Publications

Introduction: Longitudinal trends in breastfeeding (BF) are often overlooked in favor of binary or time-to-cessation measures. Characterizing these trends can inform promotion of sustained BF practices. We identified distinct BF profiles among participants of a maternal and child health program.

Methods: The Healthy Future program consisted of community health workers delivering a BF curriculum to mothers through monthly home visits. The program was evaluated in rural Sichuan, China with a cluster-randomized controlled trial (assigned to program versus not). We clustered 6-month postpartum trends (n = 949) of maternal-reported infant feeding using dynamic time warping. For each month, participants were categorized as either exclusive breastfeeding (EBF), mixed feeding (MF, feeding breastmilk plus other foods or liquids), or not breastfeeding (NBF). After identifying clusters, we regressed BF profiles on intervention assignment using adjusted multinomial logistic regression.

Results: Cluster analysis revealed seven profiles: always EBF, always MF, never breastfed, EBF until the 5th month, MF until the 5th month, mostly EBF, and NBF from the 3rd month. The intervention was associated with improved odds of always EBF (ROR = 2.61, 95% CI 1.25, 5.42), MF until the 5th month (ROR = 2.52, 95% CI 1.18, 5.39), and NBF from the 3rd month (ROR = 2.82, 95% CI 1.16, 6.87) compared to being never breastfed. Mothers in the never breastfed cluster had the lowest age, education, BF knowledge and attitudes, and decision-making power.

Discussion: Cluster analyses found the intervention significantly improved EBF, particularly in mothers characterized by higher baseline educational attainment and BF knowledge. Targeted efforts are needed to help mothers initiate EBF from birth and continue EBF through month 6.

Background
Under-resourced communities in rural China have long faced limitations in accessing and utilising caregiver and child healthcare (CCH). The COVID-19 pandemic exacerbated health inequities globally, while its precise impacts on CCH remain understudied. We report differences in parental migration, maternal mental health, household and nutrition expenditures, child feeding practices, and prenatal, postnatal, and childbirth care following pandemic lockdowns in rural China.

Methods
We compared two groups of families with children who grew to the age of six months either before or during lockdowns. We enrolled eligible households from 80 rural townships, randomly selected from four poverty-designated counties in Sichuan Province, China. We interviewed the control group of primary caregivers in November and December of 2019 (pre-COVID-19), and the case group in May of 2020 (approximately five months into the pandemic). Statistical analyses included t tests and linear regressions with adjustments. P-values <0.05 were considered statistically significant.

Results
Compared to the control group, the case group presented significantly lower paternal migration and more favourable maternal mental health. Caregiving behaviours (including household and nutrition expenditures) and child feeding practices did not differ, except for higher spending on infant micronutrient supplements. Prenatal health services utilisation, including home visits, was slightly higher, while postnatal services utilisation was lower.

Conclusions
Our findings suggest that many aspects of CCH in rural China were similar or improved during the early pandemic lockdowns. These data highlight the importance of promoting targeted public health interventions, such as mental health support initiatives, accessible perinatal care options, and family-centred education campaigns, in under-resourced communities and during future healthcare crises.

Background: Maternal empowerment - the capacity to make decisions within households - is linked to better child feeding and nutritional outcomes, but few studies have considered the mediating role of caregiver knowledge. Further, existing literature centres primarily on the husband-wife dyad while overlooking grandmothers as important childcare decision-makers.

Methods: We collected primary data through household surveys in 2019 and 2021 from 1190 households with infants zero to six months living in rural western China. We identified the primary and secondary caregivers for each infant and assessed their feeding knowledge and practices, as well as infant nutritional status. We constructed a maternal empowerment index using a seven-item decision-making questionnaire and examined the relationship between maternal empowerment in childcare and household decisions, caregivers' feeding knowledge, and infant feeding practices and nutritional outcomes.

Results: Mothers had significantly higher levels of feeding knowledge than secondary caregivers (most were grandmothers, 72.7%), with average knowledge scores of 5.4 vs. 4.1, respectively, out of 9. Mothers and secondary caregivers with higher levels of feeding knowledge had significantly higher exclusive breastfeeding rates by 13-15 percentage points (P < 0.01) and 11-13 percentage points (P < 0.01), respectively. The knowledge of secondary caregivers was even more strongly associated with not feeding formula (15 percentage points, P < 0.01). Mothers empowered to make childcare decisions were more likely to exclusively breastfeed (12-13 percentage points, P < 0.01), less likely to formula feed (9-10 percentage points, P < 0.05), and more likely to have children with higher Z-scores for length-for-age (0.32-0.33, P < 0.01) and weight-for-age (0.24-0.25, P < 0.05). Effects remained after controlling for maternal feeding knowledge.

Conclusions: While mothers' and grandmothers' feeding knowledge was both important for optimal infant feeding, grandmothers' knowledge was particularly critical for practicing exclusive breastfeeding. Given the disparity in feeding knowledge between the two caregivers, our study further shows that mothers empowered in childcare decision-making were more likely to exclusively breastfeed their infants. This implies that some mothers with adequate knowledge may not practice optimal feeding because of lower decision-making power. Overall, our study highlights the role of secondary caregivers (grandmothers) in infant care and suggests that future child nutritional interventions may benefit from involving secondary caregivers (grandmothers).

Breastfeeding self-efficacy (BSE), defined as a mother’s confidence in her ability to breastfeed, has been confirmed to predict the uptake of exclusive breastfeeding (EBF). Early experiences during the birth hospital stay, especially in-hospital formula feeding (IHFF), can impact both EBF and maternal breastfeeding confidence. Therefore, our objective was to examine the association between IHFF and EBF outcomes and investigate whether this association is influenced by BSE. The study included 778 infants from a larger cohort study conducted in 2021, with a one-year follow-up in rural areas of Sichuan Province, China. We used a causal mediation analysis to estimate the total effect (TE), natural direct (NDE), and nature indirect effects (NIE) using the paramed command in Stata. Causal mediation analyses revealed that IHFF was negatively associated with EBF (TE odds ratio = 0.47; 95% CI, 0.29 to 0.76); 28% of this association was mediated by BSE. In the subgroup analysis, there were no significant differences in the effects between parity subgroups, as well as between infant delivery subgroups. Our study found that IHFF hindered later EBF and that BSE mediated this association. Limiting the occurrence of in-hospital formula feeding or improving maternal breastfeeding self-efficacy is likely to improve exclusive breastfeeding outcomes.

Introduction Millions of young rural children in China still suffer from poor health and malnutrition, partly due to a lack of knowledge about optimal perinatal and child care among rural mothers and caregivers. Meanwhile, there is an urgent need to improve maternal mental health in rural communities. Comprehensive home visiting programmes delivered by community health workers (CHWs) can bridge the caregiver knowledge gap and improve child health and maternal well-being in low-resource settings, but the effectiveness of this approach is unknown in rural China. Additionally, grandmothers play important roles in child care and family decision-making in rural China, suggesting the importance of engaging multiple caregivers in interventions. The Healthy Future programme seeks to improve child health and maternal well-being by developing a staged-based curriculum that CHWs deliver to mothers and caregivers of young children through home visits with the assistance of a tablet-based mHealth system. This protocol describes the design and evaluation plan for this programme.

Methods and analysis We designed a cluster-randomised controlled trial among 119 rural townships in four nationally designated poverty counties in Southwestern China. We will compare the outcomes between three arms: one standard arm with only primary caregivers participating in the intervention, one encouragement arm engaging primary and secondary caregivers and one control arm with no intervention. Families with pregnant women or infants under 6 months of age are invited to enrol in the 12-month study. Primary outcomes include children’s haemoglobin levels, exclusive breastfeeding rates and dietary diversity in complementary feeding. Secondary outcomes include a combination of health, behavioural and intermediate outcomes.