Breastfeeding rates in central and western China in 2010: implications for child and population health

Bull World Health Organ 2013;91:322–331 | doi: http://dx.doi.org/10.2471/BLT.12.111310 Research 322 Breastfeeding rates in central and western China in 2010: implications for child and population health Sufang Guo,a Xulan Fu,a Robert W Scherpbier,a Yan Wang,b Hong Zhou,b Xiaoli Wangb & David B Hipgravea Introduction In 2010, China had the world’s fifth largest number of deaths among children younger than 5 years, despite child mortal- ity rates in the country having fallen steadily over the last two decades.1–4 Consequently, the timing and causes of death in children in China are different from those in countries where large numbers of children perish early in life. Globally, around two thirds of deaths in children younger than 5 years are caused by infection5 and an estimated 35% are associated with poor nutrition.6,7 By contrast, only 21.4% of comparable deaths in China in 2008 were infection-related: 16.5% were due to pneumonia; 3%, to diarrhoea and 1.9%, to neonatal sepsis.2 However, child mortality rates are much higher in poor western provinces, where infectious diseases are more common:2 the rate in children younger than 5 years in the poorest counties is more than six times higher than in large cities.8 Children are more likely to die from pneumonia and diarrhoea in the western part of China.2,4 Breastfeeding has been shown to reduce child mortality and morbidity, especially from infectious diseases.6,9–11 It may be possible, then, to reduce infection-associated child mortal- ity and morbidity in poor rural areas in China by promoting good infant and young child feeding practices, particularly breastfeeding, and by discouraging the inappropriate use of breast-milk substitutes. Moreover, infant and young child feeding practices may be associated with the long-term inci- dence of noncommunicable diseases in both developing and developed countries, regardless of socioeconomic status.12,13 Thus, improving breastfeeding practices may help reduce the future incidence of noncommunicable diseases both in China and elsewhere. Currently, few data are available on infant and young child feeding practices in China. The aim of this study, therefore, was to describe these practices and associated variables by surveying a large geographical area in China’s central and western provinces. Our survey was the first in the country to include the full range of globally recommended breastfeed- ing indicators,11 enabling comparisons to be made between China and other countries. We also examined differences in infant and young child feeding practices between China and neighbouring countries in the context of increased consump- tion of breast-milk substitutes and rising noncommunicable disease rates. Methods We conducted a community-based, cross-sectional survey of infant and young child feeding practices in 26 counties, with a total population 11 000 000, in 12 central and western prov- inces of China: Chongqing, Gansu, Guangxi, Guizhou, Inner Mongolia, Jiangxi, Qinghai, Shaanxi, Shanxi, Sichuan, Tibet and Xinjiang. The counties were selected by staff at the United Nations Children’s Fund (UNICEF) and the Chinese Ministry of Health as being representative of poor rural counties on the basis of their level of socioeconomic development and measures of maternal and child health. Child mortality was as high as 65 per 1000 live births in these counties, compared with a national rural average of 34 per 1000 live births in 2009, and the per capita gross domestic product ranged from 150 to 2210 United States dollars (US$), as calculated using the 2009 conversion rate from renminbi, compared with the national average of US$ 3680. The survey was conducted by Peking University School of Public Health and UNICEF staff Objective To describe breastfeeding practices in rural China using globally recommended indicators and to compare them with practices in neighbouring countries and large emerging economies. Methods A community-based, cross-sectional survey of 2354 children younger than 2 years in 26 poor, rural counties in 12 central and western provinces was conducted. Associations between indicators of infant and young child feeding and socioeconomic, demographic and health service variables were explored and rates were compared with the most recent data from China and other nations. Findings Overall, 98.3% of infants had been breastfed. However, only 59.4% had initiated breastfeeding early (i.e. within 1 hour of birth); only 55.5% and 9.4% had continued breastfeeding for 1 and 2 years, respectively, and only 28.7% of infants younger than 6 months had been exclusively breastfed. Early initiation of breastfeeding was positively associated with at least five antenatal clinic visits (adjusted odds ratio, aOR: 3.48; P < 0.001) and negatively associated with delivery by Caesarean (aOR: 0.53; P < 0.001) or in a referral-level facility (aOR: 0.6; P = 0.014). Exclusive breastfeeding among children younger than 6 months was positively associated with delivery in a referral-level facility (aOR: 2.22; P < 0.05). Breastfeeding was not associated with maternal age or education, ethnicity or household wealth. Surveyed rates of exclusive and continued breastfeeding were mostly lower than in other nations. Conclusion Despite efforts to promote breastfeeding in China, rates are very low. A commitment to improve infant and young child feeding is needed to reduce mortality and morbidity. a United Nations Children’s Fund China Country Office, 12 Sanlitun Lu, Beijing, 100600, China. b School of Public Health, Peking University, Beijing, China. Correspondence to: David B Hipgrave (e-mail: dhipgrave@gmail.com). (Submitted: 8 August 2012 – Revised version received: 1 December 2012 – Accepted: 19 December 2012 – Published online: 23 March 2013 ) R search Bull World Health Organ 2013;91:322–331 | doi: http://dx.doi.org/10.2471/BLT.12.111310 323 Research Breastfeeding rates in ChinaSufang Guo et al. working with local health authorities and was approved by Peking University’s ethics committee. Data collection A multistage sampling technique was used to select townships and villages in the 26 counties. First, all townships in each county were ranked by hospital delivery rate in 2009 and divided into three approximately equal strata; one township was then randomly selected from each stratum, except in sparsely populated Tibet, in which two townships were selected from two equal strata in each county. Within the selected town- ships, villages were ranked by their distance from the nearest main town and were divided into three almost equal strata; one village was then randomly selected from each stratum. Finally, ap- proximately 20 children younger than 5 years were selected in each village. In total, 4368 children were sampled from 209 villages in 75 townships. The overall purpose of the survey was to assess child health, perinatal care and associated demographic and socio- economic factors in households with a child younger than 5 years. This report focuses on breastfeeding indicators, variables associated with breastfeeding, and complementary feeding among chil- dren younger than 2 years. In families with more than one child younger than 5 years, only the youngest was surveyed. Consequently, the sample was weighted towards younger children: 2577 were less than 2 years old. After excluding 330 children left behind by mothers who migrated and hence could not breastfeed them and after weighting for sampling probability, the final data set comprised 2354 children younger than 2 years (Ap- pendix A and Appendix B, both avail- able at: http://www.unicefchina.org/en/ index.php?m=content&c=index&a=sho w&catid=214&id=1512). Interviews with mothers and care- givers were conducted between July and September 2010 by local health workers trained and supervised by UNICEF and Peking University staff. Interview- ers used a structured questionnaire developed from published indicators of infant and young child feeding practices (Appendix C; available at: http://www. unicefchina.org/en/index.php?m=con tent&c=index&a=show&catid=214& id=1512) and UNICEF’s Multiple Indil- cator Cluster Survey.11,14 Child nutrition practices were assessed using 24-hour dietary recall in accordance with the relevant World Health Organization (WHO) module.15 The questionnaire was pretested and adjusted before data collection and oral informed consent was sought before each interview. The research team monitored data collection for quality control. Survey data included demographic and socioeconomic variables for each child and mother or caregiver and in- formation on care-seeking practices. Household wealth was categorized using the ownership of electrical appliances: poor households had 0 to 2 appliances; medium-wealth households had 3; and the least poor households had 4 or more.16–18 We also surveyed the indica- tors of infant and young child feeding listed in Table 1,11,14 which include early initiation of breastfeeding (i.e. within 1 hour of birth), exclusive breastfeeding among children younger than 6 months, continued breastfeeding for 1 and 2 years after birth and age-appropriate breastfeeding, as defined in Appendix C. In addition, we surveyed the early introduction of complementary feeding, defined in Appendix C as giving any soft, semisolid or solid food to an infant before the age of 6 months, regardless of breastfeeding. The rates of five indica- tors of infant and young child feeding observed in the survey were compared with the most recent data available on corresponding national rates in most of China’s near neighbours, as well as Brazil and South Africa.19 Data analysis Data analysis was performed using Stata 11 (StataCorp. LP, College Station, United States of America) and took into account any unequal sampling prob- abilities, clustering and stratification in the study design (Appendix A and Appendix B). Point estimates of indica- tors are reported with 95% confidence intervals (CIs). Design-based F testing was used to assess associations between the early initiation of breastfeeding, exclusive breastfeeding among children younger than 6 months and survey vari- ables. Univariate analysis was performed to identify associations with these two breastfeeding indicators and crude odds ratios (ORs) and 95% CIs were derived using the Wald test. In addition, multi- variate logistic regression analysis was carried out: the initial model included fixed “a priori” variables that were as- sumed to be associated with the early initiation of breastfeeding or exclusive breastfeeding among children younger than 6 months and other variables that were found to be associated with breastfeeding in the univariate analysis (i.e. P ≤ 0.1). The fixed variables were retained throughout the analysis but other variables were excluded one by one according to their P-values: only those with P ≤ 0.10 were retained in the final Table 1. Feeding practices in children younger than 2 years in 26 counties in central and western China, 2010 Feeding practicea Children fed as described No. %b (95% CI) Breastfed at some time 2354 98.3 (97.6–99.0) Breastfeeding initiated early (within 1 hour of birth) 2354 59.4 (54.2–64.6) Exclusively breastfed (child younger than 6 months) 490 28.7 (15.0–42.3) Predominantly breastfed (child younger than 6 months) 490 68.8 (61.8–75.1) Continued breastfeeding at 1 year 356 55.5 (45.2–65.8) Continued breastfeeding at 2 years 366 9.4 (6.0–14.4) Age-appropriate breastfeeding 2354 42.2 (38.7–45.8) Median duration of breastfeeding, months 2924c 15.0 (NA) Timely introduction of complementary foodsd 419 89.7 (86.1–93.2) Non-breastfed children (aged 6–23 months) who received at least two milk feedingse 897 69.8 (64.6–75.1) Early introduction of soft, semisolid or solid food 490 18.7 (13.2–24.2) CI, confidence interval; NA, not applicable. a The feeding practice indicators are fully described in Appendix C (available at: http://www.unicefchina. org/en/index.php?m=content&c=index&a=show&catid=214&id=1512). b Figures in this column are all percentages unless otherwise stated. c The figure includes some older children who continued to breastfeed beyond 2 years of age. d The recommended age for starting complementary feeding is 6 to 8 months. e The frequency of milk feeding on the day before the survey was recorded. Bull World Health Organ 2013;91:322–331 | doi: http://dx.doi.org/10.2471/BLT.12.111310324 Research Breastfeeding rates in China Sufang Guo et al. model. The strength of each association was expressed as an adjusted OR (aOR). Since missing data and “don’t know” answers were relatively infrequent, except for maternal age, maternal education and antenatal clinic attendance in cases where maternal information was not available, we recoded them as null values and included them in both numerators and denominators, as recommended.15 Results Table 2 shows the demographic, socio- economic and clinical characteristics of the 2354 children younger than 2 years included in the analysis. The male to fe- male ratio was 1.4:1 and 53.3% were first-born children. More than a quarter were of minority ethnicity, the national minority proportion being 8.5% in 2010.20 The number of mothers younger and older than 25 years was nearly equal; only 5.7% were younger than 20 years. In addition, 71.4% had completed 9 years of education. Over 80% of mothers had attended an antenatal clinic five or more times. Among the children, 97.3% were delivered at a health-care facility and 23.8% were delivered by Caesarean section: the rate was 30.4% in county, referral-level facilities and 14.8% in first-level township hospitals (P < 0.01; data not shown). Breastfeeding indicators Overall, 98.3% of the infants and young children surveyed had been breastfed at some time and 59.4% of mothers had initiated breastfeeding early (e.g. within 1 hour of birth) (Table 1). The rates of exclusive breastfeeding among children younger than 6 months, con- tinued breastfeeding at 1 and 2 years of age and age-appropriate breastfeeding were all low. Fig. 1 shows infant and young child feeding practices during the first 2 years of life. The rate of exclusive breastfeeding was only 58.3% among newborn infants (aged 0 to 27 days); it declined further to 29.1% in those aged 3 to 4 months and to 13.6% in those aged 5 to 6 months. The most common reason for non-exclusive breastfeeding during the first 6 months, except during the first month, was giving water. The second most common reason was using breast-milk substitutes. Around 40% of newborn infants were given something other than breast milk: 27.1% received other milk; 9.4%, water; and 3.0%, soft, semisolid or solid food (Appendix D, available at: http://www.unicefchina. org/en/index.php?m=content&c=inde x&a=show&catid=214&id=1512). Generally, the introduction of complementary feeding was timely: 89.7% of infants aged 6 to 8 months, the recommended age for starting complementary feeding (Appendix C),11 had consumed soft, semisolid or solid food in the 24 hours before the survey (Table 1). However, although only 18.7% of infants younger than 6 months had commenced complementary feeding, the sharp increase from 12.2% in infants aged 4 to 5 months to 41% among those aged 5 to 6 months suggests that many started earlier than recommended. Table 2. Social, demographic and clinical characteristics of children and caregivers surveyed in central and western China, 2010 Characteristic No. (%) Children (n = 2354) Age, months < 6 491 (20.8) 6–11 797 (33.9) 12–17 522 (22.2) 18–23 544 (23.1) Sex Male 1375 (58.4) Female 979 (41.6) Elder sibling Yes 1101 (46.7) No 1254 (53.3) Ethnicity Han Chinese 1756 (74.6) Minority 598 (25.4) Household wealth Poorest 386 (16.4) Medium 780 (33.1) Least poor 1188 (50.5) Mothers and caregiversa Age, years (n = 2158)a < 20 122 (5.7) 21–25 913 (42.3) 26–30 622 (28.8) > 31 501 (23.2) Maternal education (n = 2158)a None 111 (5.2) Primary school 507 (23.5) Junior school 1338 (62.0) Senior high school and above 202 (9.4) Maternal antenatal clinic visits (n = 2158)a 0–4 407 (18.9) ≥ 5 1750 (81.1) Place of delivery (n = 2158)a County- or higher-level hospital 1230 (52.3) Township-level hospital 1024 (43.5) Private hospital 36 (1.5) Home, clinic or other 64 (2.7) Delivery method (n = 2293)a Vaginal 1746 (76.2) Caesarean section 547 (23.8) a For some children, information was available only from caregivers and, therefore, data on some maternal factors were incomplete. Bull World Health Organ 2013;91:322–331 | doi: http://dx.doi.org/10.2471/BLT.12.111310 325 Research Breastfeeding rates in ChinaSufang Guo et al. Variables associated with breastfeeding Table 3 presents the results of the univariate and multivariate analyses of variables associated with the early initiation of breastfeeding and Table 4, the results for exclusive breastfeeding among children younger than 6 months. Univariate analysis indicated that the early initiation of breastfeeding was pos- itively associated with poverty, minority ethnicity and maternal attendance at an antenatal clinic five or more times, and negatively associated with Caesarean section and delivery at a county-level or private hospital (rather than a township- level hospital). Early initiation was not associated with sex, the existence of elder siblings, maternal age or maternal education. After adjustment for other variables, multivariate analysis showed that the early initiation of breastfeeding remained negatively associated with de- livery at a county or higher-level referral hospital (OR: 0.6) and delivery by Cae- sarean section (OR: 0.53) and positively associated with attending an antenatal clinic five or more times (OR: 3.48). Univariate analysis indicated that exclusive breastfeeding among children younger than 6 months was associated with only three variables: there were positive associations with male sex and delivery at a county or higher-level refer- ral hospital and a negative association with the child’s age. After adjustment for other variables, multivariate analy- sis showed that exclusive breastfeeding among children younger than 6 months remained positively associated with de- livery at a county or higher-level referral hospital (OR: 2.22) and negatively as- sociated with the child’s age (OR: 0.77). Comparisons with selected countries Table 5 shows the rates of five indicators of infant and young child feeding from our survey, from China’s most recent national survey21 and from the most recent, large-scale surveys in most of China’s neighbouring countries plus Brazil and South Africa. In our survey, breastfeeding was initiated early in 59% of infants, which is slightly above the median of 57% for Asia and 48% for the BRICS countries (i.e. Brazil, the Russian Federation, India, China and South Af- rica). However, both nationally and in the 12 provinces covered by this survey, exclusive breastfeeding was less com- mon than in most other countries in- cluded in Table 5 and rates of continued breastfeeding at 12 to 15 months and 20 to 23 months were well below those in virtually all countries except Brazil, for which the rate at 12 to 15 months was lower than in our survey. Discussion This study identified major concerns with infant and young child feeding practices in 26 poor rural counties in central and western China. The exclusive breastfeeding rate dropped precipitously during the first 6 months of life and became one of the lowest in the region. Breast-milk substitutes were frequently introduced early, followed soon after by water and non-milk liquids and, by around 4 months, various foods. The rate of continued breastfeeding at 1 year was much lower than in most neighbouring countries; the rate at 2 years was easily the lowest. Only the rate of early initiation of breastfeeding was encouraging. We found that the rate of early initiation of breastfeeding in our rural sample was higher than in the 2008 national survey21 and we observed posi- tive associations between early breast- feeding and attendance at an antenatal clinic and delivery in a township-level hospital, both of which suggest that the recent increase in use of these facilities in China has had additional benefits.22 The reason for the negative association between early breastfeeding and delivery at a county-level hospital may be that early breastfeeding was not prioritized in these hospitals or that the infants born in them were sicker and smaller than average or came from wealthier families who give formula early. However, our experience suggests that breast-milk substitutes are often promoted at county hospitals. The negative association between the early initiation of breast- feeding and Caesarean section, which is being performed ever more frequently in China,23 has been observed elsewhere:24 it may be related to the postoperative positioning of the mother, poor pain relief, slow lactogenesis25 or increased use of breast-milk substitutes. Spinal anaesthesia, which is in common use in China, 26 should enable early breastfeed- ing if pain relief is adequate. Our findings on exclusive breast- feeding are very similar to the most recent comparable data from rural China,21 particularly from Xinjiang in the far west in 2003 to 200427 and Zhe- jiang on the east coast in 2004 to 2005.28 Possibly because exclusive breastfeeding was infrequent after the first month, we found only one variable associated with Fig. 1. Feeding practices in children aged less than 2 years in 26 counties in central and western China, 2010 Time after birth (months) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Breast milk only Breast milk and water Stopped breastfeeding Breast milk and other liquids Breast milk and other or formula milk Breast milk and solid, semisolid or soft food Pr op or tio n of ch ild re n (% ) 100 90 80 70 60 50 40 30 20 10 0 Bull World Health Organ 2013;91:322–331 | doi: http://dx.doi.org/10.2471/BLT.12.111310326 Research Breastfeeding rates in China Sufang Guo et al. exclusive breastfeeding among children younger than 6 months: delivery at a county-level hospital. Unlike other studies,29 ours showed no association with Caesarean section. In China, the most common reasons for ceasing ex- clusive breastfeeding are the perceived insufficiency of breast milk, traditional beliefs, maternal or child illness and maternal employment.27, 30–32 Marketing of breast-milk substitutes may also be a factor.33 In addition, the early introduc- tion of complementary feeding has an ancient history in China34 and related traditional beliefs are very influential in less developed areas and in areas with large minority ethnic populations.35–37 The exclusive breastfeeding rates observed in our survey, in the 2008 national survey and in the Xinjiang and Zhejiang surveys indicate that there has been no improvement over time. This lack of progress has occurred even though, in 2007, the Chinese Ministry of Health adopted the WHO recommenda- tion that exclusive breastfeeding should continue for 6 months38 and started using WHO’s definition of exclusive breastfeeding (previously it used the “predominant” breastfeeding indica- tor).11 Moreover, government policy that notionally banned the promotion of breast-milk substitutes39 has had little impact: consumption in China increased almost threefold between 2003 and 2008 and could double again by 2013,40,41 pos- sibly due to laissez-faire regulation of breast-milk substitute advertising. There are signs, however, that educated urban women are becoming more aware of the benefits of breastfeeding.41 In 2008, it was estimated that, glob- ally, suboptimal breastfeeding in the first 6 months of life accounted for 10 to 15% of deaths in children younger than 5 years and 10% of the disease burden.6 Moreover, the survey data we obtained show that breastfeeding practices are poor in many countries in Asia and in some large nations in other parts of the world, suggesting that there are widespread misconceptions about the benefits. Our survey showed that many infants and young children started complementary feeding early. In China, breast-milk substitutes are not of good quality and, in poor rural areas, they may be contaminated or diluted.42,43 Moreover, the weaning diet in rural China is known to be low in nutrient content.44 Poor-quality complementary feeding can increase the risk of under- nutrition, infectious disease and death45 and a nutrient-poor, calorie-rich diet may be associated with a higher risk of obesity, hypertension, and diabetes in later life.12 Consequently, inappropriate infant and young child feeding in rural China places many infants at risk of early illness and death and may increase their risk of developing noncommunicable diseases. In addition to being more af- fordable, breastfeeding and appropriate complementary feeding could reduce the risk of noncommunicable diseases at least as effectively as mid-life dietary and lifestyle changes or drug treatment.12 Our analysis has several limitations. First, because the survey was cross- sectional, the observed associations with breastfeeding indicators may not be causal. Second, our survey partici- pants lived in poor rural areas where the proportion of ethnic minorities was relatively high. Hence, our findings may not be generalizable to all of China. However, there is evidence that, globally, infant and young child feeding practices Table 3. Associations between survey variables and early initiation of breastfeeding in 26 counties in central and western China, 2010 Variablea No. (%) initiated breastfeeding early Univariate analysis, cOR (95% CI) Multivariate analysis, aOR (95% CI) Child’s sex Male 816 (59.4) 0.99 (0.77–1.28) ND Female 583 (59.5) 1 (NA) ND Child has elder sibling Yes 636 (57.8) 0.88 (0.63–1.23) ND No 763 (60.9) 1 (NA) ND Maternal age, years (n = 2158) < 25 660 (63.8) 1 (NA) ND 26–30 370 (59.5) 0.84 (0.64–1.09) ND > 31 292 (58.3) 0.79 (0.57–1.11) ND Maternal education (n = 2158) None or primary school 379 (61.2) 0.83 (0.46–1.49) ND Junior school 811 (60.6) 0.81 (0.48–1.36) ND Senior high school or above 133 (65.5) 1 (NA) ND Household wealth Poor 271 (70.2) 1.6 (1.06–2.41) 1.48 (0.92–2.39) Medium 420 (53.8) 0.79 (0.54–1.16) 0.77 (0.52–1.14) Least poor 708 (59.6) 1 (NA) 1 (NA) Ethnicity Han Chinese 999 (56.9) 1 (NA) 1 (NA) Minority 400 (66.8) 1.52 (0.95–2.45) 1.46 (0.88–2.41) Place of deliveryb County- or higher-level hospital 659 (53.5) 0.55 (0.39–0.77) 0.6 (0.41–0.9) Township-level hospital 695 (67.8) 1 (NA) 1 (NA) Private hospital, home or other 46 (45.5) 0.4 (0.2–0.79) 0.57 (0.13–2.52) Maternal antenatal clinic visits (n = 2158)b 0–4 156 (38.4) 1 (NA) 1 (NA) ≥ 5 1165 (66.6) 3.2 (2.05–4.99) 3.48 (2.23–5.43) Delivery methodb Caesarean section 261 (47.7) 0.52 (0.75–0.36) 0.53 (0.37–0.75) Vaginal 1110 (63.6) 1 (NA) 1 (NA) aOR, adjusted odds ratio; CI, confidence interval; cOR, crude odds ratio; NA, not applicable; ND, not determined. a There were 2354 survey respondents, except where otherwise stated. b A priori variables in the regression model. Bull World Health Organ 2013;91:322–331 | doi: http://dx.doi.org/10.2471/BLT.12.111310 327 Research Breastfeeding rates in ChinaSufang Guo et al. may be better among the poor than the rich46 and, in China, that breastfeeding is less common in urban than in rural areas.21,28 Third, since we excluded from the analysis children left behind by mothers who had migrated, our esti- mate of the breastfeeding rate may be higher than the true population rate. Fourth, the sampling strategy may have influenced the observed gender ratio. In rural China, families whose first born is a girl are permitted a second child and couples tend to continue having children until they have a boy. Thus, our selection of the youngest child in the household could have favoured the selection of males. Moreover, mothers may be more reluctant to register female children. The male to female ratio of 1.4:1 we observed is higher than the national average, which is 1.19:1 for infants and 1.24:1 for children aged 1 to 4 years, but it is not unusual for some rural areas.47 We considered using a life table to weight the sample but no appropriate data ex- ist, particularly given the current high mobility of China’s rural population. In the mid-1990s, China promoted breastfeeding by designating over 7000 hospitals “baby-friendly”. However, we recently observed that breast-milk sub- stitutes are promoted in many of these facilities. It appears that this initiative and associated community measures had little effect on infant and young child feeding practices. In 2010, the Chinese Ministry of Health re-launched the baby-friendly hospital initiative but, unfortunately, some related activities are partly sponsored by, or involve, companies associated with breast-milk substitutes. To prevent death and disability due to infectious diseases in childhood and to provide the best foundation for the prevention of noncommunicable dis- eases, China must focus on promoting breastfeeding throughout the nation. Although high- and mid-level govern- ment support is not yet widespread, some national champions are emerg- Table 4. Associations between survey variables and exclusive breastfeeding among children aged less than 6 months in 26 counties in central and western China, 2010 Variablea No. (%) aged less than 6 months and exclusively breastfed Univariate analysis, cOR (95% CI) Multivariate analysis, aOR (95% CI) Child’s sex Male 96 (32.6) 1.65 (1.08–2.50) 1.66 (0.96–2.86) Female 44 (22.7) 1 (NA) 1 (NA) Child has elder sibling Yes 58 (24.1) 0.64 (0.33–1.26) ND No 83 (33.1) 1 (NA) ND Maternal age, years < 25 79 (32.8) 1 (NA) ND 26–30 34 (25.4) 0.7 (0.28–1.72) ND > 31 23 (23.9) 0.64 (0.28–1.5) ND Maternal educationb None or primary school 32 (27.6) 0.44 (0.05–3.8) 0.39 (0.07–2.19) Junior school 74 (25.5) 0.39 (0.06–2.63) 0.34 (0.08–1.51) Senior high school or above 30 (46.7) 1 (NA) 1 (NA) Household wealthb Poor 32 (35.4) 1.24 (0.29–5.23) 1.24 (0.41–3.75) Medium 35 (21.9) 0.63 (0.13–3.15) 0.84 (0.2–3.46) Least poor 74 (30.7) 1 (NA) 1 (NA) Ethnicityb Han Chinese 109 (29.6) 1 (NA) 1 (NA) Minority 31 (25.9) 0.83 (0.28–2.47) 0.65 (0.23–1.82) Place of delivery County- or higher-level hospital 86 (38.3) 2.32(1.23–4.38) 2.22 (1.01–4.92) Township-level hospital 54 (21.1) 1 (NA) 1 (NA) Private hospital, home or other 1 (8.1) 0.33 (0.05–2.03) 0.44 (0.06–3.19) Maternal antenatal clinic visits (n = 2158)b 0–4 19 (23.5) 1 (NA) 1 (NA) ≥ 5 116 (30) 1.4 (0.49–3.95) 1.59 (0.52–4.85) Delivery method Caesarean section 35 (28.5) 1 (NA) ND Vaginal 105 (29.2) 1.04 (0.51–2.1) ND Child’s age (change per month) b NA 0.75 (0.62–0.89) 0.77 (0.64–0.94) aOR, adjusted odds ratio; CI, confidence interval; cOR, crude odds ratio; NA, not applicable; ND, not determined. a There were 490 survey respondents, except where otherwise stated. b A priori variables in the regression model. Bull World Health Organ 2013;91:322–331 | doi: http://dx.doi.org/10.2471/BLT.12.111310328 Research Breastfeeding rates in China Sufang Guo et al. ing.48 All sections of the community should be involved: appropriate infant and young child feeding practices should be encouraged, especially at an- tenatal clinics; health professionals and the community in general should be informed about the indications for, and the management of, Caesarean section; there should be strict limits on the use of breast-milk substitutes in health facili- ties; misconceptions about breast milk should be corrected; mothers should be advised against the early introduction of water, other liquids and complementary feeding; and exaggerated claims for the benefits of breast-milk substitutes and the promotion of substitutes by health- care workers should be actively chal- lenged. In addition, the inappropriate marketing of breast-milk substitutes should be controlled with much stron- ger regulation and employers should support breastfeeding among women re-entering the workforce. Finally, the revitalised baby-friendly hospital initia- tive should be implemented consistently and appropriate performance indicators established. ■ Acknowledgements The authors gratefully acknowledge the kind assistance of the provincial, county and township health bureaux in the sur- veyed locations. The opinions expressed in this article are those of the authors and are not intended to represent the perspectives of their parent institutions. Funding: This research was funded by UNICEF China. Competing interests: None declared. Table 5. Infant and young child feeding practices in China, neighbouring countries, Brazil and South Africa, 2003–2010 Country Survey year Initiated breastfeeding early (%) Aged less than 6 months and exclusively breastfed (%) Solids introduced at age 6–8 months (%) Still breastfed at age 12–15 months (%) Still breastfed at age 20–23 months (%) China (12 provinces in present survey) 2010 59 29 90 56 9 China (national survey) 2008 41 16 and 30a 43b 37 ND South-eastern Asia Cambodia 2010 65 74 82 83 43 Lao People’s Democratic Republic 2006 30 26 70 82 48 Myanmar 2009–2010 76 24 81 91 65 Thailand 2009 50c 15 ND ND ND Viet Nam 2006 58 17 70 78 23 South Asia Bangladesh 2007 43 43 74 95 91 Bhutan 2010 59 49 67 93 66 India 2005–2006 41c 46 57 88 77 Nepal 2006 35 53 75 98 95 Pakistan 2006–2007 29 37 36 79 55 Central and northern Asia Democratic People’s Republic of Korea 2004 18c 65 31 67 37 Kazakhstan 2006 64 17 39 57 16 Kyrgyzstan 2006 65 32 49 68 26 Mongolia 2005 81c 57 57 82 65 Tajikistan 2004–2005 57c 25 15 75 34 Asia, median NA 57 37 67 82 52 Other BRICSd nations Brazil 2006 43 40 70 50 25 South Africa 2003 61 8 49 66 31 BRICS nations excluding China and the Russian Federation,e median NA 48 31 59 68 44 NA, not applicable; ND, not determined. a The rate was 16% in urban areas and 30% in rural areas. b The Chinese National Health Services Survey used an older, narrower definition of complementary feeding, which resulted in a lower figure for this measure. c Data on the early initiation of breastfeeding were not derived from the same survey that provided data on the other four indicators. The alternative surveys were carried out in: 2009 in the Democratic People’s Republic of Korea; 2007 to 2008 in India: 2008 in Mongolia; 2009 in Tajikistan; and 2005 to 2006 in Thailand. d The BRICS nations comprise Brazil, the Russian Federation, India, China and South Africa. e Data were not available for the Russian Federation. Bull World Health Organ 2013;91:322–331 | doi: http://dx.doi.org/10.2471/BLT.12.111310 329 Research Breastfeeding rates in ChinaSufang Guo et al. 摘要 2010 年中国中西部母乳喂养率：对儿童和人口健康的影响 目的 使用全球推荐的指标描述中国农村的母乳喂养实践， 并将其与邻国和大型新兴经济体的实践进行比较。 方法 对12 个中西部省份贫穷乡村的2354 名2 岁以下儿童 开展以社区为基础的横断面调查。探讨婴幼儿喂养和社会 经济、人口和卫生服务因素之间的关联，并将比例与来自 中国和其他国家的最新数据进行比较。 结果 总体而言，98.3%的婴儿接受母乳喂养。然而，新生 儿早开奶率只有59.4%（即在出生后的1小时内）；分别只 有55.5%和9.4%的婴儿持续接受母乳喂养到1 至2 岁，6 个 月以下的婴儿纯母乳喂养率只有28.7%。早开奶与至少五 次产前检查呈正相关（调整后的优势比，aOR：3.48；P < 0.001），与剖宫产（aOR：0.53；P<0.001）或在县 级及以上医疗机构中分娩（aOR：0.6；P = 0.014）呈负 相关。6 个月以下婴儿纯母乳喂养与在县级及以上医疗机 构中分娩呈正相关（aOR：2.22；P = 0.05）。母乳喂养与 产妇年龄或教育、民族或家庭财富无关联。调查的纯母乳 喂养率和持续母乳喂养率大多低于其他国家。 结论 尽管中国努力促进母乳喂养，但是比例仍非常低。需 要努力改善婴幼儿喂养，降低死亡率和发病率。 Résumé Taux d’allaitement maternel en Chine centrale et occidentale en 2010: implications pour la santé de l’enfant et de la population Objectif Décrire les pratiques d’allaitement maternel dans la Chine rurale en utilisant des indicateurs recommandés au niveau mondial et en les comparant avec les usages des pays voisins et des grandes économies émergentes. Méthodes Une étude transversale a été menée, sur base communautaire, auprès de 2354 enfants âgés de moins de 2 ans, répartis dans 26 comtés ruraux pauvres de 12 provinces du centre et de l’ouest du pays. Les corrélations entre les indicateurs d’allaitement infantile et du jeune enfant et les variables socio-économiques, démographiques et des services de santé ont été explorées et les taux ont été comparés avec les données les plus récentes en provenance de Chine et d’autres pays. Résultats Dans l’ensemble, 98,3% des nourrissons avaient été nourris au sein. Cependant, seulement 59,4% avaient bénéficié d’un allaitement précoce (c’est-à-dire au cours de la première heure après la naissance), seuls 55,5% et 9,4% avaient poursuivi l’allaitement maternel pendant respectivement 1 et 2 ans et seulement 28,7% des nourrissons âgés de moins de 6 mois avaient été exclusivement nourris au sein. L’initiation précoce de l’allaitement maternel a été positivement corrélée à au moins cinq consultations prénatales (odds ratio ajusté ORa: 3,48; P<0,001) et négativement corrélée à la naissance par césarienne (ORa: 0,53; P<0,001) ou en hôpital d’aiguillage (ORa: 0,6; P=0,014). L’allaitement maternel exclusif chez les enfants âgés de moins de 6 mois a été associé positivement à une naissance dans un hôpital d’aiguillage (ORa: 2,22; P<0,05). L’allaitement n’a pas été associé à l’âge ni à l’éducation de la mère, ni même à l’ethnicité ou au niveau de richesse du foyer. L’étude a révélé des taux d’allaitement exclusif et continu généralement plus faibles que dans d’autres pays. Conclusion Malgré les efforts pour promouvoir l’allaitement maternel en Chine, les taux restent très faibles. Un engagement visant à améliorer l’alimentation du nourrisson et du jeune enfant est nécessaire afin de réduire le taux de mortalité et de morbidité dans cette catégorie de la population. صخلم ناكسلاو لفطلا ةحص لىع ةبتترلما راثلآا :2010 في ينصلا برغو طسو قطانم في ةيعيبطلا ةعاضرلا تلادعم في ةيفيرلا قطانلما في ةيعيبطلا ةعاضرلا تاسرامم فصو ضرغلا تاسرمالماب اهتنراقمو ًايلماع ابه صىولما تاشرؤلما مادختساب ينصلا .ىبركلا ةئشانلا تاداصتقلااو ةرواجلما نادلبلا في تاعاطقلا ةددعتم ةيعمتمج ةيئاصقتسا ةسارد ءارجإ مت ةقيرطلا في ةيرقف ةيفير ةعطاقم 26 في ينتنس نم رغصأ ًلافط 2354 لىع ينب تاطابترلاا ضارعتسا متو .ينصلا برغو طسو في ًمايلقإ 12 ةيعماتجلاا تايرغتلماو لافطلأا راغصو عضرلا ةيذغت تاشرؤم ةنراقم متو ةيحصلا ةمدلخا تايرغتمو ةيفارغميدلاو ةيداصتقلااو .نادلبلا نم اهيرغو ينصلا نم ةدراولا تانايبلا ثدحأب تلادعلما ةعاضر اوعضر نيذلا لافطلأا ةبسن تناك ،ماع لكشب جئاتنلا ةيعيبطلا ةعاضرلا اوأدب طقف مهنم % 59.4 نأ يرغ ،% 98.3 ةيعيبط % 55.5 لصاوو ؛)ةدلاولا نم لىولأا ةعاسلا نوضغ في( ًاركبم ،لياوتلا لىع ،ينتنسو ةنس ةدلم ةيعيبطلا ةعاضرلا طقف % 9.4و نع مهرماعأ لقت نيذلا عضرلا نم طقف % 28.7 ةبسن تعضرو في ركبلما ءدبلا طبتراو .يصرح وحن لىع ةيعيبط ةعاضر رهشأ 6 لىع ةدلاولا لبق ةيريسر تارايز سمخب ًايبايجإ ةيعيبطلا ةعاضرلا )0.001< لماتحلاا ؛3.48 :ةححصلما لماتحلاا ةبسن( لقلأا ؛0.53 :ةححصلما لماتحلاا ةبسن( ةيصريقلا ةدلاولاب ًايبلس طبتراو ةبسن( ةلاحلإا ىوتسم قفارم نم قفرم في وأ )0.001< لماتحلاا تطبتراو .)0.014 = لماتحلاا ؛0.6 :ةححصلما لماتحلاا مهرماعأ لقت نيذلا لافطلأا ينب ةيصرلحا ةيعيبطلا ةعاضرلا ةلاحلإا ىوتسم قفارم نم قفرم في ةدلاولاب ًايبايجإ رهشأ 6 نع طبترت لمو .)0.05 < لماتحلاا ؛2.22 :ةححصلما لماتحلاا ةبسن( ةورث وأ يقرعلا اهلصأ وأ اهميلعت وأ ملأا نسب ةيعيبطلا ةعاضرلا ةرمتسلماو ةيصرلحا ةيعيبطلا ةعاضرلا تلادعم تناكو .اتهسرأ نم اهيرغ في اتهايرظن نع لقأ ةيئاصقتسلاا ةساردلل تعضخ يتلا .نادلبلا نأ لاإ ،ينصلا في ةيعيبطلا ةعاضرلا زيزعت دوهج مغرب جاتنتسلاا عضرلا ةيذغت ينسحتب مازتللاا يغبنيو .ةياغلل ةضفخنم تلادعلما .ةضارلماو تايفولا لدعم ليلقتل لافطلأا راغصو Bull World Health Organ 2013;91:322–331 | doi: http://dx.doi.org/10.2471/BLT.12.111310330 Research Breastfeeding rates in China Sufang Guo et al. Резюме Показатели грудного вскармливания в центральной и западной частях Китая в 2010 году: последствия для здоровья населения и детей Цель Описать практику грудного вскармливания в сельских районах Китая, используя всемирно рекомендованные индикаторы, и сравнить их с практикой в соседних странах и крупных странах с переходной экономикой. Методы Было проведено перекрестное обследование на уровне общины 2354 детей в возрасте до двух лет в 26 бедных сельских районах в 12 центральных и западных провинциях. Изучались связи между показателями грудного вскармливания новорожденных и детей раннего возраста с социально- экономическими, демографическими и медицинскими переменными, и сравнивались показатели с последними данными, полученными из Китая и других стран. Результаты Всего на грудном вскармливании находилось 98,3% детей. Однако, только 59,4% детей получали ранее грудное вскармливание (т.е. в течение одного часа после родов); только 55,5% и 9,4% продолжали получать грудное молоко в течение одного и двух лет соответственно, и всего 28,7% младенцев в возрасте до 6 месяцев находились исключительно на грудном вскармливании. Ранее начало грудного вскармливания показало положительную статистическую связь, по крайней мере, с пятью посещениями клиники дородового наблюдения (скорректированный относительный риск, сОР: 3,48; P < 0,001) и показало отрицательную статистическую связь с родоразрешением путем кесарева сечения (сОР: 0,53; P < 0,001) или в лечебно-диагностическом центре (сОР: 0,6; P = 0,014). Исключительно грудное вскармливание среди младенцев в возрасте до 6 месяцев показало положительную статистическую связь с родоразрешением в лечебно-диагностическом центре (сОР: 2,22; P < 0,05). Грудное вскармливание не показало статистической связи с возрастом или образованием матери, этнической принадлежностью или благосостоянием семьи. Исследованные показатели исключительного и длительного грудного вскармливания были преимущественно ниже, чем в других странах. Вывод Несмотря на усилия по пропаганде грудного вскармливания в Китае показатели остаются низкими. Необходимы меры по улучшению грудного вскармливания новорожденных и детей раннего возраста для сокращения уровней смертности и заболеваемости. Resumen Los índices de lactancia en el centro y oeste de China en 2010: implicaciones para la salud infantil y de la población Objetivo Describir las prácticas de lactancia en las zonas rurales de China por medio de los indicadores recomendados a nivel internacional y compararlas con las prácticas de los países vecinos y de las grandes economías emergentes. Métodos Se llevó a cabo una encuesta transversal comunitaria de 2354 niños menores de 2 años en 26 condados rurales pobres de 12 provincias del centro y oeste del país. Se investigaron las relaciones entre los indicadores de la alimentación de lactantes y niños pequeños y las variables socioeconómicas, demográficas y del sistema sanitario, y se compararon los índices con los datos más recientes tanto de China como de otros países. Resultados En general, el 98,3% de los niños había sido amamantado. Sin embargo, solo el 59,4% inició la lactancia pronto (esto es, una hora tras el nacimiento); solo el 55,5% y el 9,4% había continuado con la lactancia durante 1 y 2 años, respectivamente, y solo el 28,7% de los lactantes menores de 6 meses había sido amamantado de forma exclusiva. El comienzo temprano de la lactancia estuvo relacionado de forma positiva con al menos cinco visitas clínicas prenatales (coeficiente de posibilidades ajustado, CPa: 3,48; P < 0,001) y relacionado de forma negativa con partos por cesárea (CPa: 0,53; P <0,001) o en un centro de derivación (CPa: 0,6; P = 0,014). La lactancia exclusiva entre los niños menores de 6 meses estuvo asociada de forma positiva con un parto en un centro de derivación (CPa: 2,22; P < 0,05). La lactancia no estuvo asociada con la edad o la educación de la madre, la etnia o la riqueza del hogar. Los índices medidos de lactancia exclusiva y continuada fueron en la mayoría de casos inferiores que los de otras naciones. Conclusión A pesar de los esfuerzos para promover la lactancia en China, los índices son muy bajos. Con objeto de reducir la mortalidad y la morbilidad, es necesario un compromiso para mejorar la alimentación de lactantes y niños pequeños. References 1. The state of the world’s children. 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