Background

In a recent study in China, less than 30% of infants under six months of age were found to be exclusively breastfeeding [1]; EBF rates were < 10% in some rural areas [2, 3]. In contrast, the infant formula market is rapidly expanding in middle-income countries like China [4], with almost 45% of rural Chinese newborns receiving formula before leaving the hospital [2]. Although China has made increasing EBF prevalence a national priority [5], it is unclear which interventions should be prioritized, especially in rural contexts challenged by poverty, traditional practices, and lack of support for EBF.

Prior research has identified many barriers to EBF in LMICs. While maternal characteristics, including returning to paid employment and rural-to-urban migration [8,9], in-hospital postpartum experiences are also predictive of later infant feeding practices. Infants who receive formula in the hospital are less likely to be exclusively breastfed for six months [7, 8, 10], whereas breastfeeding initiation within the first hour after birth [1, 7] and providing breastmilk at the first feeding [8, 10, 14] and our results support this evidence. However, empirical evidence is lacking for the impact that hospital compliance with newborn feeding guidelines could have on continued EBF in rural China. To address this gap, we first modeled the association of newborns’ in-hospital feeding experiences with current feeding practices, finding that infants who had been fed any water or formula while in-hospital were 2–3 times as likely to be non-EBF compared to EBF up to age six months. Using this model, we simulated alternate in-hospital feeding experiences and estimated the potential impact of changing in-hospital experiences at discharge on EBF prevalence during the first six months.

Importantly, our simulation results suggest that EBF prevalence could be improved meaningfully if in-hospital feeding practices were modified to reflect BFHI targets. In a hypothetical scenario specifying that 75% of infants were exclusively breastfed and no water-based feeds were given during the in-hospital postpartum period, the prevalence of infants exclusively breastfed to six months of age was estimated to increase from 38.9% (95% CI 35.7, 42.1) to 53.7% (95% CI 46.1, 61.2), a 14.8 absolute percentage point and a 38.0% relative improvement. The simulations also suggest that the elimination of in-hospital water-based feeds alone has the potential to increase later EBF prevalence by an estimated 8.6 absolute percentage points, principally by reducing the prevalence of infants later fed water and other non-milk liquids along with breastmilk. These findings are consistent with evidence [28], including from urban China [29], that infants whose feeding experiences align with BFHI guidelines are more likely to be EBF later. The results of our simulations extend this evidence to the context of rural Sichuan and suggest that promotion of BFHI guidelines may be an effective approach to increasing EBF rates, warranting consideration for policy implementation.

Fewer than half of mothers in the sample reported breastmilk or colostrum as their infant’s first feed with only 22.4% initiating breastfeeding within the first hour. Delays in breastfeeding initiation are likely attributable, in part, to the high percentage (56%) of births by C-section in our study and misinformation suggesting that women are unable to breastfeed immediately after the procedure [11, 30]. Given that only 7.5% of infants born by C-section were EBF while in the hospital, improving healthcare provider training to support early breastfeeding initiation, even after a C-section, and implementing policies to discourage non-medically indicated C-sections, could limit breastfeeding delays associated with the surgery. Further research is warranted to explore attitudes that may reflect a desire for more “medicalized” care among women undergoing non-medically indicated C-section.

The prevalence of postpartum formula use in our sample was high (≥ 68%) across all hospital types. Past migration history—our proxy for future migration and its potential influence on later infant feeding practices, for example, due to lack of designated times and places for breastfeeding in the workplace —was not associated with infants’ in-hospital feeding experiences; the percent of infants who were fed formula postpartum was similar irrespective of mother’s history of migration. Formula marketing in hospitals in China has been described in previous research [1, 31]; however, only a few women in our study reported being offered free formula samples in the hospital after childbirth. This self-reported result may have been influenced by social desirability bias, but also does not preclude formula marketing via other channels from being a possible influencing factor on their infant feeding practices. While our study did not explicitly examine the reasons for using infant formula in the hospital, the universally high rates regardless of demographic and hospital characteristics suggest that perceptions and practices around formula use may be normative. Similarly, reasons for the high prevalence of feeding newborns water or sugar water (~ 62%) are unknown in our study. As there are no medically indicated reasons for water-based feeds, these practices may also be driven by cultural beliefs and social norms, as well as by family-based misinformation, as reported elsewhere [16, 32]. While research has shown that social norms are often difficult to change, interventions explicitly targeting norms, and that engage multiple stakeholders through multiple mechanisms, can successfully transform harmful normative practices [33, 34]. Thus, alongside policies promoting BHFI feeding practices, it may be necessary to introduce social norms interventions, such as strengthening sanctions against marketing of infant formula or educating families that the benefits of EBF assume elimination of water-based feeds.

The major limitation of our study was that the data were cross-sectional, having been collected for another purpose. Temporality concerns associated with cross-sectional data were minimized by focusing on factors that occurred prior to the survey (e.g., during the in-hospital postpartum period) or were non-time varying (e.g., maternal education). However, unmeasured confounding from factors that were not assessed prior to the child’s birth, such as feeding preferences and perceived familial social support for breastfeeding, may have biased our results and limit our ability to make causal claims. This study also had possible recall bias of hospital experiences, and possible misclassification of feeding group membership, which was based on feeding during the 24 h prior to the survey rather than routinely. The use of 24-h recall to assess infant feeding is widely accepted for surveys, including UNICEF’s Multiple Indicator Cluster Surveys [22]. However, a longer recall period (e.g., 3–7 days) may be more accurate and warranted in future research. We did not collect information on the length of mothers’ hospital stay, which could also bias our findings if the length of stay was associated with hospital feeding experiences and systematically different by current feeding group. We aimed to minimize this source of bias by excluding infants who were not breastfed due to medical reasons. Differences between excluded households in child age, sex, and household wealth may be a source of selection bias. Importantly, we cannot generalize our findings to the experience of all infants in rural China, although our results are consistent with research in different regions of China including urban settings [11, 14, 15].

Conclusions

Given the importance of an infant’s first feeding experiences in the establishment and continuation of EBF, it is imperative that rural Chinese hospitals actively seek to reduce infant formula feeds to medically indicated situations and eliminate water-based feeds. Our results suggest that infant feeding outcomes would improve substantially if rural hospitals met BFHI guidelines for EBF from birth to discharge. The significance of infant first feed in the hospital has been underappreciated, understudied, and overlooked as an important target of intervention to improve EBF in China. Transforming infants’ first feeding experiences in rural China will likely require normative change, driven by national and local public health leadership, to address misinformation around best practices. Additional research is needed to improve our understanding of the role of families and social norms in influencing feeding practices during the postpartum period and how hospital policy or practices might be harnessed to address harmful normative practices. Our results also suggest the need for further examination of the role of C-section and length of hospital stay on hospital feeding experiences, as well as additional qualitative research to understand choices in infant feeding practices in rural China.