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

BACKGROUND Previous studies focused on the promotion of infant formula in big cities and among families of high socioeconomic status in China. OBJECTIVE To examine the association between the place of residence and receiving free samples and advice to feed the baby with infant formula. METHODS We analyzed cross-sectional data from face-to-face interviews with 5,112 mothers with infants aged 0-5 months from 12 districts/regions in China. The study outcomes were exposure to free samples of infant formula and receiving advice to feed the baby with infant formula. The main exposure variables were the place of residence of the mothers. RESULTS About 16% of the mothers received free samples of infant formula: 6.3% during pregnancy, 3.5% during hospital stay, and 6.3% after discharge. 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% CI: 1.65, 13.14) compared to in big cities; during the hospital stay, this likelihood was lower in big cities than in the other areas; and after discharge, it was lower in poor rural counties (OR: 0.14; 95% CI: 0.05, 0.41). About 26% of the mothers across all areas received advice to feed the baby with infant formula from: hospitals (11.4%), traditional mass media (5.1%), and modern mass media (8.6%). 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. 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 in small and medium cities were more likely to receive advice form modern mass media (OR: 1.84; 95% CI: 1.20, 2.80) compared with mothers in big cities. CONCLUSIONS The promotion of infant formula in the form of free samples and advice is common in surveyed areas in China. Promotional efforts have targeted women from different places of residence, and during the first 1000 days -- pregnancy, during delivery and after birth. The study findings suggest the need to strengthen regulation and enforcement of the Code, which restricts the promotion of breastmilk substitutes, especially within health facilities and through modern forms of media.