Advice to use infant formula and free samples are common in both urban and rural areas in China: a cross-sectional survey

Advice to use infant formula and free samples are common in

both urban and rural areas in China: a cross-sectional survey

Jia Li

, Tuan T Nguyen

, Yifan Duan

, Roger Mathisen

and Zhenyu Yang

School of Business, Nanjing University of Information Science & Technology, Nanjing, People’s Republic of China:

Alive & Thrive Southeast Asia, FHI 360, Hanoi, Vietnam:

National Institute for Nutrition and Health, Chinese Center

for Disease Control and Prevention, No.27 Nanwei Road, Xicheng District, Beijing 100050, People’s Republic of

China

Submitted 1 September 2020: Final revision received 24 November 2020: Accepted 21 December 2020: First published online 8 January 2021

Abstract

Objective: To examine the association between the place of residence and receiv-

ing free samples and advice to feed the baby with infant formula.

Design: A cross-sectional study.

Setting: The current study covered twelve counties/districts in China.

Participants: 5112 mothers with infants aged 0–5·9 months.

Results: About 16 % of the mothers received free samples of infant formula. During

pregnancy, this likelihood was higher among mothers in small and medium cities

(OR: 1·96; 95 % CI 1·14, 3·38) and non-poor rural counties (OR: 4·65; 95 % C I 1·65,

13·14) compared with mothers in big cities. During the hospital stay, it was lower in

big cities. After dis charge, it was lower in poor rural counties (OR: 0·14; 95 % CI

0·05, 0·41). About 26 % of the mothers were advised to feed their infants with infant

formula. The likelihood of receiving advice to feed the baby with infant formula

from hospitals was lower in non-poor (OR: 0·37; 95 % CI 0·21, 0·66) and poor rural

counties (OR: 0·35; 95 % CI 0·13, 0·91) than in big cities. Mothers in non-poor rural

counties were less likely to receive advice from traditional mass media (OR: 0·17;

95 % CI 0·06, 0·48), while mothers in small and medium cities were more likely to

receive advice from modern mass media (OR: 1·84; 95 % CI 1·20, 2·80) compared

with mothers in big cities.

Conclusions: The promotion strategy of infant formula varies from different places

of residence in China. The study suggests the need to strengthen enforcement of

relevant regulations, especially within health facilities and through modern mass

media.

Keywords

Breast-feeding support

China

Cross-promotion

Infant formula

International Code

of Marketing of

Breastmilk Substitutes

Aggressive promotion of breastmilk substitutes (BMS) is

one of the key barriers to successful breast-feeding and

thus poses dangers to infant health

(1,2)

. Previous studies

showed that inappropriate marketing of BMS affects

breast-feeding behaviours of women as well as medical

practice of healthcare workers related to supporting

breast-feeding

(3–5)

. For example, misconceptions related

to feeding and intention to feed infant formula at birth were

associated with increased feeding of infant formula in the

first 3 d of life, which is associated with increased feeding

of infant formula and premature cessation of breast-

feeding

(6)

. Studies in China also revealed that mothers

who received advice to feed the baby with BMS had a lower

prevalence of exclusive breast-feeding and continued

breast-feeding

(7,8)

. Promotion of infant formula hinders

progress towards achieving the Global Nutrition Targets

and Sustainable Development Goals endorsed by most

governments

(9)

Infant formula sales are high and increasing in East Asia,

including in China

(3,10,11)

. Indeed, China is the largest infant

formula market in the world

(3)

. The sale of baby food in

China, around 90 % of which was formula milk, doubled

in just 5 years from 2010 to 2014, and then one and a half

fold from 2014 to 2018

(12,13)

. BMS manufact urers and dis-

tributors employ various tactics to promote their products.

In addition to direct promotion to mothers and their

families via television, social media and home visits, man-

ufacturers and distributors promote BMS indirectly via

incentives, free samples and activities within the health ser-

vice setting during pregnancy, hospital stay and after

Public Health Nutrition: 24(8), 1977–1988 doi:10.1017/S1368980020005364

*Corresponding author: Email [email protected]

the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distri-

bution, and reproduction in any medium, provided the original work is properly cited.

https://doi.org/10.1017/S1368980020005364 Published online by Cambridge University Press

discharge

(1,4,14–17)

. Distribution of free samples of infant for-

mula or promotio nal materials to pregnant women typi-

cally happens during consultations and events organised

by BMS manufacturers and distributors, where they famil-

iarise women with the prod ucts and aim to increase the

preference for certain types of infant formula to use in

the future

(18,19)

. The promotion of infant formula during

the hospital stay and after discharge through health work-

ers and BMS representatives is also common in China

(20,21)

Additionally, cross-promotion (e.g., similar labelling,

ambiguous messages) across BMS product categories

(e.g., milk formula for pregnant women, preterm babies,

infants and toddlers) is a common practice of BMS manu-

facturers and distributors to circumvent the national Code

legislation, creating confusion for families

(2)

Given the negative impact of BMS promotion and

aggressive marketing tactics, regulating the inappropriate

practices of BMS companies has been identified as a critical

intervention to protect and build supportive environments

for breast-feeding

(22)

. The World Health Assembly adopted

the International Code of Marketing of Breastmilk

Substitutes (hereafter the Code) in 1981 to prohibit the

advertising and promotion of BMS

(23)

. Even though 136

out of 194 countries have adopted some forms of national

legal measures adhering to the Code by 2020, robust

measures are in place in only a few countries to eliminate

inappropriate promotion of BMS

(24)

. According to this

report, only some provisions of the Code are included in

the current regulations in China

(24)

. The main policy,

Administrative Measures for the Marketing of Breastmilk

Substitutes (hereafter the Measure) issued in 1995

(25)

, was

abolished in 2017, leaving the marketing of BMS in

China weakly regulated (online supplementary

Appendix A).

Furthermore, the China Food and Drug Administrat ion

introduced a new regulation in 2016 to establish standards

for infant formula

(26,27)

, creating opportunities for certain

brands to market themselves as high quality to help expand

their market into medium and small cities and rural areas

where substandard products were commonly used

(28)

.As

the Chinese economy develops, rising income makes infant

formula more affordable for mothers in lower socio-

economic groups (e.g., rural or urban poor). Introduction

of the universal two-child policy in 2015 is projected to

result in a significant increase in birth rate, especially in

small cities and rural areas of China

(29)

. BMS companies

might have captured those policy gaps and socio-

demographic dynamic changes to expand their market in

China. Previous studies in China have focused on the

promotion of infant formula in big cities

(7,20)

. Thus, info r-

mation about the promotion of infant formula in less-

urbanised areas in China is limited.

To address this gap in the literature, we analysed data

from a large-scale population survey to examine the asso-

ciation between the place of residence and receiving free

samples and advice to feed the baby with infant formula

among mothers with infants aged 0–5·9 months. We

hypothesised that the promotion of BMS varied across

places of residence.

Methods

Study design and data collection

In the current study, we used secondary data from 10 408

mothers with infants aged 0 –11 months old who partici-

pated in a cross-sectional survey on determinants of

breast-feeding practices in China

(8)

. Infants were approxi-

mately equally distributed across each month group. A

more detailed description of the study has been describ ed

elsewhere

(8)

. To summarise, survey samples were selected

via a multi-stage stratified cluster sampling approach. All

districts/counties were categorised into four strata, namely

big cities, small and medium cities, non-poor rural counties

and poor rural counties. Among twelve districts/counties

selected in the first stage, four were from big cities, four

were from small an d medium cities, two were from non-

poor rural counties and two were from poor rural counties.

In the second stage, four clusters were randomly selected

via probability proportional to size sampling method. In

each selected cluster, the data collection team visited the

corresponding immunisation clinic and invited mothers

who brought their 0–11-month-old children to the clinic

for immunisation to participate in the study. In total, the sur-

vey included face-to-face interviews of 10 408 mothers

with infants aged 0–11 months old.

Data were collected between September 2017 and

January 2018 in collaboration with research teams at the

provincial level Center for Disease Control and

Prevention. A structured questionnaire was programmed

into smartphones or tablets and then used for data collec-

tion (online supplementary Appendix B). Written consent

from all participants was obtained.

Study variables

Outcome variables

Promotion of infant formula in the current study was

defined as having received free samples of infant formula

or advice to feed the baby with infant formula, which was

assessed using two retrospective questions. The first ques-

tion was ‘when did the mothers receive free samples of

infant formula?’ We examined three time points: (1) during

pregnancy, (2) during hospital stay and (3) after discharge

as well as an overall measure of receiving free samples of

infant formula (No, when the mother did not receive any

free samples of infant formula in any of the three time

points; and Yes, for any alternative scenarios). The second

question was whether the mothers received advice to feed

the baby with infant formula, and if yes, from where. We

examined four circumstances: (1) from hospitals where

the mother gave birth, (2) from traditional mass media

1978 JLiet al.

https://doi.org/10.1017/S1368980020005364 Published online by Cambridge University Press

(e.g., TV, radio, magazine or book), (3) from modern mass

media (e.g., websites, online shopping malls, websites and

platform from hospitals or doctors, and social media such

as Weibo and WeChat) and (4) from family members,

relatives or friends.

Exposure variables

The place of residence was the main exposure in the cur-

rent study. The whole of China can be divided into twenty-

three provinces, five autonomous regions, four centrally

administered municipalities and two special administrative

regions, which are then subdivided into prefectures,

counties/districts and townships

(30,31)

. We sampled

districts/counties from big cities, small and medium cities,

non-poor rural counties and poor rural counties. Big cities

refer to central districts of municipalities directly under the

Central Government, cities under separate state planning

or provincial cities with a population over a million.

Small and medium cities refer to all districts/counties

except the central districts of big cities and county-level

cities. Poor rural counties refer to counties that are key tar-

gets in the national poverty alleviation and development

programme

(32)

. Non-poor rural counties refer to all remain-

ing counties.

Covariate variables

Maternal and paternal characteristics include level of edu-

cation (primary or below, junior high school, high school or

college and university or higher) and occupation (e.g.,

unemployed, agriculture relate d, industry related and

white-collar or professionals). Maternal age (≤ 25, 26–35

and ≥ 36 years) and ethnicity (Han and others) were also

collected. Child and perinatal characteristics consist of

age in months, gender, first birth, having at least one ante-

natal visit, place of birth (maternity facilities at national or

provincial levels, at municipal level, at county level and

others), caesarean birth, length of stay in health facility after

birth if extended (vaginal births: ≥ 4 d; caesarean births:

≥ 7 d) and special care service for the mothers such as hir-

ing a nanny or staying in a postpartum care centre during

the first month afterbirth

(33)

. For the first set of outcome var-

iables on receiving free samples of infant formula, we con-

trol for all of the above-mentioned covariates. For the

second set of outcome variables about receiving advice

to feed the baby with infant formula, we also consider addi-

tional covariates including reasons for being advised on

feeding infant formula (perceived breast-feeding difficul-

ties in hospital and after discharge) and hospital lack of

referral for breast-feeding supporting organisations at

discharge.

Statistical analysis

From 10 408 mothers interviewed, we selected 5261 moth-

ers with infants aged 0–5·9 months. Then, we further

excluded 149 records (< 3 % of 5261 records) due to

missing values in outcome variables and covariates to come

up with the final sample for statistical analysis of 5112.

Sensitivity analysis with the complete sample displayed

very similar findings with those reported in the current

study. The selection of mothers with infants aged

0–5·9 months was to minimise recall bias of the exposure

to infant formula free sample and advice.

All the data analysis was conducted using survey com-

mand in Stata 15.0 (Stata Inc.) to consider survey design

effect. First, we used descriptive analyses to report the

prevalence of exposure and covariate variables, and strati-

fied outcome variables by the place of residence. Then, we

used multivariate logistic regression models to examine

factors associated with receiving free samples or receiving

advice to feed the baby with infant formula. We used big

cities, mothers with a university education or higher, and

mothers who worked as white-collar workers or

professionals as the reference groups in the multivariate

logistic regression models.

Results

General characteristics

Among 5112 mothers with infants 0–5 months old (mean

age of 2·5 months), 86·1 % belonged to the Han ethnicity,

63·3 % were between 26 and 35 years old, 21·4 % had at

least a college degree and 44·7 % participated in business,

professional or industry-related occupations (Table 1).

Mothers in rural areas tended to be younger, had less edu-

cation and were less likely to work as white-collar workers

or professiona ls (Table 1). Fathers of infants had similar

educational and occupational patterns as mothers

(Table 1).

About half of the sample were boys and 46·8 % were the

first child. Almost all mothers had antenatal care, delivered

at a health facility and spent some days after births at the

health facility. The prevalence of caesarean births was

38·8 % and 32·5 % of the mothers had an extended stay

in a maternity facility after delivery (vaginal births: ≥ 4d;

caesarean births: ≥ 7 d).

About a quarter of mothers felt they had diffic ulty with

breast-feeding during the hospital stay or after discharge.

Less than 10 % of the mothers hired a nanny or stayed in

a postpartum care centre during the first month after birth,

and the majority of whom lived in big cities. Only one of

every ten mothers was referred to a breast-feeding support-

ing centre at discharge.

Receiving free samples of infant formula

About 16 % of mothers received free samples of infant for-

mula: 6·3 % received the sample during pregnancy, 3·5 %

during their hospital stay and 6·3 % after discharge

(Fig. 1). Although there were some variations by the place

of residence, the 95 % CI were overlapping in most

Promotion of infant formula in China 1979

https://doi.org/10.1017/S1368980020005364 Published online by Cambridge University Press

pairwise comparisons, except for free infant formula sam-

ple after discharge: 1 % of mothers in rural poor counties v.

4 % in small and medium cities and 5 % in non-poor rural

counties (Fig. 1).

In multivariate logistic regression models, the likelihood

of receiving free samples of infant formula during pregnancy

was higher for mothers in medium and small cities (OR: 1·96;

95 % CI 1·14, 3·38) and in non-poor rural counties (OR: 4·65;

95 % CI 1·65, 13·14) than in big cities (Table 2). This result

indicated that mothers in non-poor rural counties were more

than four times more likely to receive free samples than

those in large cities. Compared with mothers in big cities,

mothers in other areas were more likely to receive free sam-

ples of infant formula during hospital stay; however, this dif-

ference was only significant in non-poor rural counties (OR:

2·06; 95 % CI 1·04, 4·09). In contrast, mothers in big cities

were more likely to receive free samples after discharge,

especially when compared with mothers in poor rural

counties (OR: 0·14; 95 % CI 0·05–0·41) (Table 2). The likeli-

hood of receiving free samples after discharge was higher in

mothers working in agricultural sector (OR: 1·99; 95 % CI

1·12, 3·54) or unemployed (OR: 1·59; 95 % CI 1·24, 2·05) than

white-collar workers or professionals. The likelihood of

mothers who received free samples of infant formula after

discharge from private hospitals was higher than received

by mothers who gave birth in maternity facilities at national

and provincial levels (OR: 1·74; 95 % CI 1·07, 2·84), but lower

than received by mothers in maternity facilities at the county

(OR: 0·41; 95 % CI 0·26, 0·63) and municipal (OR: 0·51; 95 %

CI 0·29, 0·89) levels.

Table 1 Characteristics of participants (in percentage)

All sample

(n 5112)

Big cities

(n 1797)

Medium and small

cities (n 1663)

Non-poor rural

areas (n 833)

Rural poor

areas (n 819)

Parental characteristics

Maternal ethnicity

Han 86·1 84·1 80·3 99·0 88·9

Maternal age

≤ 25 years 25·2 13·0 30·4 29·1 37·7

26–35 years 63·3 69·7 60·4 65·3 53·4

≥36 years 11·4 17·3 9·3 5·6 8·9

Maternal education levels

University or higher 21·4 44·1 15·2 3·1 3·1

High school or college 36·5 39·0 40·2 40·9 19·3

Junior high school 34·9 15·1 34·3 54·0 60·1

Primary or below 7·1 1·8 10·3 1·9 17·6

Maternal occupations

White-collar or professionals 36·0 57·1 33·0 21·5 10·4

Industry related 8·7 9·6 9·8 8·8 4·2

Agriculture related 17·3 2·8 15·0 16·6 54·3

Unemployed related 38·1 30·5 42·2 53·2 31·1

Paternal education levels

University or higher 22·1 46·4 14·9 2·8 2·9

High school or college 35·3 38·1 38·1 35·8 23·2

Junior high school 35·8 13·8 37·8 57·4 58·1

Primary or below 6·8 1·7 9·3 4·1 15·8

Paternal occupations

White-collar or professionals 48·2 70·0 47·1 35·3 15·9

Industry related 28·4 23·3 28·9 45·6 21·0

Agriculture related 18·5 2·9 18·2 17·4 54·6

Unemployed related 4·9 3·8 5·8 1·7 8·5

Child and perinatal characteristics

The first birth 46·8 52·9 47·8 32·5 45·9

The child was male 50·2 50·4 50·5 50·1 49·2

Had antenatal visits 95·2 93·4 97·4 98·1 91·5

Health facilities the mothers gave births

National and provincial levels 18·5 44·8 4·0 0·4 8·7

Municipal level 29·3 40·5 38·2 10·2 6·1

County level 50·3 10·1 57·5 88·2 85·2

Others (mostly private) 1·9 4·7 0·3 1·2 0·0

Caesarean delivery 38·8 33·9 43·2 48·0 30·9

Long stay in health facility after births* 32·5 27·8 29·0 15·6 67·0

Had breastfeeding difficulties in hospital 26·3 36·4 21·9 20·8 18·7

Had breast-feeding difficulties after discharge 26·5 39·8 20·0 20·0 17·3

Hired a nanny or stayed in a postpartum care

centre during the first month afterbirth

7·6 16·6 4·9 1·1 0·1

Hospital where the woman gave birth did not

recommended breast-feeding supporting

centre at discharge

92·4 88·2 96·1 98·7 87·9

*Long stay in health facility after births: vaginal births: ≥ 4 d; caesarean births: ≥ 7d.

1980 JLiet al.

https://doi.org/10.1017/S1368980020005364 Published online by Cambridge University Press

Receiving advice to feed the baby with infant

formula

About 26 % of mothers in this sample received advice to

feed the baby with infant formula: 11·4 % from hospitals,

5·1 % from tradi tional mass media like TV, radio, magazines

and books, 8·6 % from modern mass media such as the

internet and social media and 3·1 % from family members,

relatives or friends (Fig. 1). More mothers in big cities

received this advice from the hospitals and traditional mass

media (e.g., TV, radio, magazine and books) than those liv-

ing in other areas (Fig. 1). Receiving the advice from

modern mass media such as internet and social media

was higher in big cities th an in rural poor counties (non-

overlapping 95 % CI) (Fig. 1).

Multivariate logistic regression models showed that the

likelihood of receiving advice to feed the baby with infant

formula from hospitals was lower in non-poor rural

counties (OR: 0·37; 95 % CI 0·21, 0·66) and poor rural

counties (OR: 0·35; 95 % CI 0·13, 0·91) than in big cities

(Table 3). The likelihood of receiving advice to feed the

baby with infant formula from mass media was lower in

non-poor rural counties for traditional mas s media (OR:

0·17; 95 % CI 0·06, 0·48) but higher in small and medium

cities for modern mass media (OR: 1·84; 95 % CI 1·20,

2·80) compared with mothers in big cities. The likelihood

of receiving advice to feed the baby with infant formula

was similar across most education levels, while it slightly

differed across occupations of mothers and fathers

(Table 3). Notably, mothers working in industry were more

likely to receive advice to feed the baby with infant formula

from modern mass media (OR: 1·53; 95 % CI 1·23, 1·91) and

family members, relatives or friends (OR: 1·66; 95 % CI1·0 2,

2·72), and fathers working in industry (OR: 1·44; 95 % CI

1·10, 1·89) for traditional mass media compared with those

working as white-collar workers or professionals. The

prevalence of receiving advice to feed the baby with infant

formula was higher in mothers giving birth in maternity

facilities at national and provincial levels than in other level

facilities (Table 3). Mothers who encountered breast-

feeding difficulties during their hospital stay were more

likely to receive advice to feed the baby with infant formula

from hospitals (OR: 1·42; 95 % CI 1·05, 1·92), modern mass

media (OR: 1·54; 95 % CI 1·21, 1·97) and family members,

relatives or friends (OR: 1·60; 95 % CI 1·23, 2·09) (Table 3).

Moreover, mothers were more than two times as likely to

receive advice of using infant formula from their family

50 %

40 %

30 %

20 %

10 %

50 %

40 %

30 %

20 %

10 %

Any circumstances

Any sources/

circumstances

Hospital to give

births

Traditional mass

media

Modern mass media

During pregnancy During hospital stay After discharge

(A)

(B)

Fig. 1 Prevalence (%, 95 % CI) of receiving free samples of infant formula (A) and advice (B) among mothers with infants < 6 months

old in China by the place of residence * for non-overlapping 95 % CI. Traditional mass media: TV, radio, magazine or book; modern

mass media: Websites, online shopping malls, websites and platform from hospitals or doctors, and social media such as Weibo and

WeChat.

, big cities; , small and medium cities; , non-poor rural areas; , poor rural areas

Promotion of infant formula in China 1981

https://doi.org/10.1017/S1368980020005364 Published online by Cambridge University Press

Table 2 Factors associated with receiving free samples of infant formula among mothers with infants < 6 months old in China†,‡

Any circumstances During pregnancy During hospital stay After discharge

(n 5112) (n 5112) (n 5112) (n 5112)

OR 95 % CI OR 95 % CI OR 95 % CI OR 95 % CI

Residence (reference: big cities)

Small and medium cities 0·94 0·52, 1·70 1·96* 1·14, 3·38 1·44 0·72, 2·88 0·41 0·15, 1·12

Non-poor rural areas 1·76 0·64, 4·82 4·65** 1·65, 13·14 2·06* 1·04, 4·09 0·45 0·17, 1·19

Poor rural areas 0·56 0·19, 1·70 0·98 0·30, 3·19 1·55 0·63, 3·80 0·14*** 0·05, 0·41

Parental characteristics

Maternal age (reference: ≤ 25 years)

26–35 years 0·97 0·81, 1·17 1·04 0·82, 1·31 0·88 0·65, 1·18 1·03 0·73, 1·44

36þ years 0·72 0·50, 1·02 0·77 0·41, 1·44 0·77 0·45, 1·33 0·77 0·49, 1·21

Maternal ethnicity (reference: others)

Han 1·96* 1·07, 3·58 1·31 0·67, 2·56 3·18* 1·22, 8·27 2·24* 1·05, 4·75

Maternal education levels (reference: university or higher)

High school or college 1·01 0·77, 1·30 0·97 0·72, 1·31 0·92 0·54, 1·56 1·05 0·73, 1·51

Junior high school 1·13 0·74, 1·72 1·16 0·95, 1·41 1·26 0·59, 2·69 0·88 0·44, 1·77

Primary or below 0·72 0·35, 1·48 0·34* 0·13, 0·86 0·95 0·29, 3·10 1·09 0·34, 3·51

Maternal occupations (reference: white-collar or professionals)

Industry related 0·91 0·71, 1·18 1·04 0·74, 1·46 0·67 0·44, 1·02 0·90 0·60, 1·36

Agriculture related 0·74 0·44, 1·26 0·43* 0·22, 0·83 0·54 0·19, 1·51 1·99* 1·12, 3·54

Unemployed 1·01 0·73, 1·40 0·88 0·62, 1·23 0·62 0·33, 1·14 1·59*** 1·24, 2·05

Paternal education levels (reference: university or higher)

High school or college 1·23 0·94, 1·62 0·97 0·66, 1·41 1·39 0·76, 2·51 1·43* 1·02, 2·00

Junior high school 0·98 0·77, 1·24 0·85 0·55, 1·32 0·84 0·35, 2·03 1·32 0·82, 2·12

Primary or below 0·92 0·54, 1·58 1·08 0·52, 2·27 0·35* 0·12, 1·00 1·38 0·48, 3·96

Paternal occupations (reference: white-collar or professionals)

Industry related 0·91 0·68, 1·22 0·94 0·67, 1·33 0·74 0·42, 1·30 0·94 0·61, 1·43

Agriculture related 0·67** 0·51, 0·87 0·72 0·46, 1·15 1·26 0·79, 2·01 0·21*** 0·13, 0·35

Unemployed 0·65 0·42, 1·00 0·58* 0·35, 0·96 0·28 0·06, 1·24 0·83 0·36, 1·93

Child characteristics

The first birth 1·01 0·85, 1·19 0·91 0·71, 1·16 0·99 0·68, 1·45 1·18 0·88, 1·59

The child was male§ 1·06 0·93, 1·20 1·00 0·71, 1·42 1·16 0·96, 1·40

Age in months|| 1·07** 1·02, 1·13 1·10* 1·00, 1·21

Perinatal characteristics

Had antenatal visits 0·99 0·71, 1·39 1·91 0·87, 4·20 0·44** 0·26, 0·73 1·11 0·55, 2·25

Health facilities the mothers gave births (reference: at national

or provincial levels)

Municipal level 0·73 0·47, 1·14 0·95 0·57, 1·56 0·78 0·33, 1·84 0·51* 0·29, 0·89

County level 0·49*** 0·34, 0·72 0·55 0·28, 1·06 0·65 0·31, 1·35 0·41*** 0·26, 0·63

Others (mostly private facilities) 2·20** 1·22, 3·97 1·64 0·64, 4·22 2·72 0·85, 8·75 1·74* 1·07, 2·84

Caesarean births¶ 1·22 1·00, 1·49 1·18 0·94, 1·49 0·99 0·75, 1·30

Long stay in health facility after births†† 0·90 0·61, 1·32 0·92 0·69, 1·24 0·64 0·32, 1·31

Hired a nanny or stayed in a postpartum care centre

during the first month afterbirth‡‡

0·88 0·41, 1·92 0·40 0·09, 1·72

†Values are adjusted OR and 95 % CI from survey multivariate logistic regression models.

‡Significantly different from the null value (OR of 1): *P < 0·05, **P < 0·01, ***P < 0·001.

§Gender of the child was not controlled for since it was unknown during pregnancy.

||Age in months was not controlled for since it is not related to receiving free samples of infant formula during pregnancy and hospital stay.

¶Caesarean births were not controlled for since it was unknown during pregnancy.

††Long stay in health facility after births: vaginal births: ≥ 4 d; caesarean births: ≥ 7 d. It was not controlled for since it was unknown during pregnancy.

‡‡Hired a nanny or stayed in a postpartum care centre during the first month afterbirth was not controlled for since it happened after discharge.

1982 JLiet al.

https://doi.org/10.1017/S1368980020005364 Published online by Cambridge University Press

Table 3 Associate factors of receiving advice to feed the baby with infant formula among mothers with infants < 6 months old in China†,‡

Any sources/circum-

stances (n 5112) Hospitals (n 5112)

Traditional mass

media§ (n 5112)

Modern mass media||

(n 5112)

Family members,

relatives or friend

(n 5112)

OR 95 % CI OR 95 % CI OR 95 % CI OR 95 % CI OR 95 % CI

Residence (reference: big cities)

Small and medium cities 0·83 0·45, 1·53 0·65 0·38, 1·11 0·57 0·27, 1·21 1·84** 1·20, 2·80 0·94 0·29–3·00

Non-poor rural areas 0·69 0·34, 1·39 0·37*** 0·21, 0·66 0·17*** 0·06, 0·48 0·84 0·44, 1·62 1·31 0·52–3·31

Poor rural areas 0·73 0·39, 1·36 0·35* 0·13, 0·91 0·51 0·20, 1·28 1·19 0·73, 1·94 1·80 0·67–4·84

Parental characteristics

Maternal age (reference: ≤ 25 years)

26–35 years 1·14 0·93, 1·40 1·11 0·80, 1·54 1·33 0·87, 2·02 1·12 0·80, 1·56 1·10 0·73–1·64

36þ years 1·25 0·93, 1·67 1·18 0·75, 1·87 2·13*** 1·36, 3·34 1·20 0·77, 1·87 0·65 0·34–1·26

Maternal ethnicity (reference: others)

Han 1·30 0·93, 1·81 1·51 0·92, 2·49 1·13 0·61, 2·09 1·61** 1·15, 2·27 0·62 0·32–1·23

Maternal education levels (reference:

university or higher)

High school or college 1·08 0·91, 1·28 1·15 0·80, 1·66 1·38 0·80, 2·38 1·02 0·68, 1·53 0·89 0·60–1·30

Junior high school 0·90 0·71, 1·15 1·11 0·79, 1·57 1·12 0·51, 2·43 0·73 0·43, 1·23 0·70 0·27–1·80

Primary or below 0·65* 0·44, 0·96 1·23 0·75, 2·00 0·72 0·24, 2·18 0·49 0·23, 1·07 0·65 0·20–·16

Maternal occupations (reference:

white-collar or professionals)

Industry related 1·14 0·82, 1·58 0·90 0·50, 1·63 0·94 0·43, 2·06 1·53*** 1·23, 1·91 1·66* 1·02–2·72

Agriculture related 0·74 0·46, 1·21 0·93 0·46, 1·86 0·63 0·23, 1·71 1·17 0·67, 2·03 0·50 0·13–1·94

Unemployed 0·99 0·81, 1·21 0·97 0·75, 1·27 0·88 0·66, 1·17 1·19 0·91, 1·57 1·21 0·77–1·90

Paternal education levels (reference:

university or higher)

High school or college 1·26 0·90, 1·77 1·29 0·89, 1·88 0·90 0·66, 1·22 1·08 0·72, 1·61 1·09 0·46–2·57

Junior high school 1·10 0·71, 1·72 1·11 0·69, 1·78 0·84 0·41, 1·71 1·09 0·68, 1·73 0·86 0·25–2·89

Primary or below 1·34 0·75, 2·39 1·47 0·68, 3·17 0·55 0·19, 1·61 1·05 0·54, 2·05 0·40 0·06–2·91

Paternal occupations (reference:

white-collar or professionals)

Industry related 0·86 0·72, 1·02 0·86 0·68, 1·08 1·44** 1·10, 1·89 0·87 0·64, 1·19 0·86 0·58–1·27

Agriculture related 0·59** 0·43, 0·81 0·80 0·47, 1·37 0·77 0·28, 2·13 0·46*** 0·31, 0·71 0·41 0·10–1·72

Unemployed 0·74 0·47, 1·15 0·78 0·36, 1·67 0·69 0·32, 1·49 0·43* 0·22, 0·84 1·65 0·63–4·31

Child characteristics

The first birth 1·20 0·96, 1·51 1·13 0·91, 1·39 1·30 0·89, 1·88 1·17 0·93, 1·47 1·24 0·71–2·15

The child was male 1·03 0·90, 1·18 1·11 0·88, 1·38 1·01 0·78, 1·29 0·93 0·79, 1·08 1·04 0·78–1·39

Age in months 1·10** 1·03, 1·18 1·00 0·92, 1·08 1·09 0·99, 1·19 1·12** 1·04, 1·19 1·21*** 1·10–1·33

Perinatal characteristics

Had antenatal visits 1·20 0·86, 1·68 0·77 0·46, 1·28 1·00 0·44, 2·26 1·15 0·87, 1·52 2·33 0·75–7·23

Health facilities the mothers gave births

(reference: at national or provincial

levels)

Municipal level 0·76* 0·61, 0·96 0·66*** 0·53, 0·82 1·02 0·59, 1·76 0·58** 0·38, 0·86 1·77* 1·10–2·85

County level 0·64** 0·47, 0·86 0·58*** 0·43, 0·78 0·69 0·44, 1·08 0·37*** 0·24, 0·55 2·26* 1·03–4·92

Others (mostly private facilities) 1·11 0·50, 2·47 0·63 0·30, 1·31 0·34*** 0·24, 0·47 0·32*** 0·17, 0·60 0·47 0·12–1·87

Caesarean births 1·21 0·97, 1·52 1·15 0·86, 1·54 1·06 0·84, 1·35 0·98 0·68, 1·41 1·22 0·92–1·64

Promotion of infant formula in China 1983

https://doi.org/10.1017/S1368980020005364 Published online by Cambridge University Press

members, relatives or friends if they encountered breast-

feeding difficulties after discharge (OR: 2·37; 95 % CI

1·69, 3·33).

Discussions

Principal results

In the current study, we found that the promotion of infant

formula in the form of free samples and advice was

common in China. Mothers reported receiving infant for-

mula promotion from multiple channels and at different

time points including during pregnancy, hospital stay

and after discharge.

First, the likelihood of receiving free samples of infant

formula was still high (about 20 % in big cities and 16 %

overall). This likelihood is lower than what has been found

in previous studies in six big cities in China

(20)

. In a sample

of almost 300 mothers recruited from outpatient clinics in

seventeen hospitals in 2012, previous study documented

that 40 % of the mothers received free samples of infant for-

mula; 76 % received samples in or near hospitals, mostly by

BMS sale representatives (61 %) and health workers

(37 %)

(20)

. Our study was a population-based study across

the country with a sample size of more than 5000 mothers,

and thus the findings might not be readily comparable to

the hospital-based studies in big cities. The lower preva-

lence of receiving free samples of infant formula, however,

might indicate a certain progress towards promoting

breast-feeding in China, including strengthening the

baby-friendly environment through baby-friendly hospital

reassessment

(34)

and the implementa tion of early essential

newborn care (EENC)

(35,36)

. Most of the hospitals participat-

ing in the studies

(20)

had been accredited as baby-friendly

hospitals and thus would have good background to shift

back to a supportive environment for breast-feeding. A

recent report by China Consumers Association on the pro-

motion and sales of BMS revealed that mothers who gave

birth to their babies in non-baby-friendly hospitals were

more likely to use BMS

(37)

. In addition, introduction of

EENC in the last decade in China may have helped to

improve early and exclusive breast-feeding practices in

the hospitals

(35)

, leading to a decline in the use of infant for-

mula and support continuing breast-feeding

(38)

In addition, the infant formula promotion in terms of

providing free samples in China might have expanded to

target mothers in lower socio-economic groups and in rural

areas. For example, our data showed that more mothers in

small and medium cities and non-poor rural counties

received free samples compared with mothers in big cities

during pregnancy and their hospital stay. The proportion of

mothers who received free samples after hospital discharge

was about the same across all areas. Socio-economic status

of the mothers and fathers was not a factor, suggesting that

BMS manufacturers and distributors are expanding their

focus to the whole population. More importantly, the

Table 3 Continued

Any sources/circum-

stances (n 5112) Hospitals (n 5112)

Traditional mass

media§ (n 5112)

Modern mass media||

(n 5112)

Family members,

relatives or friend

(n 5112)

OR 95 % CI OR 95 % CI OR 95 % CI OR 95 % CI OR 95 % CI

Long stay in health facility after births†† 0·83 0·67, 1·01 1·03 0·86, 1·22 1·09 0·83, 1·42 0·96 0·70, 1·31 0·74 0·47–1·16

Hired a nanny or stayed in a postpartum

care centre during the first month after-

birth

1·13 0·71, 1·80 1·11 0·83, 1·49 1·33 0·91, 1·94 1·00 0·71, 1·41 0·40–2·12

Breastfeeding difficulties in hospital 1·53*** 1·24, 1·89 1·42* 1·05, 1·92 0·96 0·65, 1·39 1·54*** 1·21, 1·97 1·60*** 1·23–2·09

Breast-feeding difficulties after discharge 1·36** 1·10, 1·69 1·19 0·93, 1·53 0·91 0·70, 1·20 1·14 0·85, 1·52 2·37*** 1·69–3·33

Hospital where the woman gave birth did

not recommended breast-feeding support

centre at discharge

1·01 0·75, 1·35 1·05 0·78, 1·43 0·75 0·42, 1·34 0·85 0·65, 1·10 0·76 0·39–1·50

†Values are adjusted OR and 95 % CI from survey multivariate logistic regression.

‡Significantly different from the null value (OR of 1): *P < 0·05, **P < 0·01, ***P < 0·001.

§Traditional mass media: TV, radio, magazine or book.

||Modern mass media: Websites, online shopping malls, websites and platform from hospitals or doctors, and social media such as Weibo and WeChat.

††Long stay in health facility after births: vaginal births: ≥ 4 d; caesarean births: ≥ 7d.

1984 JLiet al.

https://doi.org/10.1017/S1368980020005364 Published online by Cambridge University Press

likelihood of mothers receiving free samples of infant

formula after discharge was higher in mothers working

in agriculture or unemployed than those working as

white-collar or professionals. Compared with mothers with

university or higher education level, the likelihood of

receiving free samples of infant formula after discharge

was higher in mothers with high school or college educa-

tion level. By introducing free samples of infant formula in

various locations and time points, the BMS manufacturers

and distributors might increase the use and dependence on

infant formula

(39)

Second, we found that one of every four mothers received

advice to feed the baby with infant formula. This prevalence

was higher when they gave birth in national or provincial hos-

pitals. In China, patients tended to pursue higher quality

healthcare services, including births in tertiary and secondary

hospitals

(40)

. To reach more mothers, BMS manufacturers and

distributors would target national and provincial hospitals and

their health staff, who then might promote infant formula or

tolerate violations

(7,20)

. For example, a study in Hangzhou and

Shenzhen cities revealed that around 60% of health workers

recommended infant formula to mothers

(7)

. Vague statements

about the benefits of infant formula might have been used to

impose it as a ‘solution’ for vulnerable mothers (e.g., mental

distress, pressure of feeding and caring for her child)

(41)

Giving advice to feed the baby with infant formula might

be an easy ‘solution’ for health staff who did not have enough

time, knowledge and/or skills to support a mother to success-

fully breastfeed her infant

(41)

. A study in Wuhan revealed

that only one of every five female physicians and nurses

received any breast-feeding training and coaching after

graduation and their knowledge was surprisingly poor

(42)

Breast-feedi ng education, training and coachi ng programmes

in both China and other countries have proven to be effective

in improving knowledge and practice of health staff

(43,44)

It is essential to build capacity of health staff to support moth-

ers from pregnancy, during their hospital stay and after

discharge.

Moreover, mothers who encountered breast-feeding

difficulties during their hospital stay were more likely to

receive advice to feed the baby with infant formula from

hospitals, modern mass media as well as their family mem-

bers, relatives or friends. Those mothers greatly needed

support to overcome breast-feeding challenge. As dis-

cussed above, a lack of time, capacity and skills of health

workers to support breast-feeding might explain the higher

prevalence of receiving advice of feeding infant formula

from hospitals. Advice of feeding infant formula may come

from multiple sources through modern mass media. First,

BMS manufacturers and distributors are using modern mas s

media to reach more mothers and fathers. The BMS man-

ufacturers and distributors might still make use of existing

traditional mass media in cities such as TV, radio, maga-

zines and books. An adjusted logistic regression model

showed that the prevalence of receiving advice to feed

the baby with infant formula from modern mass media in

big cities was as high as that in non-poor and poor rural

counties but lower than that in small and medium cities.

Predominant platforms of modern mass media were

WeChat moments or QQ chats (50·6 %), maternal and baby

product malls (49·4 %) and organisations’ or companies’

websites, WeChat or Weib o (37·8 %). A recent stud y also

found many infant formula promotions on parenting apps

in China

(15)

. Inappropriate promotion of BMS products

through modern mass media is difficult to monitor and

sanction compared with traditional mass media

(45,46)

Specifically, mothers may get advice of infant formula feed-

ing from social media. China has the world’s largest number

of internet users and most active environment for social

media

(47)

. Social media is a good channel in China as com-

puters, tablets, smart phones and internet plans are acces-

sible and affordable, as well as popular among members of

younger generations

(48)

. Infant feeding advice from family

members (especially spouses) and friends might shape the

practices of the mothers directly or indirectly through daily

interactions and use of social media. Thus, future interven-

tions should include immediate social networks of mothers

especially their family members

(49,50)

Third, since abolishment of the Measure in 2017, only

the Maternal and Infant Health Care Law and its

Implementation Measures

(51)

and the Advertising Law

(52)

have provisions regarding the regulation of the inappropri-

ate marketing of BMS in China. There are still major gaps in

these two laws compared with the requirem ents of the

Code and in view of the actual needs for regulating the mar-

keting of BMS in China. The current report from WHO,

UNICEF and IBFAN shows that policies in China cover only

few provisions of the Code and has big gaps in informa-

tional/educational materials, promotion to general public,

promotion in health care facilities, engagement with

health workers and systems, labelling, monitoring and

enforcement

(24)

. China would benefit from strengthening

policies and regulations in alignment with the Code

because it would create a legal corridor for breast-feeding

promotion, protection and supports in all settings

(4)

. For

example, giving free sample and advice on using BMS in

health facilities and point-of-sales would then become

illegal and be regulated

(23,24)

. In addition to regulating tradi-

tional media, modern mass media should be regulated

too

(4,46)

. To monitor contents in modern mass media, max-

imising the role of international and governmental organi-

sations, civil society groups in report violations can be an

effective measure

(4,46)

. Given BMS companies are using

and sponsoring groups or individuals to use modern media

channels to promote their products, media firms should

ensure the contents are compliant to the Code and national

regulations

(46,53)

Strengths and limitations

Compared with previous studies, the current study has sev-

eral strengths. Firstly, by using data from a large sample of

Promotion of infant formula in China 1985

https://doi.org/10.1017/S1368980020005364 Published online by Cambridge University Press

mothers from various locations and of different socio-

economic status, it provides updated information on the

marketing of BMS in China and compares promotional tac-

tics of BMS manufacturers and distributors across different

locations. Secondly, limiting the sample to mothers of infants

0–5·9 months reduced recall bias of exposure to infant for-

mula promotion. However, the current study also faced sev-

eral limitations. Health systems in twelve sample sites

selected in the first stage have comparatively higher levels

of executive capacity, which may be correlated with their

capacity to provide a better supporting environment for

maternal and child health. Thus, cautions are needed when

generalising results suggested in the current study nationally

and comparing these results with existing literature. Second,

responses of mothers may still suffer from recall bias and

social desirability bias. Third, the cross-sectional nature of

the current study might suggest the possible associations

between the place of residence or socio-economic status

with the exposure to infant formula promotion rather than

confirm the association. However, the reverse association

would be small: it is more likely that a BMS manufacturer

or distributor targets a certain group of mothers than expo-

sure to infant formula promotion changes the place of resi-

dence or socio-economic status of the mothers. Fourth,

although we capture key information relating to BMS, the

content of our questionnaire was not as exhaustive as the

complete list of the WHO’s NetCode Assessment Module

(54)

Nonetheless, we captured two main aspects of infant formula

promotion: free samples and advice to feed the baby with

infant formula. Also, several questions are left unanswered

by the survey. For example, it is not clear who recommended

the formula in the hospitals, whether they received antenatal

and postnatal care at the same hospital where they deliver.

Conclusions

In conclusion, the promotion of infant formula in the form

of free sam ples and advice is common in surveyed areas in

China. The promotion has targeted women from different

socio-economic groups, place of residence and at various

time points such as during pregnancy, delivery, postnatal

period and beyond . The study findings would suggest

the need to strengthen regulation and enforcement of the

Code that restricts the promotion of BMS, especially within

health facilities and through modern forms of media. The

local government, health sector, media, civil groups, moth-

ers and family members in less urbanised areas should also

be prepared to protect recommended breast-feeding prac-

tices and against the negative effect of BMS promotion.

Acknowledgements

Acknowledgements: We are grateful to Joy Del Rosso,

Jessica Escobar-Alegria, Sujata Bose and Andres Martinez

from Alive & Thrive/FHI 360 Headquarters for their com-

ments and suggestions to improve this manuscript.

Financial support: The study was partially funded by the

Bill & Melinda Gates Foundation to China Development

Research Foundation (grant number OPP1152715) and

Alive & Thrive (grant number OPP50838). Conflict of inter-

est: None of the authors had a conflict of interest related to

any part of the current study or manuscript. Authorship:

The authors’ responsibilities were as follow s: J.L., T.T.N.

and Z.Y. designed the study; Y.D. and Z.Y. collected the

data; J.L. and T.T.N. analysed the data; J.L., T.T.N., Z.Y.

and R.M. interpreted the data; J.L. and T.T.N. drafted this

manuscript and R.M., Y.D. and Z.Y. provided critical intel-

lectual feedback to help revise the manuscript. All authors

have read and approved the final manuscript. Ethics of

human subject participation: The current study was con-

ducted according to the guidelines laid down in the

Declaration of Helsinki and all procedures involving

research study participants were approved by the

Medical Research Ethnics Committee at the National

Institute for Nutrition and Health at the Chinese Center

for Disease Control and Prevention (NINH, China CDC).

Written informed consent was obtained from all subjects.

Supplementary material

For supplementary material accompanying this paper

please visit https://doi.org/10.1017/S1368980020005364

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