeding are mostly
qualitative or community-based quantitative studies (Lou
et al., 2014; Zhao, Zhao, Du, Binns, & Lee, 2017; Zhou
et al., 2018). A recent study, based on a national-level sur-
vey in China involving 12 regions, explored the social
determinants of breastfeeding. However, the survey
focused on family health rather than breastfeeding, and the
small sample size in the study was a limitation to conduct-
ing further analysis (Chen, Cheng, & Pan, 2017). Similar
breastfeeding surveys in Asian regions have similar prob-
lems, including ignoring the social determinants (Benedict
et al., 2018; Chung et al., 2013; Patel et al., 2015; Wang
et al., 2014), being outdated (Chung et al., 2013; Patel
et al., 2015; Wang et al., 2014), or having a non-represen-
tative sample (Patal, Bansal et al., 2015). Thus, an updated
breastfeeding survey regarding the social determinants of
breastfeeding in China could narrow the research gap in
China and in Asia more generally. We aimed to (1) explore
the latest patterns and (2) identify the determinants of
breastfeeding in Chinese populations.
Methods
Design
Our study was a population-based, cross-sectional survey.
Cross-sectional studies estimate the distribution of a variable
at a point in time, which can be used to study the prevalence or
risk factor at a relatively low cost compared to case-control
and cohort studies (Satten & Grummer-Strawn, 2014). It was
the appropriate study design to investigate current breastfeed-
ing patterns. Institutional Review Board approval was obtained
from the China Centre for Disease Control and Prevention.
Key Messages
• Only 29.32% (n = 3,052) of study participants in
the 12 selected regions exclusively breastfed their
infants for 6 months.
• The three leading reasons participants reported
for discontinuing breastfeeding were insufficient
human milk supply, their belief that it was time to
discontinue breastfeeding, and returning to work
or school.
• Interventions that seek to promote breastfeeding
should focus on early weaning risk factors, includ-
ing culture, and socio-demographic and biophysi-
cal variables.
Setting
The study was conducted in 12 regions of China. Due to rapid
economic development in China, both the family income and
education level of citizens have increased remarkably. Women
have become an important part of the workforce for the
national economy. Moreover, China has become the largest
market for infant formula in the world (Tang, Binns, & Lee,
2015). That means mothers are more likely to be able to
afford human milk substitutes and are more likely to return to
work after delivery, which has a negative influence on exclu-
sive breastfeeding (Zhang, Jin, Vereijken, Stahl, & Jiang,
2015). Maternal and child care is primarily obstetrician-led.
Pregnant women are required to see an obstetrician every 4
weeks until 28 weeks of gestation, every 2 weeks until 36
weeks, and weekly until birth (Yang, Ip, & Gao, 2018). A
breastfeeding education session focusing on the benefits of
and skills for breastfeeding is offered freely to pregnant
women registered in the hospital. It is delivered by nurses and
generally lasts for approximately 1 hr. In the postnatal ward,
mothers get detailed guidance for breastfeeding practices,
including postures, nipple treatment, etc., given by obstetric
nurses. Certified lactation support providers in China are rare
and most of the care and education is delivered by nurses
(Yang et al., 2018). Smartphone-based online antenatal and
postnatal education is becoming more and more popular in
recent years (Ke, Ouyang, & Redding, 2018).
Sample
The target population was Chinese mothers whose children
were under 12 months. Women who had already delivered
their children and those with children under 12 months were
considered as possible participants. Only those who could
speak and read Chinese were considered. The exclusion cri-
teria included psychiatric disorders, inability to answer ques-
tions independently, and unavailability of informed consent.
Multi-stage stratified random sampling was used to select
participants. In the first stage, a population proportionate
sampling (PPS) method was applied based on socioeconomic
Fang et al. 3

Table 1. Definition of Breastfeeding Indicators.

Measurement Definition Citation

Early initiation of breastfeeding
Exclusive breastfeeding
Predominant breastfeeding
Ever breastfeeding
Current breastfeeding
Infants born in the last 12 months were put
to the breast within an hour of birth
Infants aged 0–5 months were fed exclusively
human milk
Infants aged 0–5 months were predominantly
breastfed: mainly comprised infants who
were fed by human milk and water
Infants born in the last 12 months who were
ever breastfed.
Any breastfeeding in the last 24 hr for infants
under 12 months
WHO. (2008). Indicators for assessing infant and
young child feeding practices: Conclusions of a
consensus meeting held 6–8 November 2007 in
Washington DC, USA: WHO.
Lung’aho et al. (1996). Tool kit for monitoring and
evaluating breastfeeding practices and programs.
Washington, DC: Wellstart International.
Lung’aho et al. (1996). Tool kit for monitoring and
evaluating breastfeeding practices and programs.
Washington, DC: Wellstart International.
WHO. (2008). Indicators for assessing infant and
young child feeding practices: Conclusions of a
consensus meeting held 6–8 November 2007 in
Washington DC, USA: WHO.
Lung’aho et al. (1996). Tool kit for monitoring and
evaluating breastfeeding practices and programs.
Washington, DC: Wellstart International.

development status, population structure, and maternal and
child health status. Participants in 12 regions were divided
into urban and rural types (four megacities, four medium-
sized cities, two countryside areas, and two poor rural areas),
two resident status groups (permanent resident and floating
population), and two age groups (0–5 months and 6–11
months). Because the floating population mainly gathered in
cities, migrant participants were surveyed only at urban sur-
vey points. In the second stage, one district or county was
chosen in each of the 12 regions using simple random sam-
pling methods. In the third stage, a simple sampling method
was implemented to select 4–8 communities or villages from
the chosen district or county in each of the 12 regions. In the
last stage, potentially eligible participants were selected and
invited by local community health workers or village doc-
tors. We took the prevalence of exclusive breastfeeding in
the 2013 China National Nutrition and Health Survey
(CNNHS) as our estimated prevalence. The sample size
u 2 p (1 − p )
was calculated based on the equation N = deff
d2
(p = 20.8%, r = 20%, d = r × p = 4.16%, u = 1.96, deff = 2,
response rate = 90%). The adequate sample size was 9760.
Eventually, 10,408 eligible participants were recruited.
Measurement
Four breastfeeding outcomes were analyzed, including early
initiation of breastfeeding (EIB), exclusive breastfeeding
under 6 months (EBF), predominant breastfeeding under 6
months (PBF), and ever breastfeeding (ever BF). Their defi-
nitions are presented in Table 1. EIB and ever BF were
defined according to WHO indicators (WHO, 2008). The
final calculation of EIB prevalence and ever BF prevalence
was conducted among participants with children aged 0–12
months. EIB prevalence was defined as the proportion of
participants with children born in the last 12 months who
were put to the breast within 1 hr of birth. Ever BF preva-
lence was defined as the proportion of infants born in the last
12 months who were ever breastfed. EBF and PBF were
defined and evaluated according to Wellstart International’s
toolkit for monitoring and evaluating breastfeeding activities
(Lung’aho, Huffman, Labbok, Sommerfelt, & Baker, 1996),
using a 24 hr recall methodology. The 24 hr recall methodol-
ogy to access EBF and PBF, and the method to access EIB
and ever BF, were recommended by the WHO (2010)
because these indicators represented the best option for esti-
mating breastfeeding outcomes, were more sensitive to cap-
turing change, had been used in some large-scale research
projects (including the Demographic and Health Surveys
[DHS] conducted in over 90 developing countries), and were
seen as comparably reliable and valid (www.dhsprogram.
com; Lung’aho et al., 1996; WHO, 2010). Participants were
asked to recall the food they fed to their children in the last
24 hr, and the final calculation of EBF prevalence and PBF
prevalence was conducted among participants with children
aged 0–5 months. EBF prevalence was defined as the pro-
portion of infants aged 0–5 months who were fed exclusively
human milk. PBF prevalence was defined as the proportion
of infants aged 0–5 months who were predominantly breast-
fed, which mainly comprised infants who were fed human
milk and water (Lung’aho et al., 1996). Furthermore, to
explore participants’ current breastfeeding situation, we also
implemented the indicator of current breastfeeding (CBF)
prevalence, defined as any breastfeeding in the last 24 hr of
infants under 12 months (Lung’aho et al., 1996).
Mother–infant indicators and family socio-demo-eco-
nomic status were the two categories of covariates incorpo-
rated in the study. Mother–infant indicators included maternal
age, pre-pregnancy BMI, gestational age, infant birth weight,
infant sex, parity, nipple problems, delivery method, and
4 Journal of Human Lactation 00(0)
delivery place. Nipple problems included cracked nipples,
abnormally shaped nipples, swollen breasts, mastitis, or duct
blockage of breast. Family socio-demo-economic status
comprised residence location, migration status, maternal
education, paternal education, household income, and mater-
nal working status. Residence location was classified into
four categories including megacity, medium-sized city,
countryside, and poor rural areas. We use the term megacity
as defined by the Chinese government: a city with over five
million permanent residents. Poor rural areas were identified
through a list of national-level poor counties compiled by the
Poverty Alleviation Group of the State Council. Migration
status was according to the national definition of a migrant
resident in the latest China population census: People who
had not lived in their domicile counties (their registered
place of residence) for the last 6 months were regarded as
migrant residents. Education level was categorized into illit-
erate, primary school, secondary school (middle and high
school), college/university, and above.
Data Collection
The data collection was led and conducted by the China
Centre for Disease Control and Prevention from June–
November, 2017. The original questionnaire (in Chinese) is
included in the supplemental material for this article. After
registration and giving their informed consent, participants
answered questions asked by well-trained health workers
using a smartphone-based questionnaire. The health workers
entered participants’ responses into the smartphone app.
When asked why breastfeeding was discontinued or stopped,
participants were asked to pick from multiple choice
responses. Over 90% completed all the questions. Data was
kept secure under the rigorous management of the National
Institute for Nutrition and Health, China Centre for Disease
Control and Prevention. Original data transmitted from
smartphones were archived for quality control in the well-
protected data system, and data in the smartphones were
cleared. Only researchers who had authorization from the
National Institute had access to the dataset. The data could
not be utilized for commercial purposes. Any identifying
information in the original questionnaire was replaced with
serial numbers, and contact information was omitted in the
dataset.
Data Analysis
Study Aim 1: Latest Patterns of Breastfeeding. Using quantita-
tive analysis, descriptive statistics were applied to report the
baseline characteristics of participants. Mother–infant indi-
cators, family socio-demo-economic factors, breastfeeding
practices, and breastfeeding-related environments were used
in the analyses. We also examined the prevalence of breast-
feeding indicators and the percentage of various self-reported
reasons for discontinuing breastfeeding.
Study Aim 2: Determinants of Breastfeeding. The associations
between determinants and breastfeeding outcomes were ana-
lyzed using a logistic regression model (Asfaw, Argaw, &
Kefene, 2015; Mogre, Dery, & Gaa, 2016). All the odds ratios
were presented with 95% CI. Logistic models were con-
structed, adjusting for maternal age, pre-pregnancy BMI, ges-
tational age, infant birth weight, infant sex, parity, delivery
method, delivery place, maternal education, paternal educa-
tion, maternal working status, resident status, household
income, maternal occupation, and region. All the analyses
were conducted using SAS version 9.4 (SAS Institute, 2018).
Results
Characteristics of the Sample
Participants’ basic characteristics are shown in Table 2. The
mean maternal age was 29.15 (SD = 5.11) and the mean pre-
pregnancy BMI was 22.26 kg/m2 (SD = 7.37). The mean
gestational week was 39.00 weeks (SD = 1.41). The mean
infant age and birth weight were 5.95 months (SD = 3.51)
and 3.36 kg (SD = 0.66), respectively.
Study Aim 1: Latest Patterns of Breastfeeding
The prevalence of breastfeeding practices among the study
population are presented in Table 3. Figure 1 shows the cur-
rent breastfeeding prevalence in infants aged 0–11 months,
and exclusive breastfeeding prevalence in infants aged 0–5
months. It can be seen that the current breastfeeding rate
decreased from 96.4% (n = 10,033) to 65.0% (n = 6,765) in
infants aged 0–11 months, and the exclusive breastfeeding
rate decreased from 32.71% (n = 1,729) to 15.83% (n = 837)
among infants aged 0–5 months in the survey regions. Figure
2 shows the distribution of participants’ self-reported reasons
for discontinuing breastfeeding. Figure 3 presents the status
of receiving complementary food described by age.
Study Aim 2: Determinants of Breastfeeding
Table 4 shows the factors associated with early breastfeeding
initiation. Pre-pregnancy BMI, primiparous birth experiences,
cesarean section, low birthweight, and gestational week less
than 37 weeks were negatively associated with early initiation.
The Table also shows that current employment and cesarean
sections were negatively associated with both exclusive and
predominant breastfeeding. In addition, annual household
income and regions were also associated with exclusive breast-
feeding. Low birthweight and nipple problems were negatively
associated with predominant breastfeeding.
Discussion
We discovered that the prevalence of breastfeeding indica-
tors decreased as infants grew up, and we presented the latest
Fang et al. 5

Table 2. Basic Characteristics of the Study Population (N = 10,408).

Characteristics n (%) Characteristics n (%)

Maternal age (year)a Nipple problems
15–23 1316 (12.64) Yes 3978 (38.22)
24–34 7372 (70.83) No 6430 (61.78)
35–53 1720 (16.53) Parityd
Pre-pregnancy BMI (kg/m2) Primiparous 4780 (46.01)
< 24.0 8129 (78.10) Multiparous 5610 (53.99)
24.0–27.9 1675 (16.09) Delivery methode
> 28 604 (5.80) Normal 6314 (60.78)
Gestational age (weeks) Cesarean section 4074 (39.22)
< 37 541 (5.20) Delivery placef
37–42 9852 (94.66) Home/ township hospital village clinic 297 (2.86)
> 42 15 (0.14) County-level/prefectural/provincial hospital
Maternal working status 9923 (95.63)
Non-working 5934 (57.01)
Working 4474 (42.99) Private hospital/other 157 (1.51)
Maternal educationb Region
Illiterate 85 (0.82) megacity 3614 (34.72)
Primary 715 (6.88) Medium-sized city 3381 (32.48)
Secondary 5661(54.53) countryside 1700 (16.33)
Higher education 3922 (37.77) Poor rural 1713 (16.46)
Paternal educationc Household income (Yuan)
Illiterate 29 (0.28) < 40,000 6195 (59.52)
Primary 726 (6.99) 40,000–60,000 1172 (11.26)
Secondary 5832 (56.18) 60,000–100,000 1297 (12.46)
Higher education 3795 (36.55) ≥ 100,000 1744 (16.76)
Infant age (month) Geographical region
<1 921 (8.85) North China 1744 (16.76)
1–3 2600 (24.98) East China 2732 (26.25)
4–6 2580 (24.79) South China 838 (8.05)
7–9 2538 (24.39) Northeast 1697 (16.30)
10–12 1769 (17.00) Southwest 1690 (16.24)
Infant birth weight (kg) Northwest 855 ( 8.21)
< 2.5 458 (4.40) Central 852 (8.19)
2.5–3.0 2298 (22.08) Resident status
3.1–4.0 6994 (67.20) Local 9071 (87.15)
> 4.0 658 (6.32) Migrant 1337 (12.85)
Infant gender
Male 5278 (50.71)
Female 5130 (49.29)

Note. BMI = body mass index; nipple problems included sore nipples, cracked nipples, abnormally shaped nipples, mastitis, or duct blockage in breast.
Conversion of Yuan to US dollars: 40,000 Yuan = $5,817 USD; 60,000 Yuan = $8,725 USD; 100,000; Yuan = $14,542 USD.
Missing values: a31, b25, c26, d18, e20, f31.

Table 3. Breastfeeding Indicators in the Study Population (N = 10,408).

Breastfeeding Practices n (%) 95% CI p

Early initiation of breastfeeding 7481 (71.88) 71.01–72.74 .00*
Current breastfeeding 9052 (86.97) 86.31–87.61 .00*
Ever breastfeeding 10143 (97.46) 97.16–97.77 .00*
Exclusive breastfeeding 1550 (29.32) 28.09–30.54 .00*
Predominant breastfeeding 3166 (59.69) 58.37–61.04 .00*

Note. Exclusive and predominant breastfeeding practices had a sample size of 5,287.
*Z-test (null hypothesis = 0.5): p = <. 01.
6 Journal of Human Lactation 00(0)

Figure 1. Exclusive and current breastfeeding prevalence in 12 selected regions, China, 2017.

Figure 2. Self-reported reasons for stopping breastfeeding among infants under 12 months.

prevalence of exclusive breastfeeding in 12 selected regions
in China. We have also shown the multiple complex determi-
nants involving socioeconomic and biophysical factors asso-
ciated with breastfeeding. It could be argued that participants
failed to adhere strictly to the WHO recommendation of
exclusive breastfeeding for 6 months on account of comple-
mentary food introduction (Benedict et al., 2018; Jiang et al.,
2014). Sub-optimum breastfeeding resulted in a higher risk
of mortality in the first 2 years of life, children’s infections
and malocclusion, a delay in intelligence development, over-
weight, and diabetes (Victora et al., 2016). Participants with
infants under 6 months stated that they began adding water,
nutritional supplements, or infant formula to breastmilk
mostly on the recommendation of acquaintances and doctors,
perceived nutritional need, and insufficient lactation. Thus,
we urge that knowledge dissemination occur during
Fang et al.
Figure 3. Complementary feeding by infant age in 12 selected regions, China, 2017.
antenatal and postnatal clinic visits, highlighting the benefits
of exclusive breastfeeding and the harmful impacts of pre-
maturely introducing complementary food.
The common reasons for ceasing exclusive breastfeeding
in developing countries are a perceived insufficiency of
human milk, traditional beliefs, maternal or child illness,
and maternal employment (Brown, Dodds, Legge, Bryanton,
& Semenic, 2014; Galipeau, Dumas, & Lepage, 2017).
Among these factors, insufficient human milk supply tends
to be the major reason for breastfeeding cessation (Brown
et al., 2014; Zhang et al., 2015). Researchers demonstrated
that only a small percentage of mothers were biologically
unable to breastfeed and most of the insufficiencies of
human milk were due to mothers’ own perceptions
(Galipeau, Baillot, Trottier, & Lemire, 2018; Galipeau et al.,
2017). This perception often coincided with softness of
breasts, babies growing slowly, poor knowledge of the lac-
tation process, and technical difficulties in producing ade-
quate human milk (Galipeau et al., 2018; Sun, Chen, Yin,
Wu, & Gao, 2017). A mother’s intention to breastfeed was
strengthened by support from health professionals and
social networks (Wray & Garside, 2018).
A variety of socio-demographic and biophysical factors
were associated with breastfeeding indicators in this study.
Researchers have found that older women in China were
more likely to keep breastfeeding for a longer period than
their younger counterparts (Tang, Lee, & Binns, 2015). A
recent study in India, however, showed that maternal age was
adversely associated with exclusive breastfeeding (Benedict
et al., 2018). A negative association between maternal age
and predominant breastfeeding was also found in this study.
Discrepancies in exclusive breastfeeding among participants
of different ages were not observed. It is possible that well
educated women take the initiative to receive prenatal
7
education and are more accessible to advice from doctors or
nurses (Pang et al., 2016). However, we found that exclusive
breastfeeding prevalence was significantly lower among par-
ticipants whose education level was middle/high school
compared to participants who were illiterate. A systematic
review conducted in China also found a negative association
between breastfeeding indicators and maternal education.
The review speculated that maternal leave, occupation, and
incorrect traditional perceptions contributed to the negative
association (Zhao et al., 2017). Consistent with a study using
a 2013 survey in China (Duan et al., 2018), and a study con-
ducted in India (Meena et al., 2018), participants in rural
areas were more likely to exclusively or predominantly
breastfeed compared to those in urban areas. This can be
attributed to infant formula advertising extravagant claims of
its superiority over breastfeeding, and the wider availability
of human milk substitutes in urban regions (Tang et al., 2014;
Zhang et al., 2015). In this study, when residential location
was divided further, exclusive breastfeeding was more likely
to be abandoned in medium-sized cities and poor rural areas
than in megacities. This might be attributed to government
interventions, relatively higher qualities of breastfeeding
education, and more mother support groups and lactation
facilities in megacities (Zhang et al., 2015; Zhang et al.,
2018). While infant formula has been widely advertised in
megacities, the government has also taken measures to pro-
mote efficient health education in the targeted population,
and has established Baby-Friendly Hospitals, and developed
community services.
Participants undergoing cesarean sections were observed
to be more likely to delay initiation of breastfeeding and
abandon exclusive and predominant breastfeeding than those
who delivered vaginally. This factor has previously been
shown to hinder breastfeeding and disrupt lactation (Hobbs,
8 Journal of Human Lactation 00(0)

Table 4. Multivariate Analysis for Factors Associated with Main Breastfeeding Indicators.

Early Initiation Exclusive Breastfeeding Predominant Breastfeeding

(n = 10,408) (n = 5,287) (n = 5,287)

OR [95% CI] OR [95% CI] OR [95% CI]

Maternal age (year)
15–23 1.42 [1.22–1.66] 1.14 [0.93–1.38] 0.99 [0.83–1.19]
24–34 1.00 1.00 1.00
35–53 0.95 [0.84–1.09] 0.87 [0.72–1.04] 0.75 [0.64–0.89]
Pre-pregnancy BMI (kg/m2)
< 24.0 1.00 1.00 1.00
24.0–27.9 0.83 [0.73–0.93] 0.84 [0.71–0.99] 0.91 [0.78–1.07]
≥ 28 0.66 [0.55–0.79] 0.89 [0.68–1.16] 0.79 [0.63–1.00]
Gestational age (week)
< 37 0.34 [0.28–0.42] 0.73 [0.52–1.01] 0.76 [0.57–1.00]
37–42 1.00 1.00 1.00
> 42 0.48 [0.16–1.39] 4.28 [1.17–15.62] 2.62 [0.55–12.51]
Maternal working status
Non-working 1.00 1.00 1.00
Working 0.95 [0.86–1.05] 0.73 [0.63–0.84] 0.66 [0.58–0.75]
Maternal education
Illiterate 1.00 1.00 1.00
Primary 0.82 [0.57–1.16] 0.80 [0.49–1.32] 1.29 [0.80–2.08]
Middle and high school 1.18 [0.85–1.62] 0.58 [0.37–0.89] 1.12 [0.74–1.71]
Higher education 1.66 [1.17–2.35] 0.63 [0.39–1.01] 0.93 [0.60–1.46]
Paternal education
Illiterate 1.00 1.00 1.00
Primary 0.88 [0.58–1.35] 0.84 [0.47–1.51] 0.99 [0.57–1.73]
Middle and high school 0.94 [0.63–1.40] 0.79 [0.46–1.35] 0.95 [0.57–1.59]
Higher education 0.96 [0.63–1.46] 1.24 [0.71–2.18] 1.12 [0.65–1.90]
Infant birth weight (kg)
< 2.5 1.00 1.00 1.00
2.5–3.0 1.82 [1.44–2.29] 0.98 [0.70–1.39] 1.45 [1.07–1.96]
3.1–4.0 2.25 [1.80–2.82] 1.05 [0.75–1.46] 1.55 [1.16–2.08]
> 4.0 2.14 [1.62–2.83] 1.04 [0.69–1.57] 1.39 [0.97–2.00]
Infant sex
Male 0.94 [0.86–1.03] 0.98 [0.87–1.11] 0.91 [0.81–1.02]
Female 1.00 1.00 1.00
Nipple problems
Yes 0.84 [0.76–0.93] 0.92 [0.81–1.05] 0.77 [0.69–0.87]
No 1.00 1.00 1.00
Parity
Primiparous 1.00 1.00 1.00
Multiparous 1.31 [1.18–1.45] 1.14 [0.99–1.32] 1.08 [0.95–1.23]
Delivery method
Normal 1.00 1.00 1.00
Cesarean section 0.33 [0.30–0.36] 0.78 [0.69–0.89] 0.73 [0.65–0.8]
Delivery place
Home/township hospital/village clinic 1.11 [0.84–1.48] 1.37 [0.95–1.98] 1.16 [0.82–1.66]
County-level/prefectural/Provincial hospital 1.00 1.00 1.00
Private hospital/other 1.25 [0.86–1.84] 1.26 [0.83–1.91] 1.04 [0.69–1.57]
Region
Megacity 1.00 1.00 1.00
Medium-sized city 0.47 [0.42–0.54] 0.64 [0.54–0.76] 0.96 [0.82–1.13]
Countryside 0.56 [0.48–0.66] 1.17 [0.95–1.45] 1.37 [1.12–1.68]

(continued)
Fang et al.
Table 4. (continued)
Poor rural
Household income (Yuan)
< 40,000
40,000–60,000
60,000–10,000
≥ 100,000
Resident status
Local
Migrant
Note. Exclusive breastfeeding = infants aged 0–5 months fed human milk exclusively; predominant breastfeeding = infants aged 0–5 months predominantly
breastfed and fed human milk and water, too, adjusting for maternal age, pre-pregnancy BMI, gestational age, infant birth weight, infant sex, parity, delivery
method, delivery place, maternal education, paternal education, maternal working status, resident status, household income, maternal occupation and
region.
Mannion, McDonald, Brockway, & Tough, 2016; Patel,
Bucher et al., 2015). After a cesarean delivery, pregnant
women may still have spinal anaesthetization or suffer sur-
gery pain and other complications. A poor physical state and
mother–infant separation delays early breastfeeding initia-
tion, further exerting an adverse impact on exclusive breast-
feeding. In addition, caesarean sections are associated with
postpartum depression (Eckerdal et al., 2018; Silverman
et al., 2017). Anatomical, medical, and psychological issues
were reported as reasons why overweight/obese women
were less likely to breastfeed. Obese women often have large
breasts and have practical difficulties attaching the infant to
the breast. Overly large breasts are usually a sign of a true
poverty of human milk (Ramji, Quinlan, Murphy, & Crane,
2016; Turcksin, Bel, Galjaard, & Devlieger, 2014). In gen-
eral, multiparous participants were more likely to have early
initiation after birth than primiparous ones. Research in
Japan and Hong Kong has also found that multiparous moth-
ers, especially those with past breastfeeding experiences,
were more likely to breastfeed their children (Bai, Fong, &
Tarrant, 2015; Kitano et al., 2016).
Nipple problems were reported as a negative factor for
early initiation and predominant breastfeeding. Sore and
cracked nipples were a barrier to successful breastfeeding,
which may be caused by incorrect breastfeeding position,
incorrect latching, and inappropriate nipple sucking (da Silva
Santos et al., 2016; Puapornpong, Paritakul, Suksamarnwong,
Srisuwan, & Ketsuwan, 2017). Most latch-on problems can be
avoided if mothers are informed of techniques for appropriate
attachment, positioning, and suckling through education and
support from trained health professionals in the postpartum
period (da Silva Santos et al., 2016; Degefa et al., 2019; Joshi,
Magon, & Raina, 2016). Research has shown that effective
breastfeeding technique has been associated with receiving
breastfeeding technique counseling immediately after birth
9
Early Initiation Exclusive Breastfeeding Predominant Breastfeeding
(n = 10,408) (n = 5,287) (n = 5,287)
OR [95% CI] OR [95% CI] OR [95% CI]
0.77 [0.65–0.91] 0.67 [0.54–0.84] 0.96 [0.79–1.18]
1.00 1.00 1.00
0.95 [0.77–1.17] 1.23 [0.91–1.65] 1.14 [0.86–1.51]
0.87 [0.76–0.99] 0.93 [0.77–1.12] 0.98 [0.83–1.17]
1.02 [0.91–1.14] 0.78 [0.67–0.90] 0.96 [0.84–1.09]
1.00 1.00 1.00
0.86 [0.74–0.99] 1.06 [0.88–1.28] 1.01 [0.84–1.20]
and during at least two postnatal visits (Tiruye, Mesfin, Geda,
& Shiferaw, 2018). In addition, many therapies for nipple
treatment have been studied (Niazi et al., 2018). Untreated
nipple problems lead to further lactation issues, mastitis, and
psychological stress (Kent et al., 2015).
Based on our findings, we suggest that breastfeeding pro-
motion should be targeted at overweight/obese women older
than 35, with a middle/high school education level, who live
in medium-developed cities. Those mothers were identified
as the most vulnerable group at risk of abandoning exclusive
breastfeeding. Appropriate infant feeding practices should be
popularized vigorously, especially at antenatal clinics.
Information regarding the superiority of exclusive breast-
feeding and the inferiority of human milk substitutes should
be disseminated among the population including not only
mothers themselves but also their partners, and their mothers
and mothers-in-law. They should be advised against the early
introduction of water, other liquids, or complementary feed-
ing. For mothers who return to work or school, supportive
work environments, including the provision of a lactation
room, paid maternity leave, and flexible work schedules,
have been shown to have a significant positive influence on
breastfeeding duration (Jantzer, Anderson, & Kuehl, 2018;
Zhao et al., 2017). Social and family support should be
strengthened with the aim of helping mothers reinforce posi-
tive breastfeeding skills, grow their confidence, and promote
self-efficacy to prolong breastfeeding.
Health professionals in hospitals and in community pri-
mary health centers should support mothers, through in-per-
son or online communication, to overcome breastfeeding
challenges during postpartum hospitalization and shortly
after they are discharged. In particular, mothers need to be
taught that pain means that something is wrong with the way
breastfeeding is happening and that they need to seek help
from knowledgeable healthcare providers. Moreover, it is
10
expected that the caesarean section rate will decrease in the
future: In a study using data from more than 6 million births
in 438 large hospitals in China, the caesarean section rate
declined from 45.3% in 2012 to 41.1% in 2016 (Liang et al.,
2018). Government interventions include hands-on training
for obstetrician and midwives, the revision of guidelines for
the management of dystocia, public education on the advan-
tages of natural birth, and restrictions for a maximum caesar-
ean section rate (Li et al., 2017).
Interventions, including legislation, policy, and media and
social mobilization, have been applied in both low- and high-
income countries. For example, intensified interpersonal
counseling, mass media, and community mobilization inter-
ventions delivered at scale in the context of policy advocacy
in Bangladesh and Vietnam lasted for 6 years (Menon et al.,
2016). In the US, lactation counseling is facilitated through
mandatory insurance coverage, and breastfeeding in public is
protected through legislation. In the UK, a full year of paid
maternity leave is offered (Rollins et al., 2016).
This study mainly explored the patterns and social deter-
minants of breastfeeding. Breastfeeding, however, is a com-
plex issue influenced by biological, social, and cultural
factors. Studies concerning genetics, generational differ-
ences, and other physiological factors are needed to explore
the biological basis of breastfeeding. Qualitative studies
exploring cultural influences are also needed. Meanwhile, in
order to design cost-effective interventions to promote
breastfeeding, large scale experimental research could be
implemented.
Limitations
The sample size in the present study was large, providing
access to a wide spectrum of participants of various socio-
economic strata at one site. However, it was not without limi-
tations in design, implementation, and interpretation. The
first limitation was recall bias due to the retrospective nature
of data collection, possibly resulting in over or under estima-
tion of actual breastfeeding practices. We were not able to
obtain some maternal variables, including smoking and alco-
hol consumption, contraceptive usage, pre-existing diabetes,
and hypertension, which may have introduced confounding
bias. In addition, evidence about breastfeeding in the four
classifications of regions we used (megacities, medium-sized
cities, countryside, and poor rural areas) was scant, so we
failed to interpret differences in early initiation and exclusive
breastfeeding between the regions.
Conclusion
We studied the latest patterns and practices of breastfeeding
involving participants with diverse characteristics in 12 geo-
graphically dispersed regions throughout China. The preva-
lence of exclusive breastfeeding found in this study was far
below the WHO recommended prevalence, demonstrating a
Journal of Human Lactation 00(0)
wide gap between desired and actual practice. Identifying
and understanding the potential factors contributing to the
low prevalence of breastfeeding in China can offer valuable
insights into how to promote breastfeeding, not only in China
but also in countries that have entered, or will enter, an era of
rapid economic growth while still having unbalanced and
inadequate development.
Acknowledgments
We would like to thank the Chinese Center for Disease Control and
Prevention for providing the data.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This
study was supported by the Bill & Melinda Gates Foundation and
the China Development Research Foundation.
ORCID iD
Kun Tang https://orcid.org/0000-0002-5444-186X
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