Effect of Baby-Led Self-Attachment Breastfeeding Technique in the Postpartum Period on Breastfeeding Rates: A Randomized Study

Abstract

Objective:

To evaluate the effects of a baby-led self-attachment breastfeeding support intervention on the prevalence and duration of exclusive breastfeeding and nipple pain at 3 days, 6 weeks, 3 months, and 6 months postpartum among Chinese mothers.

Materials and Methods:

A randomized study was conducted with 504 mother–infant dyads allocated to the baby-led self-attachment breastfeeding support intervention (n = 251) and standard postpartum care (n = 253). Data on the prevalence and duration of exclusive breastfeeding and nipple pain were collected at 3 days, 6 weeks, 3 months and 6 months postpartum.

Results:

Mothers in the intervention group were significantly more likely exclusively breastfeeding at 3 days (mean difference = 12.1%, 95% confidence interval [CI]: 3.9–20.2%, p = 0.004) and 6 months postpartum (mean difference = 17.8%, 95% CI: 8.3–27.4%, p < 0.001). They were less likely to stop breastfeeding over the 6-month period, compared with the control group (Hazard ratio = 0.65; 95% CI: 0.49–0.87). They were also less likely to experience nipple pain at 3 days (mean difference = −8.1%, 95% CI: −15.9 to −0.4%, p = 0.04) and 3 months postpartum (mean difference = −4.9%, 95% CI: −8.7 to −1.2%, p = 0.01).

Conclusions:

The baby-led self-attachment breastfeeding support is clinically effective in increasing the prevalence and duration of exclusive breastfeeding and reducing nipple pain among Chinese mothers.

Introduction

Exclusive breastfeeding is recommended as the most beneficial nutrition to infants in their first 6 months of life, which protects them against childhood illness and the risk of mortality and morbidity.¹ Exclusive breastfeeding means that the infant receives only breast milk or expressed milk, and no solid food or fluid is given.² The World Health Organization (WHO) recommended that infants should be exclusively breastfed for the first 6 months of life, followed by continued breastfeeding for up to 2 years or beyond.² However, studies showed that many mothers discontinued breastfeeding well before the 6 months due to nipple pain or other breastfeeding complications.³ In Chinese population, most women initiated breastfeeding at birth (87.5%), but only 26.3% continued to exclusively breastfeed for the first 6 months of life.⁴ A national survey of 14,458 infants across 30 provinces in China reported that the prevalence of exclusive breastfeeding at 6 months was 20.7%.⁵ This figure is much lower than the target of 50% recommended by the WHO.⁶

A variety of interventions have been developed to promote exclusive breastfeeding up to 6 months after birth. Evidence indicates that the effectiveness of the interventions increase when health care professionals are involved to support exclusive breastfeeding.^7,8 Traditional breastfeeding support focuses on hand-on skills to manipulate the infant's body and the mother's breast to manually position and attach the infant onto the mother's nipple.^9,10 However, the current approach emphasizes the importance of physiologic breastfeeding and involvement of health care professionals in providing a noninterventive and dyad-centered support. This approach recognizes mothers' and infants' abilities to breastfeed independently and encourages instinctive breastfeeding to facilitate breastfeeding success.¹¹ Fletcher and Harris¹² found that the prevalence of breastfeeding was higher when mothers received “hands-off” support than “handed-on” help during hospital stay in the United States. Another study of 1,400 mothers in the United Kingdom by Ingram et al.¹³ found that health care professionals adopted a “hands-off” breastfeeding technique, which allowed the mothers to self-attach their infants by the physiology of suckling, improved the breastfeeding rate.

There is growing evidence to suggest that newborns have innate reflex and ability to search the nipple, latch onto the breast, and start breastfeeding.^14–16 Widström et al.¹⁷ observed 21 healthy term newborns and identified nine instinctive stages of newborn behavior, including the birth cry, relaxation, awakening, activity, crawling, resting, familiarization, suckling, and sleeping, which contribute to the infants' ability to self-attach to their mothers' breast. In a study of 100 mothers in India, Girish et al.¹⁶ found that breast crawl had a significant positive effect on the breastfeeding initiation and helped reduce nipple pain. In an observation study of 78 mother–infant dyads of feeding behaviors in Australia,¹⁵ effective suckling was found to be predicted by naked body contact and positioning the infants when they could instinctively move their chin underneath their mother's breast to attach to the nipple.

In a study of 40 mother–infant dyads in the United Kingdom, Colson et al.¹⁴ identified primitive neonatal reflexes and various feeding positions as “biological nurturing,” and found that a semireclined maternal posture was better than upright or side-lying in interacting with neonatal positions to release primitive neonatal reflexes and stimulate breastfeeding. In a retrospective study of 635 mothers in Australia, Thompson et al.¹⁸ found that traditional taught techniques involving the cross cradle hold and manipulation of the breast, nipple, and infants were associated with nipple trauma due to nipple malalignment, which limited the infants' instinctive ability to self-attach to their mothers' breast. The findings suggest that breastfeeding initiation is innate for both mothers and infants. The potential benefit of the physiologic approach to breastfeeding is to allow infants to self-attach to the breast, which promotes breastfeeding and minimizes the risk of breastfeeding complications. Currently, research on clinical approaches supporting physiologic breastfeeding is limited, particularly among the Chinese population. Given that health care professionals play an active and crucial role in supporting breastfeeding,¹¹ empirically based knowledge on the effectiveness of a baby-led self-attachment breastfeeding support based on physiologic breastfeeding is of paramount importance. Thus, the aims of this study were to examine the effects of a baby-led self-attachment breastfeeding support intervention on the prevalence and duration of exclusive breastfeeding and nipple pain at 3 days, 6 weeks, 3 months, and 6 months postpartum among Chinese mothers.

Materials and Methods

Design and participants

This is a randomized study. A convenience sample of mother–infant dyads was recruited between June 2016 and July 2017 at a public hospital in Guangzhou, China, where ∼20,000 babies are born every year. Inclusion criteria were first-time Chinese-speaking mothers who intended to breastfeed, gave birth to a full-term singleton infant with birth weight ≥2,500 g, and Apgar score ≥9 at 5 minutes. Exclusion criteria included maternal or infant health issues that could affect breastfeeding, and infants admitted to neonatal intensive units.

A sequence of numbers were given to mothers when they admitted to the postnatal units. Those with odd numbers were assigned to the intervention group to receive the baby-led self-attachment breastfeeding support. Those with even numbers were assigned to the control group and they received the routine teaching in breastfeeding, which included sitting, side-lying, cradle, cross cradle, and football positions.

Intervention

The baby-led self-attachment breastfeeding support intervention was developed based on physiologic breastfeeding, which includes skin-to-skin contact, biological nurturing and activation of both maternal and infant instincts by allowing the newborn to self-attach to their mother's breast and initiate breastfeeding.^11,14 Skin-to-skin contact allows naked infants to lie prone on mothers' bare chest. This facilitates infant feeding behaviors conductive to suckling ability, thus promoting breastfeeding.¹⁹ Biological nurturing advocates that newborns can be breastfed in any positions and it emphasizes that semireclining or laid-back position with a prone infant is more likely to facilitate a neonatal reflex and maternal instinct that promote successful breastfeeding.¹⁴ It is believed that the physiologic approach to breastfeeding allows newborns instinctively learn how to approach the nipple and self-latch to suckle, and mothers are capable of activating the neonatal reflexes of infants through instinctive breastfeeding behaviors.¹¹ Thus, the role of nurses is to support mothers and her infants to follow their natural instincts to continue breastfeeding and to provide a calm and comfortable environment for mothers during breastfeeding. A structured intervention protocol based on the physiologic approach to breastfeeding was developed and reviewed by a panel of experts consisting of lactation consultants and senior midwives/nurses with the experience of providing breastfeeding support.

Mothers in the intervention group received support from nurses who had received a 2-day training workshop on the principles of physiologic breastfeeding. The physiologic approach to breastfeeding was adopted with the mothers in a reclining or laid-back posture and their naked infants lying prone on their bare chests. The infants were free to follow their innate breastfeeding instincts to self-attach to their mothers' breast and initiate breastfeeding. The nurses facilitated the process by ensuring that the environment was warmth, comfort, and safe. They also encouraged the mothers to establish breastfeeding by following their instincts and responding to their infants' needs.¹¹ The mothers were encouraged to continue the breastfeeding based on the principles of physiologic breastfeeding at home after discharged from hospital.

Standard care

The mothers and infants in both the intervention and control groups received the standard postpartum care provided by the hospital. In China, the average length of hospital stay is 24 hours for mothers with vaginal birth and 72 hours for those with cesarean birth. The study hospital is accredited as a Baby-Friendly Hospital Initiative (BFHI). The standard postpartum care included breastfeeding on demand, rooming-in, and cell phone texts on the benefits of breastfeeding.

Measures

Prevalence and duration of exclusive breastfeeding

The prevalence of exclusive breastfeeding refers to the proportion of women feeding their infants only breast milk and no food or other liquids, with the exception of vitamins or mineral supplements or medications.² For example, the proportion of infants younger than 3 days who are exclusively breastfed is calculated as the number of infants younger than 3 days who are exclusively breastfed in the last 24 hours divided by the total number of infants younger than 3 days.² The duration of exclusive breastfeeding was measured as the infant's age in days when the mothers first introduce infant formula.

Nipple pain

The frequency of nipple pain was assessed by a yes-no question. Score 1 was assigned to the presence of nipple pain, while score 0 was assigned to no pain.

Perception of intervention

Perception of the baby-led self-attachment breastfeeding support was collected from the mothers and fathers, who participated in the intervention by asking them an open-ended question: “How do you feel about participation in the baby-led self-attachment breastfeeding support intervention?”

Data collection

An approval from the Ethics Committee of Guangzhou Women and Children Medical Center was obtained. Eligible mother–infant dyads were recruited when they were transferred to the postnatal units and informed written consent was received from mothers who agreed to participate in the study. Data on exclusive breastfeeding and nipple pain were collected at 3 days, 6 weeks, 3 months, and 6 months postpartum through telephone interview by a research assistant who was blinded to the intervention assignment.

Data analysis

Data analysis was conducted using the SPSS version 26. Participants' characteristics and study variables were summarized by descriptive statistics. Generalized linear mixed models (GLMMs) with the logit link were used to examine the prevalence of exclusive breastfeeding and nipple pain at follow-up points. Kaplan–Meier survival curves and Cox regression were used to compare the overall duration of exclusive breastfeeding between the intervention and control groups over the 6-month period. The sample size of 504 mother–infant dyads was estimated based on a previous study¹⁶ to detect a 15% difference between the intervention and control groups in the proportion of exclusively breastfeeding with 80% power at a significance level of 0.05 and an estimated attrition rate of about 20%.

Results

Characteristics of participants

A total of 504 mother–infant dyads were recruited and randomized to the intervention group (n = 251) and control group (n = 253). Of the women who were randomized to the intervention group, 245 (97.6%), 244 (97.2%), 219 (87.3%), and 251 (100%) completed the outcome assessments at 3 days, 6 weeks, 3 months, and 6 months postpartum, respectively. For the women in the control group, 203 (80.2%), 203 (80.2%), 203 (80.2%), and 253 (100%) completed the outcome assessments at 3 days, 6 weeks, 3 months, and 6 months postpartum, respectively. Dropout rates were 17.9% (n = 45) and 19.8% (n = 50) for the intervention and control groups, respectively. A total of 206 participants in the intervention group and 203 in the control group were analyzed.

The mean age of the mothers in the intervention and control groups were 32.0 ± 7.0 years and 31.0 ± 7.0 years, respectively. The gestation at birth was 39 ± 1 weeks for both groups. Over half of the mothers in the intervention (51%) and control groups (64.5%) had vaginal delivery. The newborn birth weights of the intervention and control groups were 3.2 ± 0.4 kg and 3.3 ± 0.4 kg, respectively.

Intervention effect on exclusive breastfeeding

The findings of GLMMs showed significant group-by-time interaction effects on the prevalence of exclusive breastfeeding (F_3,1628 = 3.86, p = 0.009). The prevalence of exclusive breastfeeding in the intervention group was 82.5%, 83.5%, 77.7%, and 61.7% at 3 days, 6 weeks, 3 months, and 6 months postpartum, respectively, while those in the control group was 70.4%, 80.8%, 76.4%, and 43.8% at 3 days, 6 weeks, 3 months, and 6 months postpartum, respectively (Fig. 1). The difference was significant at 3 days (mean difference = 12.1%, 95% confidence interval [CI]: 3.9–20.2%, p = 0.004) and 6 months postpartum (mean difference = 17.8%, 95% CI: 8.3–27.4%, p < 0.001), indicating that mothers in the intervention group were significantly more likely to be exclusively breastfeeding at 3 days and 6 months postpartum comparing to the control group. Mothers in the intervention group were also more likely to be exclusively breastfeeding at 6 weeks (mean difference = 2.7%, 95% CI: −4.7–10.2%, p = 0.48) and 3 months postpartum (mean difference = 1.3%, 95% CI: −6.9–9.5%, p = 0.75) than the control group, but the difference was not statistically significant (Table 1).

FIG. 1.

Changes in the prevalence of exclusive breastfeeding across time.

Table 1.

Generalized Linear Mixed Models of Group Differences Across Time in Prevalence of Exclusive Breastfeeding and Nipple Pain

	Intervention group (n = 206)	Control group (n = 203)	Contrast (intervention-control)	95% CI	t	p
	Mean (SE)	Mean (SE)	Contrast (intervention-control)	95% CI	t	p
Exclusive breastfeeding
3 days postpartum	82.5 (2.7)	70.4 (3.2)	12.1	3.9 to 20.2	2.9	0.004
6 weeks postpartum	83.5 (2.6)	80.8 (2.8)	2.70	−4.7 to 10.2	0.71	0.48
3 months postpartum	77.7 (2.9)	76.4 (3.0)	1.30	−6.9 to 9.5	0.32	0.75
6 months postpartum	61.7 (3.4)	43.8 (3.5)	17.8	8.3 to 27.4	3.66	<0.001
Nipple pain
3 days postpartum	16.0 (2.6)	24.1 (3.0)	−8.1	−15.9 to −0.4	−2.1	0.04
6 weeks postpartum	8.7 (2.0)	9.9 (21)	−1.1	−6.8 to 4.5	−0.4	0.70
3 months postpartum	1.5 (0.8)	6.4 (1.7)	−4.9	−8.7 to −1.2	−2.9	0.01
6 months postpartum	0.5 (0.5)	1.0 (0.7)	−0.5	−2.2 to 1.2	−0.6	0.56

CI, confidence interval; SE, standard error.

Kaplan–Meier analysis revealed a statistically significant difference in time to the cessation of exclusive breastfeeding between the intervention and control groups over the 6-month postpartum period (log rank test, p = 0.001). Median breastfeeding duration was 6 months for the intervention group and 3 months for mothers in the control group (Fig. 2). Mothers in the intervention group were less likely to stop breastfeeding over the 6-month period (Hazard ratio of 0.65; 95% CI: 0.49–0.87).

FIG. 2.

Duration of exclusive breastfeeding between intervention and control groups.

Intervention effect on nipple pain

The prevalence of nipple pain in the intervention group was 16.0%, 8.7%, 1.5%, and 0.5% at 3 days, 6 weeks, 3 months, and 6 months postpartum, respectively, while those in the control group was 24.1%, 9.9%, 6.4%, and 1.0% at 3 days, 6 weeks, 3 months, and 6 months postpartum, respectively (Fig. 3). The difference was significant at 3 days (mean difference = −8.1%, 95% CI: −15.9 to −0.4%, p = 0.04) and 3 months postpartum (mean difference = −4.9%, 95% CI: −8.7 to −1.2%, p = 0.01), indicating that mothers in the intervention group were significantly less likely to have nipple pain at 3 days and 3 months postpartum comparing to the control group. Mothers in the intervention group were also less likely to have nipple pain at 6 weeks (mean difference = 1.1%, 95% CI: −6.8–4.5%, p = 0.70) and 6 months postpartum (mean difference = 0.5%, 95% CI: −2.2–1.2%, p = 0.56), but the difference was not statistically significant (Table 1).

FIG. 3.

Changes in the prevalence of nipple pain across time.

Perception of intervention

Almost all mothers and fathers were satisfied with the baby-led self-attachment breastfeeding support and they used a variety of words to express their feelings, such as amazing, joyful, excitement, happy, grateful, confident, and ambitious to breastfeed their child. The majority of the fathers showed support (88.3%) to their partners during breastfeeding and over one third (69.9%) of them were involved in the intervention.

Discussion

To the best of our knowledge, this is the first randomized controlled trial to evaluate the effect of a baby-led self-attachment breastfeeding support on exclusive breastfeeding and nipple pain in the Chinese population. The results provide evidence for the effectiveness of the baby-led self-attachment breastfeeding support in increasing the prevalence and duration of exclusive breastfeeding and reducing nipple pain among Chinese mothers. Consistent with the findings in previous studies,^14–16 the mothers who have adopted the physiologic breastfeeding demonstrated a higher prevalence of exclusive breastfeeding at 3 days and 6 months postpartum and a longer duration of exclusive breastfeeding up to 6 months postpartum. The findings support physiologic breastfeeding, which emphasizes the importance of skin-to-skin contact, biological nurturing and innate maternal and neonatal breastfeeding abilities by allowing newborns to self-attach to the breast and initiate breastfeeding.¹¹

Although most hospitals in China have followed the BFHI guidelines and placed naked infants immediately on their mothers' bare chest to initiate breastfeeding at the labor and delivery units, this practice is often not continued for subsequent breastfeeds at the postnatal units.²⁰ The present findings suggest the importance of continuing the practice of maternal-infant naked body contact that allows infants to instinctively seek out their mothers' breast and self-attach to the breast to maintain exclusive breastfeeding in the postnatal period.

Furthermore, the baby-led self-attachment breastfeeding support has been found to reduce nipple pain during the early stage of breastfeeding when the cessation rate is usually highest.³ The result is in line with a previous study that biological nurturing significantly reduced the incidence of breastfeeding complications, such as cracked and sore nipples.²¹ Biological nurturing in a laid-back posture is believed to help reduce nipple pain and facilitate better attachment, thus promotes the establishment of exclusive breastfeeding.¹⁴ Moreover, fathers have often been found to play an essential role in supporting mothers' decision to breastfeed.^22,23 The positive attitude of fathers toward physiologic breastfeeding in this study and their involvement and support for their partners during breastfeeding probably have enhanced the confidence of mothers in continuing breastfeed exclusively.

The prevalence of exclusive breastfeeding increased slightly at 6 weeks postpartum followed by declines at 3 and 6 months postpartum in both the intervention and control groups, which is similar to the findings in previous studies.^24,25 Studies have found that mothers who return to work are less likely to continue exclusive breastfeeding.^26,27 Given that the length of maternity leave in China is only 14 weeks, the need of mothers to return to work probably has resulted in a decline in exclusive breastfeeding. Furthermore, complementary food is often introduced 4 months after the birth of infants in Chinese society due to the traditional belief that exclusive breastfeeding cannot satisfy the need for food of infants up to 6 months of age.²⁶ This probably has led to a further decline in exclusive breastfeeding rate.

Nevertheless, the prevalence of exclusive breastfeeding for both the intervention and control groups across the 6-month period are comparatively higher than those reported in previous studies.^5,28 Given that the study hospital is accredited as a BFHI, it is possible that mothers in the present study received continuous support from the health care professionals when they encountered breastfeeding difficulties. This support might improve the mothers' ability to initiate and establish breastfeeding successfully, thus sustained the exclusive breastfeeding rate. Furthermore, there was a relatively lower incidence of nipple pain reported by the mothers in this study when compared to those reported in previous studies.^21,29 This probably has contributed to the success of exclusive breastfeeding, particularly over the early postpartum when the cessation of exclusive breastfeeding is often highest.

Limitations

The participants were recruited from a single hospital accredited as BFHI in China, hence may not represent all mothers at postpartum. Future study should evaluate the baby-led self-attachment breastfeeding support intervention in different settings and cultural groups. Besides, demographic data and clinical characteristics of the participants, such as education level and family income, were not available. This may limit the generalizability of the study.

Conclusions

This study has provided evidence that the baby-led self-attachment breastfeeding support intervention is clinically effective in enhancing exclusive breastfeeding and reducing nipple pain. The findings suggest that there is a need to extend the duration of skin-to-skin contact between mothers and infants, and to assist mothers to establish physiologic breastfeeding at the postnatal period. Given that the annual economic cost of nonbreastfeeding was estimated to be over US$66 billion,³⁰ it is important to incorporate the principles of physiologic breastfeeding by allowing infants to self-attach to their mother's breast in the design of interventions to facilitate successful breastfeeding.

Footnotes

Acknowledgments

The authors would like to thank H Zeng, XY Zhang, Q Xu, XL He, JY He and BL Fu, who assisted in the intervention and data collection, and all the families who participated in this study.

Disclosure Statement

The authors declared no potential conflicts of interest.

Funding Information

No funding was received.

References

Victora

, Bahl

, Barros

AJD

, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet, 2016; 387:475–490.

World Health Organization. Indicators for Assessing Infant and Young Child Feeding Practices Part 2: Measurement. Geneva: World Health Organization, 2010.

Dennis

, Jackson

, Watson

Interventions for treating painful nipples among breastfeeding women. Cochrane Database Syst Rev 2014, DOI: 10.1002/14651858.CD007366.pub2.

Family Health Service. Breastfeeding Survey 2019. Hong Kong: Family Health Service, Department of Health, 2019.

Duan

, Yang

, Lai

, et al. Exclusive breastfeeding rate and complementary feeding indicators in China: A national representative survey in 2013. Nutrients, 2018; 10:249.

WHO/UNICEF. Global Nutrition Targets 2025: Breastfeeding Policy Brief (WHO/NMH/NHD/14.7). Geneva: World Health Organization, 2014.

Kim

, Park

, Oh

, et al. Interventions promoting exclusive breastfeeding up to six months after birth: A systematic review and meta-analysis of randomized controlled trials. Int J Nurs Stud, 2018; 80:94–105.

Renfrew

, McCormick

, Wade

, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev, 2012; 5:CD001141.

Cooke

, Cantrill

, Creedy

. Midwives' reported practice supporting the first breastfeed. Matern Child Nutr, 2009; 5:334–346.

10.

Burns

, Fenwick

, Sheehan

, et al. Mining for liquid gold: Midwifery language and practices associated with early breastfeeding support. Matern Child Nutr, 2013; 9:57–73.

11.

Schafer

, Genna

. Physiologic breastfeeding: A contemporary approach to breastfeeding initiation. J Midwifery Womens Health, 2015; 60:546–553.

12.

Fletcher

, Harris

. The implementation of the HOT program at the Royal Women's Hospital [online]. Breastfeed Rev, 2000; 8:19–23.

13.

Ingram

, Johnson

, Greenwood

. Breastfeeding in Bristol: Teaching good positioning, and support from fathers and families. Midwifery, 2002; 18:87–101.

14.

Colson

, Meek

, Hawdon

. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev, 2008; 84:441–449.

15.

Cantrill

, Creedy

, Cooke

, et al. Effective suckling in relation to naked maternal-infant body contact in the first hour of life: An observation study. BMC Pregnancy Childbirth, 2014; 14:20.

16.

Girish

, Mujawar

, Gotmare

, et al. Impact and feasibility of breast crawl in a tertiary care hospital. J Perinatol, 2013; 33:288–291.

17.

Widström

A-M

, Lilja

, Aaltomaa-Michalias

, et al. Newborn behaviour to locate the breast when skin-to-skin: A possible method for enabling early self-regulation. Acta Paediatr, 2011; 100:79–85.

18.

Thompson

, Kruske

, Barclay

, et al. Potential predictors of nipple trauma from an in-home breastfeeding programme: A cross-sectional study. Women Birth, 2016; 29:336–344.

19.

Moore

, Bergman

, Anderson

, et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev, 2016; 11:CD003519.

20.

Zhang

, Jin

, Vereijken

, et al. Breastfeeding experience, challenges and service demands among Chinese mothers: A qualitative study in two cities. Appetite, 2018; 128:263–270.

21.

Milinco

, Travan

, Cattaneo

, et al. Effectiveness of biological nurturing on early breastfeeding problems: A randomized controlled trial. Int Breastfeed J, 2020; 15:21.

22.

Zhu

, Chan

WCS

, Zhou

, et al. Predictors of breast feeding self-efficacy among Chinese mothers: A cross-sectional questionnaire survey. Midwifery, 2014; 30:705–711.

23.

Huang

, Ren

, Liu

, et al. Factors affecting breastfeeding adherence among Chinese mothers: A multicenter study. Medicine (Baltimore), 2017; 96:e7619.

24.

, Ouyang

Y-Q

. Father's role in breastfeeding promotion: Lessons from a quasi-experimental trial in China. Breastfeed Med, 2016; 11:144–149.

25.

, Ouyang

Y-Q

, Redding

. Family-centered breastfeeding education to promote primiparas' exclusive breastfeeding in China. J Hum Lact, 2017; 34:365–378.

26.

Jia

, Dong

X-y

, Song

Y-p

. Paid maternity leave and breastfeeding in urban China. Fem Econ, 2018; 24:31–53.

27.

Mirkovic

, Perrine

, Scanlon

. Paid maternity leave and breastfeeding outcomes. Birth, 2016; 43:233–239.

28.

, Nguyen

, Wang

, et al. Breastfeeding practices and associated factors at the individual, family, health facility and environmental levels in China. Matern Child Nutr, 2020; 16(S2):e13002.

29.

Bourdillon

, McCausland

, Jones

. Latch-related nipple pain in breastfeeding women: The impact on breastfeeding outcomes. Br J Midwifery, 2020; 28:406–414.

30.

Walters

, Phan

LTH

, Mathisen

. The cost of not breastfeeding: Global results from a new tool. Health Policy Plan, 2019; 34:407–417.