Grandmothers’ breastfeeding knowledge, attitudes, maternal support perception, and breastfeeding practice: A prospective cohort survey

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Methods A quantitative, prospective cohort study was set in an obstetrics and gynecology specialist hospital. 310 mother-grandmother dyads completed structured questionnaires, and 282 mothers were followed up to 6 weeks postpartum to investigate breastfeeding practice. Results T he grandmother’s breastfeeding knowledge score was 9.32 (SD = 2.33). The grandmothers’ breastfeeding attitude score were 62.03 (SD = 4.46) at a positive level. The mother’s perception of the grandmother’s support score was 27.77 (SD = 3.40) at a positive level. There were positive correlations among grandmothers’ breastfeeding knowledge, grandmothers’ breastfeeding attitudes, and mothers’ perception of breastfeeding support of grandmothers. Mother's breastfeeding plan ( P = 0.02), mother's perceived breastfeeding support ( P = 0.04), grandmother's education level ( P < 0.01), and attitude towards breastfeeding ( P < 0.01) were independent influencing factors of breastfeeding practice. Conclusion Grandmothers' breastfeeding knowledge and attitudes and mothers' breastfeeding support perceptions of grandmothers were positive, but there is a vast scope for betterment. Healthcare professionals must identify the factors that impact breastfeeding practice and create interventions to improve it. grandmother breastfeeding knowledge attitude Introduction The articles on the importance of breastfeeding published in the Lancet thoroughly documented the health and economic benefits of breastfeeding [ 1 , 2 ]. The benefits are apparent, but exclusive breastfeeding (EBF) rates are low worldwide [ 3 ]. Research has indicated that only 36% of global infants and 20.7% of Chinese infants were exclusively breastfed until six months postpartum, which is lower than the 50% global nutrition target for 2025 recommended by the World Health Organization [ 4 , 5 ]. With the implementation of national policies and the development of baby-friendly hospitals, most mothers have realized the benefits of breastfeeding. However, recent estimates indicate that the rate of EBF in China has a downward trend [ 6 , 7 ]. Scholars have always emphasized the key role of family support in breastfeeding practice. A systematic review concluded that grandmothers’ positive attitude would increase breastfeeding rates by 12%, while a negative attitude can decrease rates by 70% [ 8 ]. Grandmothers' preference for formula feeding can shorten breastfeeding duration [ 9 ]. In the traditional concept, grandmothers, as representatives of older women in the family, are considered the holders and authority of breastfeeding knowledge. They pass on the information they think is correct to the next generation or direct care for infants, which could directly impact breastfeeding practices [ 10 ]. Therefore, it is necessary to explore grandmother's breastfeeding knowledge and attitudes in depth to improve breastfeeding practice. The relationship between grandmother and mother is complex and diverse for breastfeeding. In some countries, especially in underdeveloped areas, mothers are embedded in a family system of caring and supervision where grandmothers play essential and sometimes coercive roles in breastfeeding [ 11 , 12 ]. But, in some countries, grandmothers face balancing difficulties; as a grandmother said, “I only advise if I am asked.” [ 13 ]. Thus, grandmothers' influence on breastfeeding differs in different cultural backgrounds. In Chinese traditional culture, the grandmother has a vital voice in the family. However, the relationship between mothers and grandmothers changes with cultural innovation and educational development. The literature review found that most current Chinese studies focus on communities and fathers rather than grandmothers [ 14 – 16 ]. Therefore, the study aimed to scan the Chinese status of grandmothers’ knowledge and attitudes towards breastfeeding, explore the relationship between grandmothers’ knowledge, attitudes, and the mother's breastfeeding support perception, and further study whether those factors directly impact breastfeeding practices. Methods Design and Setting A quantitative, prospective cohort study was designed involving grandmothers and primiparous mothers of an infant at the obstetrics ward in a baby-friendly tertiary Maternity and Children’s hospital in China. Study Population and Data Collection Grandmother-mother pairs were recruited using convenience sampling at the Obstetrics Department of Fujian Maternity and Child Health Hospital from 1st March to 29th June 2021. A researcher explained to potential participants the objective and other details of the study, such as the research process, period, or other interesting questions, and invited them to participate. A checklist for inclusion and exclusion criteria was used to screen participants. If they fulfilled the eligibility criteria and agreed to participate in the survey, they would sign an informed consent and become a pair of participants. Then, the mother wrote the electronic questionnaire, and the paper questionnaire was filled in by the grandmothers and adopted a one-to-one structured interview to facilitate a correct understanding of the questionnaires. Mothers were followed up to 6 weeks postpartum to investigate their breastfeeding practice. The inclusion criteria for grandmothers were: (1) being able to understand and communicate with Mandarin, (2) having regular contact with mothers after delivery. Grandmothers with cognitive impairment led to impact data collection were excluded. The inclusion criteria for daughters or daughters-in-law were: (1) primiparous, (2) having a singleton infant with term and healthy (Apgar score > eight at 5 minutes), (3) being willing to breastfeed. The exclusion criteria included: (1) the time of mother-infant separation over 48 hours; (2) the mother and infant with a medical condition or contraindication to breastfeeding. The PASS calculated the sample size, considering 95% power at a 0.05 significance level. Referring to the study of Karm Acharya C et al. [ 17 ], an odds ratio (OR) of 2.3 for the correct feeding practices in households with grandmothers, the rate of EBF at six weeks postpartum in households without grandmothers was 37.6%, a minimum sample size of 290 participants. Considering the possibility of 10% refusals and unqualified, 319 participants were required. Measurement Self-administered questionnaires were used to address the objective of the study, which included the questionnaire filled in by grandmothers (Part 1), the questionnaire filled in by mothers (Part 2), and the questionnaire on the feeding method (Part 3). Part 1 included grandmothers’ general situations, the Breastfeeding Knowledge Questionnaire, and the Iowa Infant Feeding Attitude Scale (IIFAS). The general situation consisted of grandmothers’ demo-graphic data (age, employment, ethnicity, education, family income, whether to live with children), their children’s feeding mode, and whether they participated in breastfeeding courses. Grandmothers’ Knowledge of Breastfeeding questionnaire was developed based on Layal H [ 18 ], a 14-item instrument to evaluate mothers’ breastfeeding knowledge. The items were responded to by three options: true (1 point), false or I do not know (0 points), or not sure (0 points). The total overall score is from 0 to 14, with higher scores indicating a higher level of knowledge. IIFAS had 17 items, and it was a valid and reliable scale that was adopted to measure grandmothers’ breastfeeding attitudes. Permission was obtained from the original author in advance. IIFAS was developed to test maternal attitudes toward infant feeding [ 19 ], and Dai translated this scale into Chinese and verified its validity and reliability among Chinese mothers [ 20 ]. We further confirmed the scale could be used to measure grandmothers’ attitudes toward infant feeding. Before the formal investigation, ten grandmothers were recruited for a pre-investigation to ensure the breastfeeding knowledge and attitude scale could be understood correctly. 10% of the breastfeeding knowledge and attitude scale was randomly selected to test the reliability among grandmothers, with Cronbach's alpha values of 0.705 and 0.700, separately. Part 1 included the mothers’ and infants’ situation and the Mothers’ Perception of Grandmothers’ Breastfeeding Support Scale (MPGBSS). The mothers’ and infants’ situation included mothers’ age, employment, ethnicity, education, family income, pregnancy complications, whether to participate in breastfeeding courses, and postpartum data (infant age, delivery method, and delivery complications). MPGBSS was developed by Zhu, a 9-item instrument to evaluate mothers’ perceived family support for breastfeeding. The scale was a four-point Likert scale (1 point means strongly disagree and 4 points mean strongly agree) consisting of psychological and behavioral support with Cronbach's alpha value of 0.874 [ 21 ]. In Part 3, mothers were asked, “ How did you feed your baby within six weeks postpartum? ” Seven responses were set based on the breastfeeding definition from the United Nations Children's Fund [ 22 ]: (1) exclusive breastfeeding (breast milk only); (2) almost exclusive breastfeeding (breast milk and other fluids, but not formula); (3) partial breastfeeding (breast milk and formula; (4) breast given to comfort the baby but not for nutrition; (5) bottle-feeding (no breast milk at all). Only the first option was considered to be exclusively breastfeeding. Data analysis All data were analyzed using the IBM Statistical Package for the Social Sciences (SPSS) version 25.0. Descriptive analysis was used to summarize the participants’ socio-demographic characteristics and the mean scores of variables. Independent sample t -tests were used to determine the differences in continuous variables within two distinct sociodemographic subgroups. One-way analysis of variance was used to determine the differences in the continuous variables within three or more different groups. The Chi-square was used for categorical variables. Pearson’s correlation coefficient method examined relationships between all outcome variables. Binary logistic regression using the enter method was employed to explore the factors influencing mothers’ breastfeeding practices. All variables with significant correlations with mothers' breastfeeding were entered into the regression model ( P < 0.05). Results 319 mother-grandmother dyads were invited, 310 dyads participated in the current study with a response rate of 97.18%, and 282 infants’ feeding methods within six weeks postpartum were followed up with a response rate of 90.97%. The detailed socio-demographic data for mothers and grandmothers is shown in Table 1 . Table 1 The socio-demographic characteristics of mothers and grandmothers (N = 310) Variables Group N (%) Mothers Age in years ≤ 30 208 (67.1%) > 30 102 (32.9%) Education level Primary school and below 14 (4.5%) Technical secondary school/high school 39 (12.6%) College/Undergraduate 239 (77.1%) Postgraduate and above 18 (5.8%) Monthly income (¥) Less than 5000 36 (11.6%) 5000–7999 70 (22.6%) 8000-10,000 53 (17.1%) More than 10,000 151 (48.7%) Employment status Unemployed 76 (24.5%) Full-time 223 (71.9%) Part-time 11 (3.5%) Delivery mode Vaginal delivery 210 (67.7%) Cesarean section 100 (32.3%) Participated in breastfeeding courses No 191 (61.6%) Yes 119 (38.4%) Early contact with infants No 86 (27.7%) Yes 224 (72.3%) Feeding plan Definitely breastfeed 196 (63.2%) May breastfeed 25 (8.1%) Go with the flow 89 (28.7%) Grandmothers Age in years ≤ 55 175 (56.5%) > 55 135 (43.5%) Education level Primary school and below 138 (44.5%) Junior school 95 (30.6%) High school and above 77 (24.8%) Monthly income (¥) Less than 5000 145 (46.8%) 5000–7999 89 (28.7%) More than 8000 76 (24.5%) Employment status Unemployed 175 (56.5%) Employed 44 (14.2%) Retirement 91 (29.4%) Living condition Live alone 86 (27.7%) Live with new mother 224 (72.3%) Fed breast milk to own child No 89 (28.7%) Yes 221 (71.3%) Participated in breastfeeding courses No 246 (20.6%) Yes 64 (79.4%) Grandmothers’ knowledge about breastfeeding The grandmothers’ breastfeeding knowledge scores ranged from 3 to 14, with a mean score of 9.32 ( SD = 2.33), and the correct response rate is reported in Table 2 . Most grandmothers generally knew the maternal and infant benefits of breastfeeding, the importance of starting breastfeeding as soon as possible after childbirth, sucking promotes milk production, and the high nutritional value of colostrum. However, 31.9% of grandmothers did not realize or disagreed that breastfeeding can prevent childhood obesity, 64.5% thought breastmilk within three days postpartum could not meet infants’ needs, 29.4% agreed infants need to be breastfed on a schedule, 50.6% thought the remaining milk should be left in the breast after breastfeeding, 38.4% agreed with daily urine amount is a reliable sign on fed adequately, 46.1% thought breastfeeding should last six months, and 51.6% agreed that breastmilk can fully meet all the nutritional needs of 6-month-old babies without adding any other food and drinks. The results showed grandmothers with high school education and above had the most breastfeeding knowledge (10.00 ± 2.05), followed by primary school and below (9.11 ± 2.39), junior school (9.08 ± 2.36) ( P = 0.012). The higher the grandmothers’ income, the more accurate the knowledge of breastfeeding ( P < 0.001), and when grandmothers attended lectures at the hospital, their understanding of breastfeeding was more abundant ( P = 0.001). Table 2 The survey result of the grandmothers’ breastfeeding knowledge (N = 310) Items Correct rate (%) Breastfeeding can reduce the incidence of maternal breast diseases and ovarian cancer. (Ture) 80.0 Breastfeeding can reduce postpartum bleeding and promote maternal postpartum recovery. (Ture) 83.5 Breastfeeding is good for the infant's physical health. (Ture) 99.4 Breastfeeding can promote the infant's intellectual development. (Ture) 91.6 Breastfeeding can prevent childhood obesity. (True) 68.1 It is recommended that women start breastfeeding as soon as possible after childbirth (True) 90.0 The more the baby sucks, the mother’s milk production is greater. (True) 89.7 The milk secreted by the mother can meet the infant's needs within three days after delivery. (True) 35.5 The nutritional value of colostrum is very high. (True) 78.4 Baby needs to be breastfed on a schedule, not when the baby is hungry, or the mother's breasts are swollen. (False) 29.4 After breastfeeding, the remaining milk should be left in the breast. (True) 50.6 A reliable sign an infant is fed adequately is based on the daily urine amount. (True) 38.4 Breastfeeding should last six months postpartum. (True) 46.1 Breast milk can fully meet all the nutritional needs of 6-month-old babies without adding other food and drinks. (True) 51.6 Grandmothers’ attitude about breastfeeding The total scores were divided into three parts: negative ( 61 points) [ 23 ]. Grandmothers’ breastfeeding attitude scores ranged from 48 to 75, with a mean score of 62.03 ( SD = 4.46) at a positive level. Most of the grandmothers agreed that breast milk was the ideal food for babies and supported breastfeeding behavior, as shown in Table 3 . However, 43.9% of the grandmothers believed that formula feeding was not an act of missing maternal love, and nearly a quarter (24.5%) of them maintained a neutral attitude towards this statement. 61.0% of grandmothers agreed that formula feeding is better if the mother plans to return to work, and 15.5% were neutral. The view that "mothers should not breastfeed in public" was agreed upon by 39.4% of grandmothers. Grandmother’s education level ( P = 0.001), monthly income ( P = 0.03), employment status ( P = 0.004), and attending hospital lectures ( P = 0.04) were significant factors in breastfeeding attitudes. Table 3 The survey result of the grandmothers’ breastfeeding attitudes (N = 310) Items Agree Neutral Disagree SD The benefits of breastfeeding last only as long as the baby is breast-fed. a 11.9 15.2 72.9 3.77 (0.87) Formula feeding is more convenient than breastfeeding. a 15.2 6.8 77.8 3.87 (0.95) Breastfeeding increases the intimacy between mother and child. 93.6 3.2 3.2 4.04 (0.63) Breast milk is lacking in iron. a 11.6 37.1 51.3 3.45 (0.78) Formula-fed babies are more likely to be overfed than breastfed babies. 60.6 35.5 3.9 3.58 (0.60) Formula feeding is better if the mother plans to return to work. a 61.0 15.5 23.5 2.64 (0.92) Mothers who formula feed miss one of the great joys of motherhood. 43.9 24.5 31.6 3.12 (0.96) Women should not breastfeed in public places such as restaurants. a 46.4 14.2 39.4 2.98 (1.06) Breastfed babies are healthier than formula-fed babies. 80.3 12.6 7.1 3.87 (0.82) Breastfed babies are more likely to be overfed than formula-fed babies. a 7.1 43.5 49.3 3.44 (0.65) Fathers feel left out if a mother breast-feeds. a 16.4 10.3 64.2 3.65 (0.91) Breast milk is the ideal food for babies. 91.9 5.2 2.9 4.07 (0.65) Breast milk is more easily digested than formula. 90.0 5.8 4.2 3.95 (0.70) The formula is as healthy for an infant as breast milk. a 9.0 12.0 79.0 3.95 (0.92) Breastfeeding is more convenient than formula. 88.1 7.7 4.2 3.93 (0.66) Breast milk is cheaper than formula. 86.4 8.4 5.2 3.85 (0.63) A mother who occasionally drinks alcohol should not breastfeed her baby. a 6.5 7.6 85.9 3.86 (0.74) a Reverse scored item Mothers’ perception of grandmothers’ breastfeeding support The mother’s perception of grandmothers’ breastfeeding support scores ranged from 17 to 36, with a mean score of 27.77 ( SD = 3.40). 30.3% of grandmothers thought formula could replace breast milk, 58.7% thought mothers need to add formula to infants, and other details as shown in Table 4 . Mothers with postgraduate and above had the most support from grandmothers (28.78 ± 4.20), followed by college/undergraduate (28.08 ± 3.68), technical secondary school/high school (27.51 ± 3.07), primary school and below (25.00 ± 3.68) ( P = 0.01). Working mothers (28.12 ± 3.73) felt more grandmothers’ support than unemployed mothers (26.61 ± 3.00), and part-time mothers (30.26 ± 4.03) had the highest grandmothers’ support score ( P < 0.01). Mothers planning to breastfeed had higher grandmothers’ support score (28.57 ± 3.42, P < 0.01). Relationship among grandmothers’ knowledge, attitudes, and mothers’ perception Grandmothers’ attitudes toward breastfeeding were significantly and positively correlated to grandmothers’ knowledge ( r = 0.215, P < 0.01) and mothers’ perception of grandmothers’ breastfeeding support (r = 0.282, P < .01). At the same time, the grandmothers' knowledge of breastfeeding was also related to the mothers’ perception of grandmothers’ breastfeeding support (r = 0.269, P < 0.01). Factors Affecting Breastfeeding Practice Mothers were followed up to 6 weeks postpartum to collect their infant feeding methods, and the process was divided into two aspects, exclusive and non-exclusive. Single-factor analysis results showed feeding mode was influenced by the mother’s education level ( P = 0.01), occupation ( P = 0.03), and breastfeeding plan ( P = 0.02), as well as the grandmother’s education level ( P = 0.01), occupation ( P < 0.01), knowledge ( P = 0.046), attitude ( P < 0.01) towards breastfeeding, and the mother’s perception of the grandmother’s support ( P < 0.01). The binary logistic regression analysis showed that the mother's breastfeeding plan ( P = 0.02), the mother's perceived breastfeeding support (P = 0.04), the grandmother's education level ( P < 0.01), and breastfeeding attitudes ( P < 0.01) were influencing factors of breastfeeding practice. Table 4 The survey result of the mothers’ perception of grandmothers’ breastfeeding support (N = 310) Items Agree Disagree SD Grandmothers wants me to breastfeed. 98.4 1.6 3.43 (0.57) Grandmothers often help me take care of the baby. 98.1 1.9 3.39 (1.76) Grandmothers often cook me meals to promote lactation. 95.1 4.8 3.23 (0.52) Grandmothers often encourage me to breastfeed. 97.4 2.6 3.36 (0.56) Grandmothers can help me solve the problems encountered in breastfeeding. 87.1 12.9 3.05 (0.60) Grandmothers think the milk will be enough if the baby eats more of my milk. 94.8 5.2 3.19 (0.55) Grandmothers believe that formula can replace breast milk. a 30.3 69.7 2.83 (0.68) Grandmothers think I need to add formula to my baby. a 58.7 41.3 2.45 (0.70) Grandmothers think infants cry as breast milk is not good. a 22.9 77.1 2.95 (0.63) a Reverse scored item Discussion The result showed the grandmothers’ knowledge mean scores were 9.32, lower than the mothers’ average scores of 10.83 [ 18 ]. Most grandmothers knew the benefits of breastfeeding, but about half did not know breastfeeding duration well, similar to other studies [ 24 ]. In some grandmothers’ options, water or other food should be complemented to meet infants’ nutrition or other requirements such as treating asthma [ 25 ]. At the same time, we found some scientific feeding knowledge had not been mastered by the partial grandmothers, such as the adequacy of colostrum, feeding on demand, not squeezing remaining breast milk, and judging the adequacy of feeding by the amount of urine. Our results showed that grandmothers with a high school education and above had the most breastfeeding knowledge, and the possible reason is that grandmothers with higher education backgrounds have better abilities or ways to accept breastfeeding knowledge. However, grandmothers with primary and below education have higher knowledge scores than junior or high school levels. This may be related to their better practical experience in breastfeeding or the small sample size, which needs further verification. Grandmothers’ higher income is related to more accurate breastfeeding knowledge, which may reflect the relationship between better socioeconomic levels and learning ability. The result indicated that breastfeeding lectures could improve grandmothers’ knowledge. However, in most cases, despite grandmothers' critical role within households, hospital staff often belittle their expertise and do not consider the design of health education [ 10 ]. Therefore, future clinical practice should consider these gaps in grandmothers’ breastfeeding health education. This study found that grandmothers had a positive attitude towards breastfeeding, and grandmothers with higher educational levels and higher monthly incomes, who were not working, participated in breastfeeding literature and had a more excellent attitude towards breastfeeding. This might be because these grandmothers had a higher demand for the nutrition of infants and young children and had more time and scientific channels to understand breastfeeding advantages. Consistent with previous research, grandmothers’ education levels were positively related to breastfeeding attitudes [ 26 ]. The higher participation of unemployed female elders in supporting family breastfeeding might be related to the fact that older women are highly respected and occupy a higher status in the family [ 27 , 28 ]. Besides, grandmothers had negative attitudes toward public breastfeeding. Over one-third of grandmothers thought mothers should not breastfeed in public, and over half of grandmothers agreed that formula feeding is the better choice if the mother returns to work. Thus, we may need to value breastfeeding importance, solve loopholes in current health education, and design multi-form plans to change grandmothers’ public breastfeeding attitudes in the future. The mean score for mothers’ perception of grandmothers’ breastfeeding support scale was 27.77, with a positive level. However, some negative support was seen in the formula, which was the same as in previous research [ 21 ]. This phenomenon may be related to the prevalence of formula advertising and the lack of evaluation knowledge related to breastfeeding [ 29 ]. This study found that mothers with postgraduate and above, part-time working, and breastfeeding plans had more support from grandmothers, which may give them more time and skills to communicate and cooperate with their grandmothers [ 30 ]. In addition, the results showed that the higher the grandmother's scores on breastfeeding attitudes and knowledge, the higher the mothers' perceptions of family support for breastfeeding, which may be related to the grandmother's better knowledge and attitude to facilitate effective communication. The results showed that mothers’ breastfeeding plans and support perception, grandmothers’ attitudes, and education level significantly impacted breastfeeding practices within six weeks postpartum. The theory of planned behavior states that attitudes and self-perceived behaviors influence a person's intention and actual behavior to perform a specific behavior [ 31 ]. Previous research also demonstrated that the mother’s feeding intention was independently related to the cessation of breastfeeding in the early postpartum period, which may be why breastfeeding plans affect practice [ 32 , 33 ]. Attitudes toward the behavior affect the degree to which an individual evaluates and evaluates the behavior, while perceived behavioral control predicts the perceived difficulty in executing the behavior. Ong et al. [ 34 ] showed that female relatives (mother and mother-in-law) play an essential role in supporting new parents, and their breastfeeding attitude may affect the mother's self-perception, thus affecting breastfeeding practice. The study of Liu et al. [ 35 ] believed that highly educated grandmothers are related to the reduction of exclusive breastfeeding, which may reflect the relationship between better family socioeconomic status and preference for formula milk powder because formula milk powder is regarded as an indicator of higher socioeconomic status. Contrary to their research results, our study showed the education level of grandmothers had a positive effect on breastfeeding practice and further illustrated that the health management department had achieved staged victory in restricting the advertising of formula milk powder on infant feeding choices and vigorously supporting the practice of exclusive breastfeeding. Some limitations must be considered when interpreting the result. First, grandmothers were recruited through convenience sampling in the postpartum ward, which might lead to research bias, mainly because grandmothers accompanying primiparous women might be more motivated to participate in breastfeeding. Second, 27.7% of grandmothers in this study lived separately from primiparas, which impacted mothers' perception of family support for breastfeeding and breastfeeding practices. However, the analysis showed that this effect was not statistically significant. Third, this study was conducted in an obstetrics and gynecology specialist hospital in Fujian Province, which may limit the generalizability of the results to other populations and settings. Conclusion This is the first study to scan the current status of grandmothers’ breastfeeding knowledge and attitudes and explore the impact of grandmothers' breastfeeding knowledge, attitudes, and mothers' perception of grandmothers' breastfeeding support on breastfeeding practices in the early postpartum period. Grandmothers' breastfeeding knowledge and attitudes and mothers' breastfeeding support perceptions of grandmothers were positive, but there is a vast scope for betterment. Healthcare professionals must identify the factors that impact breastfeeding practice and create interventions to improve it. Declarations Ethics approval and consent to participant Ensure voluntary participation and maintain the confidentiality of the data obtained, which was approved by the medical ethics committee of the study hospital (2019-153). Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study will be available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding Not applicable. Authors' Contributions J.-L.W. designed the study, collected data, and drafted the first manuscript. X.-Y. Z. analyzed the data. X.-M. J. provided the survey conditions and revised the paper substantively. Acknowledgments Thanks to all participants for their valuable contribution to this study. Author information Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China. Jing-Ling Wu Maternal and Child Health Hospital of Hubei Province, Wuhan, China. Xiao -Yun Zhang Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China. 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Aidam BA, MacDonald CA, Wee R, Simba J, Aubel J, Reinsma KR, Girard AW. An Innovative Grandmother-Inclusive Approach for Addressing Suboptimal Infant and Young Child Feeding Practices in Sierra Leone. Curr Dev Nutr. 2020;4(12):nzaa174. Simkhada B, Porter MA, van Teijlingen ER. The role of mothers-in-law in antenatal care decision-making in Nepal: a qualitative study. BMC Pregnancy Childbirth. 2010;10:34. Parry K, Taylor E, Hall-Dardess P, Walker M, Labbok M. Understanding women's interpretations of infant formula advertising. Birth. 2013;40(2):115–24. Woods Barr AL, Miller E, Smith JL, Cummings SM, Schafer EJ. #EveryGenerationMatters: Intergenerational Perceptions of Infant Feeding Information and Communication Among African American Women. Breastfeed Med. 2021;16(2):131–9. Ajzen I. The theory of planned behaviour: reactions and reflections. Psychol Health. 2011;26(9):1113–27. Oakley LL, Henderson J, Redshaw M, Quigley MA. The role of support and other factors in early breastfeeding cessation: an analysis of data from a maternity survey in England. BMC Pregnancy Childbirth. 2014;14:88. Kronborg H, Foverskov E. Multifactorial influence on duration of exclusive breastfeeding; a Danish cohort study. PLoS ONE. 2020;15(9):e0238363. Ong SF, Chan WC, Shorey S, Chong YS, Klainin-Yobas P, He HG. Postnatal experiences and support needs of first-time mothers in Singapore: a descriptive qualitative study. Midwifery. 2014;30(6):772–8. Liu J, Shi Z, Spatz D, Loh R, Sun G, Grisso J. Social and demographic determinants for breastfeeding in a rural, suburban and city area of South East China. Contemp Nurse. 2013;45(2):234–43. Additional Declarations No competing interests reported. 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The benefits are apparent, but exclusive breastfeeding (EBF) rates are low worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Research has indicated that only 36% of global infants and 20.7% of Chinese infants were exclusively breastfed until six months postpartum, which is lower than the 50% global nutrition target for 2025 recommended by the World Health Organization [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. With the implementation of national policies and the development of baby-friendly hospitals, most mothers have realized the benefits of breastfeeding. However, recent estimates indicate that the rate of EBF in China has a downward trend [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eScholars have always emphasized the key role of family support in breastfeeding practice. A systematic review concluded that grandmothers\u0026rsquo; positive attitude would increase breastfeeding rates by 12%, while a negative attitude can decrease rates by 70% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Grandmothers' preference for formula feeding can shorten breastfeeding duration [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In the traditional concept, grandmothers, as representatives of older women in the family, are considered the holders and authority of breastfeeding knowledge. They pass on the information they think is correct to the next generation or direct care for infants, which could directly impact breastfeeding practices [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Therefore, it is necessary to explore grandmother's breastfeeding knowledge and attitudes in depth to improve breastfeeding practice.\u003c/p\u003e \u003cp\u003eThe relationship between grandmother and mother is complex and diverse for breastfeeding. In some countries, especially in underdeveloped areas, mothers are embedded in a family system of caring and supervision where grandmothers play essential and sometimes coercive roles in breastfeeding [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. But, in some countries, grandmothers face balancing difficulties; as a grandmother said, \u0026ldquo;I only advise if I am asked.\u0026rdquo; [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Thus, grandmothers' influence on breastfeeding differs in different cultural backgrounds. In Chinese traditional culture, the grandmother has a vital voice in the family. However, the relationship between mothers and grandmothers changes with cultural innovation and educational development. The literature review found that most current Chinese studies focus on communities and fathers rather than grandmothers [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, the study aimed to scan the Chinese status of grandmothers\u0026rsquo; knowledge and attitudes towards breastfeeding, explore the relationship between grandmothers\u0026rsquo; knowledge, attitudes, and the mother's breastfeeding support perception, and further study whether those factors directly impact breastfeeding practices.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and Setting\u003c/h2\u003e \u003cp\u003eA quantitative, prospective cohort study was designed involving grandmothers and primiparous mothers of an infant at the obstetrics ward in a baby-friendly tertiary Maternity and Children\u0026rsquo;s hospital in China.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population and Data Collection\u003c/h2\u003e \u003cp\u003eGrandmother-mother pairs were recruited using convenience sampling at the Obstetrics Department of Fujian Maternity and Child Health Hospital from 1st March to 29th June 2021. A researcher explained to potential participants the objective and other details of the study, such as the research process, period, or other interesting questions, and invited them to participate. A checklist for inclusion and exclusion criteria was used to screen participants. If they fulfilled the eligibility criteria and agreed to participate in the survey, they would sign an informed consent and become a pair of participants. Then, the mother wrote the electronic questionnaire, and the paper questionnaire was filled in by the grandmothers and adopted a one-to-one structured interview to facilitate a correct understanding of the questionnaires. Mothers were followed up to 6 weeks postpartum to investigate their breastfeeding practice.\u003c/p\u003e \u003cp\u003eThe inclusion criteria for grandmothers were: (1) being able to understand and communicate with Mandarin, (2) having regular contact with mothers after delivery. Grandmothers with cognitive impairment led to impact data collection were excluded. The inclusion criteria for daughters or daughters-in-law were: (1) primiparous, (2) having a singleton infant with term and healthy (Apgar score\u0026thinsp;\u0026gt;\u0026thinsp;eight at 5 minutes), (3) being willing to breastfeed. The exclusion criteria included: (1) the time of mother-infant separation over 48 hours; (2) the mother and infant with a medical condition or contraindication to breastfeeding. The PASS calculated the sample size, considering 95% power at a 0.05 significance level. Referring to the study of Karm Acharya C et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], an odds ratio (OR) of 2.3 for the correct feeding practices in households with grandmothers, the rate of EBF at six weeks postpartum in households without grandmothers was 37.6%, a minimum sample size of 290 participants. Considering the possibility of 10% refusals and unqualified, 319 participants were required.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement\u003c/h2\u003e \u003cp\u003eSelf-administered questionnaires were used to address the objective of the study, which included the questionnaire filled in by grandmothers (Part 1), the questionnaire filled in by mothers (Part 2), and the questionnaire on the feeding method (Part 3).\u003c/p\u003e \u003cp\u003ePart 1 included grandmothers\u0026rsquo; general situations, the Breastfeeding Knowledge Questionnaire, and the Iowa Infant Feeding Attitude Scale (IIFAS). The general situation consisted of grandmothers\u0026rsquo; demo-graphic data (age, employment, ethnicity, education, family income, whether to live with children), their children\u0026rsquo;s feeding mode, and whether they participated in breastfeeding courses. Grandmothers\u0026rsquo; Knowledge of Breastfeeding questionnaire was developed based on Layal H [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], a 14-item instrument to evaluate mothers\u0026rsquo; breastfeeding knowledge. The items were responded to by three options: true (1 point), false or I do not know (0 points), or not sure (0 points). The total overall score is from 0 to 14, with higher scores indicating a higher level of knowledge. IIFAS had 17 items, and it was a valid and reliable scale that was adopted to measure grandmothers\u0026rsquo; breastfeeding attitudes. Permission was obtained from the original author in advance. IIFAS was developed to test maternal attitudes toward infant feeding [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and Dai translated this scale into Chinese and verified its validity and reliability among Chinese mothers [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. We further confirmed the scale could be used to measure grandmothers\u0026rsquo; attitudes toward infant feeding. Before the formal investigation, ten grandmothers were recruited for a pre-investigation to ensure the breastfeeding knowledge and attitude scale could be understood correctly. 10% of the breastfeeding knowledge and attitude scale was randomly selected to test the reliability among grandmothers, with Cronbach's alpha values of 0.705 and 0.700, separately.\u003c/p\u003e \u003cp\u003ePart 1 included the mothers\u0026rsquo; and infants\u0026rsquo; situation and the Mothers\u0026rsquo; Perception of Grandmothers\u0026rsquo; Breastfeeding Support Scale (MPGBSS). The mothers\u0026rsquo; and infants\u0026rsquo; situation included mothers\u0026rsquo; age, employment, ethnicity, education, family income, pregnancy complications, whether to participate in breastfeeding courses, and postpartum data (infant age, delivery method, and delivery complications). MPGBSS was developed by Zhu, a 9-item instrument to evaluate mothers\u0026rsquo; perceived family support for breastfeeding. The scale was a four-point Likert scale (1 point means strongly disagree and 4 points mean strongly agree) consisting of psychological and behavioral support with Cronbach's alpha value of 0.874 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Part 3, mothers were asked, \u0026ldquo;\u003cem\u003eHow did you feed your baby within six weeks postpartum?\u003c/em\u003e\u0026rdquo; Seven responses were set based on the breastfeeding definition from the United Nations Children's Fund [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]: (1) exclusive breastfeeding (breast milk only); (2) almost exclusive breastfeeding (breast milk and other fluids, but not formula); (3) partial breastfeeding (breast milk and formula; (4) breast given to comfort the baby but not for nutrition; (5) bottle-feeding (no breast milk at all). Only the first option was considered to be exclusively breastfeeding.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll data were analyzed using the IBM Statistical Package for the Social Sciences (SPSS) version 25.0. Descriptive analysis was used to summarize the participants\u0026rsquo; socio-demographic characteristics and the mean scores of variables. Independent sample \u003cem\u003et\u003c/em\u003e-tests were used to determine the differences in continuous variables within two distinct sociodemographic subgroups. One-way analysis of variance was used to determine the differences in the continuous variables within three or more different groups. The Chi-square was used for categorical variables. Pearson\u0026rsquo;s correlation coefficient method examined relationships between all outcome variables. Binary logistic regression using the enter method was employed to explore the factors influencing mothers\u0026rsquo; breastfeeding practices. All variables with significant correlations with mothers' breastfeeding were entered into the regression model (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e319 mother-grandmother dyads were invited, 310 dyads participated in the current study with a response rate of 97.18%, and 282 infants\u0026rsquo; feeding methods within six weeks postpartum were followed up with a response rate of 90.97%. The detailed socio-demographic data for mothers and grandmothers is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe socio-demographic characteristics of mothers and grandmothers (N\u0026thinsp;=\u0026thinsp;310)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMothers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge in years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e208 (67.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (32.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTechnical secondary school/high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (12.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege/Undergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e239 (77.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostgraduate and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMonthly income (\u0026yen;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than 5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (11.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5000\u0026ndash;7999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (22.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8000-10,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (17.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 10,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e151 (48.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEmployment status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull-time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e223 (71.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePart-time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDelivery mode\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaginal delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e210 (67.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCesarean section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100 (32.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eParticipated in breastfeeding courses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e191 (61.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e119 (38.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEarly contact with infants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (27.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e224 (72.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFeeding plan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDefinitely breastfeed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e196 (63.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMay breastfeed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGo with the flow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (28.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGrandmothers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge in years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e175 (56.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e135 (43.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e138 (44.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJunior school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95 (30.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (24.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMonthly income (\u0026yen;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than 5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e145 (46.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5000\u0026ndash;7999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (28.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 8000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEmployment status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e175 (56.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (14.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetirement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (29.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLiving condition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLive alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (27.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLive with new mother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e224 (72.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFed breast milk to own child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (28.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e221 (71.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eParticipated in breastfeeding courses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e246 (20.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (79.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGrandmothers\u0026rsquo; knowledge about breastfeeding\u003c/h2\u003e \u003cp\u003eThe grandmothers\u0026rsquo; breastfeeding knowledge scores ranged from 3 to 14, with a mean score of 9.32 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.33), and the correct response rate is reported in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Most grandmothers generally knew the maternal and infant benefits of breastfeeding, the importance of starting breastfeeding as soon as possible after childbirth, sucking promotes milk production, and the high nutritional value of colostrum. However, 31.9% of grandmothers did not realize or disagreed that breastfeeding can prevent childhood obesity, 64.5% thought breastmilk within three days postpartum could not meet infants\u0026rsquo; needs, 29.4% agreed infants need to be breastfed on a schedule, 50.6% thought the remaining milk should be left in the breast after breastfeeding, 38.4% agreed with daily urine amount is a reliable sign on fed adequately, 46.1% thought breastfeeding should last six months, and 51.6% agreed that breastmilk can fully meet all the nutritional needs of 6-month-old babies without adding any other food and drinks. The results showed grandmothers with high school education and above had the most breastfeeding knowledge (10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05), followed by primary school and below (9.11\u0026thinsp;\u0026plusmn;\u0026thinsp;2.39), junior school (9.08\u0026thinsp;\u0026plusmn;\u0026thinsp;2.36) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012). The higher the grandmothers\u0026rsquo; income, the more accurate the knowledge of breastfeeding (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and when grandmothers attended lectures at the hospital, their understanding of breastfeeding was more abundant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe survey result of the grandmothers\u0026rsquo; breastfeeding knowledge (N\u0026thinsp;=\u0026thinsp;310)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrect rate (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding can reduce the incidence of maternal breast diseases and ovarian cancer. (Ture)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding can reduce postpartum bleeding and promote maternal postpartum recovery. (Ture)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding is good for the infant's physical health. (Ture)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e99.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding can promote the infant's intellectual development. (Ture)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e91.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding can prevent childhood obesity. (True)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIt is recommended that women start breastfeeding as soon as possible after childbirth (True)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe more the baby sucks, the mother\u0026rsquo;s milk production is greater. (True)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe milk secreted by the mother can meet the infant's needs within three days after delivery. (True)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe nutritional value of colostrum is very high. (True)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaby needs to be breastfed on a schedule, not when the baby is hungry, or the mother's breasts are swollen. (False)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter breastfeeding, the remaining milk should be left in the breast. (True)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA reliable sign an infant is fed adequately is based on the daily urine amount. (True)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding should last six months postpartum. (True)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast milk can fully meet all the nutritional needs of 6-month-old babies without adding other food and drinks. (True)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e\u003cem\u003eGrandmothers\u0026rsquo; attitude about breastfeeding\u003c/em\u003e\u003c/h2\u003e \u003cp\u003eThe total scores were divided into three parts: negative (\u0026lt;\u0026thinsp;55 points), neutral (55\u0026ndash;61 points), and positive (\u0026gt;\u0026thinsp;61 points) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Grandmothers\u0026rsquo; breastfeeding attitude scores ranged from 48 to 75, with a mean score of 62.03 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.46) at a positive level. Most of the grandmothers agreed that breast milk was the ideal food for babies and supported breastfeeding behavior, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. However, 43.9% of the grandmothers believed that formula feeding was not an act of missing maternal love, and nearly a quarter (24.5%) of them maintained a neutral attitude towards this statement. 61.0% of grandmothers agreed that formula feeding is better if the mother plans to return to work, and 15.5% were neutral. The view that \"mothers should not breastfeed in public\" was agreed upon by 39.4% of grandmothers. Grandmother\u0026rsquo;s education level (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), monthly income (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03), employment status (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004), and attending hospital lectures (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04) were significant factors in breastfeeding attitudes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe survey result of the grandmothers\u0026rsquo; breastfeeding attitudes (N\u0026thinsp;=\u0026thinsp;310)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe benefits of breastfeeding last only as long as the baby is breast-fed. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.77 (0.87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormula feeding is more convenient than breastfeeding. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.87 (0.95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding increases the intimacy between mother and child.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.04 (0.63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast milk is lacking in iron. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.45 (0.78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormula-fed babies are more likely to be overfed than breastfed babies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.58 (0.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormula feeding is better if the mother plans to return to work. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.64 (0.92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMothers who formula feed miss one of the great joys of motherhood.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.12 (0.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen should not breastfeed in public places such as restaurants. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.98 (1.06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfed babies are healthier than formula-fed babies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.87 (0.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfed babies are more likely to be overfed than formula-fed babies. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.44 (0.65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFathers feel left out if a mother breast-feeds. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.65 (0.91)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast milk is the ideal food for babies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.07 (0.65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast milk is more easily digested than formula.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.95 (0.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe formula is as healthy for an infant as breast milk. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.95 (0.92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreastfeeding is more convenient than formula.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.93 (0.66)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast milk is cheaper than formula.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.85 (0.63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA mother who occasionally drinks alcohol should not breastfeed her baby. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.86 (0.74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Reverse scored item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eMothers\u0026rsquo; perception of grandmothers\u0026rsquo; breastfeeding support\u003c/h2\u003e \u003cp\u003eThe mother\u0026rsquo;s perception of grandmothers\u0026rsquo; breastfeeding support scores ranged from 17 to 36, with a mean score of 27.77 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.40). 30.3% of grandmothers thought formula could replace breast milk, 58.7% thought mothers need to add formula to infants, and other details as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Mothers with postgraduate and above had the most support from grandmothers (28.78\u0026thinsp;\u0026plusmn;\u0026thinsp;4.20), followed by college/undergraduate (28.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.68), technical secondary school/high school (27.51\u0026thinsp;\u0026plusmn;\u0026thinsp;3.07), primary school and below (25.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.68) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01). Working mothers (28.12\u0026thinsp;\u0026plusmn;\u0026thinsp;3.73) felt more grandmothers\u0026rsquo; support than unemployed mothers (26.61\u0026thinsp;\u0026plusmn;\u0026thinsp;3.00), and part-time mothers (30.26\u0026thinsp;\u0026plusmn;\u0026thinsp;4.03) had the highest grandmothers\u0026rsquo; support score (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Mothers planning to breastfeed had higher grandmothers\u0026rsquo; support score (28.57\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRelationship among grandmothers\u0026rsquo; knowledge, attitudes, and mothers\u0026rsquo; perception\u003c/h2\u003e \u003cp\u003eGrandmothers\u0026rsquo; attitudes toward breastfeeding were significantly and positively correlated to grandmothers\u0026rsquo; knowledge (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.215, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and mothers\u0026rsquo; perception of grandmothers\u0026rsquo; breastfeeding support (r\u0026thinsp;=\u0026thinsp;0.282, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01). At the same time, the grandmothers' knowledge of breastfeeding was also related to the mothers\u0026rsquo; perception of grandmothers\u0026rsquo; breastfeeding support (r\u0026thinsp;=\u0026thinsp;0.269, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFactors Affecting Breastfeeding Practice\u003c/h2\u003e \u003cp\u003eMothers were followed up to 6 weeks postpartum to collect their infant feeding methods, and the process was divided into two aspects, exclusive and non-exclusive. Single-factor analysis results showed feeding mode was influenced by the mother\u0026rsquo;s education level (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01), occupation (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03), and breastfeeding plan (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02), as well as the grandmother\u0026rsquo;s education level (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01), occupation (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), knowledge (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.046), attitude (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) towards breastfeeding, and the mother\u0026rsquo;s perception of the grandmother\u0026rsquo;s support (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The binary logistic regression analysis showed that the mother's breastfeeding plan (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02), the mother's perceived breastfeeding support (P\u0026thinsp;=\u0026thinsp;0.04), the grandmother's education level (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and breastfeeding attitudes (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) were influencing factors of breastfeeding practice.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe survey result of the mothers\u0026rsquo; perception of grandmothers\u0026rsquo; breastfeeding support (N\u0026thinsp;=\u0026thinsp;310)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrandmothers wants me to breastfeed.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.43 (0.57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrandmothers often help me take care of the baby.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.39 (1.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrandmothers often cook me meals to promote lactation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.23 (0.52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrandmothers often encourage me to breastfeed.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.36 (0.56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrandmothers can help me solve the problems encountered in breastfeeding.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.05 (0.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrandmothers think the milk will be enough if the baby eats more of my milk.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.19 (0.55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrandmothers believe that formula can replace breast milk. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.83 (0.68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrandmothers think I need to add formula to my baby. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.45 (0.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrandmothers think infants cry as breast milk is not good. \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.95 (0.63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Reverse scored item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe result showed the grandmothers\u0026rsquo; knowledge mean scores were 9.32, lower than the mothers\u0026rsquo; average scores of 10.83 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Most grandmothers knew the benefits of breastfeeding, but about half did not know breastfeeding duration well, similar to other studies [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In some grandmothers\u0026rsquo; options, water or other food should be complemented to meet infants\u0026rsquo; nutrition or other requirements such as treating asthma [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. At the same time, we found some scientific feeding knowledge had not been mastered by the partial grandmothers, such as the adequacy of colostrum, feeding on demand, not squeezing remaining breast milk, and judging the adequacy of feeding by the amount of urine. Our results showed that grandmothers with a high school education and above had the most breastfeeding knowledge, and the possible reason is that grandmothers with higher education backgrounds have better abilities or ways to accept breastfeeding knowledge. However, grandmothers with primary and below education have higher knowledge scores than junior or high school levels. This may be related to their better practical experience in breastfeeding or the small sample size, which needs further verification. Grandmothers\u0026rsquo; higher income is related to more accurate breastfeeding knowledge, which may reflect the relationship between better socioeconomic levels and learning ability. The result indicated that breastfeeding lectures could improve grandmothers\u0026rsquo; knowledge. However, in most cases, despite grandmothers' critical role within households, hospital staff often belittle their expertise and do not consider the design of health education [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Therefore, future clinical practice should consider these gaps in grandmothers\u0026rsquo; breastfeeding health education.\u003c/p\u003e \u003cp\u003eThis study found that grandmothers had a positive attitude towards breastfeeding, and grandmothers with higher educational levels and higher monthly incomes, who were not working, participated in breastfeeding literature and had a more excellent attitude towards breastfeeding. This might be because these grandmothers had a higher demand for the nutrition of infants and young children and had more time and scientific channels to understand breastfeeding advantages. Consistent with previous research, grandmothers\u0026rsquo; education levels were positively related to breastfeeding attitudes [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The higher participation of unemployed female elders in supporting family breastfeeding might be related to the fact that older women are highly respected and occupy a higher status in the family [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Besides, grandmothers had negative attitudes toward public breastfeeding. Over one-third of grandmothers thought mothers should not breastfeed in public, and over half of grandmothers agreed that formula feeding is the better choice if the mother returns to work. Thus, we may need to value breastfeeding importance, solve loopholes in current health education, and design multi-form plans to change grandmothers\u0026rsquo; public breastfeeding attitudes in the future.\u003c/p\u003e \u003cp\u003eThe mean score for mothers\u0026rsquo; perception of grandmothers\u0026rsquo; breastfeeding support scale was 27.77, with a positive level. However, some negative support was seen in the formula, which was the same as in previous research [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This phenomenon may be related to the prevalence of formula advertising and the lack of evaluation knowledge related to breastfeeding [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This study found that mothers with postgraduate and above, part-time working, and breastfeeding plans had more support from grandmothers, which may give them more time and skills to communicate and cooperate with their grandmothers [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In addition, the results showed that the higher the grandmother's scores on breastfeeding attitudes and knowledge, the higher the mothers' perceptions of family support for breastfeeding, which may be related to the grandmother's better knowledge and attitude to facilitate effective communication.\u003c/p\u003e \u003cp\u003eThe results showed that mothers\u0026rsquo; breastfeeding plans and support perception, grandmothers\u0026rsquo; attitudes, and education level significantly impacted breastfeeding practices within six weeks postpartum. The theory of planned behavior states that attitudes and self-perceived behaviors influence a person's intention and actual behavior to perform a specific behavior [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Previous research also demonstrated that the mother\u0026rsquo;s feeding intention was independently related to the cessation of breastfeeding in the early postpartum period, which may be why breastfeeding plans affect practice [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Attitudes toward the behavior affect the degree to which an individual evaluates and evaluates the behavior, while perceived behavioral control predicts the perceived difficulty in executing the behavior. Ong et al. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] showed that female relatives (mother and mother-in-law) play an essential role in supporting new parents, and their breastfeeding attitude may affect the mother's self-perception, thus affecting breastfeeding practice. The study of Liu et al. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] believed that highly educated grandmothers are related to the reduction of exclusive breastfeeding, which may reflect the relationship between better family socioeconomic status and preference for formula milk powder because formula milk powder is regarded as an indicator of higher socioeconomic status. Contrary to their research results, our study showed the education level of grandmothers had a positive effect on breastfeeding practice and further illustrated that the health management department had achieved staged victory in restricting the advertising of formula milk powder on infant feeding choices and vigorously supporting the practice of exclusive breastfeeding.\u003c/p\u003e \u003cp\u003eSome limitations must be considered when interpreting the result. First, grandmothers were recruited through convenience sampling in the postpartum ward, which might lead to research bias, mainly because grandmothers accompanying primiparous women might be more motivated to participate in breastfeeding. Second, 27.7% of grandmothers in this study lived separately from primiparas, which impacted mothers' perception of family support for breastfeeding and breastfeeding practices. However, the analysis showed that this effect was not statistically significant. Third, this study was conducted in an obstetrics and gynecology specialist hospital in Fujian Province, which may limit the generalizability of the results to other populations and settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis is the first study to scan the current status of grandmothers\u0026rsquo; breastfeeding knowledge and attitudes and explore the impact of grandmothers' breastfeeding knowledge, attitudes, and mothers' perception of grandmothers' breastfeeding support on breastfeeding practices in the early postpartum period. Grandmothers' breastfeeding knowledge and attitudes and mothers' breastfeeding support perceptions of grandmothers were positive, but there is a vast scope for betterment. Healthcare professionals must identify the factors that impact breastfeeding practice and create interventions to improve it.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participant\u003c/p\u003e\n\u003cp\u003eEnsure voluntary participation and maintain the confidentiality of the data obtained,\u0026nbsp;which was approved by the medical ethics committee of the study hospital (2019-153).\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study will be available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos;\u0026nbsp;Contributions\u003c/p\u003e\n\u003cp\u003eJ.-L.W. designed the study, collected data, and drafted the first manuscript. X.-Y. Z. analyzed the data. X.-M. J. provided the survey conditions and revised the paper substantively.\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eThanks to all participants for their valuable contribution to this study.\u003c/p\u003e\n\u003cp\u003eAuthor information\u003c/p\u003e\n\u003cp\u003eWomen\u0026apos;s Hospital, School of Medicine, Zhejiang University, Hangzhou, China. Jing-Ling Wu\u003c/p\u003e\n\u003cp\u003eMaternal and Child Health Hospital of Hubei Province, Wuhan, China. Xiao -Yun Zhang\u003c/p\u003e\n\u003cp\u003eFujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics \u0026amp; Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China. Xiu-Min Jiang\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piwoz EG, Richter LM, Victora CG. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387(10017):491\u0026ndash;504.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVictora CG, Bahl R, Barros AJ, Fran\u0026ccedil;a GV, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLauria L, Spinelli A, Grandolfo M. Prevalence of breastfeeding in Italy: a population based follow-up study. Ann Ist Super Sanita. 2016;52(3):457\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuan Y, Yang Z, Lai J, Yu D, Chang S, Pang X, Jiang S, Zhang H, Bi Y, Wang J et al. Exclusive Breastfeeding Rate and Complementary Feeding Indicators in China: A National Representative Survey in 2013. Nutrients 2018, 10(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO Guidelines Approved by the Guidelines Review Committee. In: Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services. edn. Geneva: World Health Organization Copyright \u0026copy; World Health Organization 2017.; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi J, Nguyen TT, Wang X, Mathisen R, Fang J. Breastfeeding practices and associated factors at the individual, family, health facility and environmental levels in China. Matern Child Nutr. 2020;16(Suppl 2):e13002.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF. Children in China: An atlas of social indicators of children in China 2018. Beijing. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNegin J, Coffman J, Vizintin P, Raynes-Greenow C. The influence of grandmothers on breastfeeding rates: a systematic review. BMC Pregnancy Childbirth. 2016;16:91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDashti M, Scott JA, Edwards CA, Al-Sughayer M. Predictors of breastfeeding duration among women in Kuwait: results of a prospective cohort study. Nutrients. 2014;6(2):711\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBezner Kerr R, Dakishoni L, Shumba L, Msachi R, Chirwa M. We grandmothers know plenty: breastfeeding, complementary feeding and the multifaceted role of grandmothers in Malawi. Soc Sci Med. 2008;66(5):1095\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoseph FI, Earland J. A qualitative exploration of the sociocultural determinants of exclusive breastfeeding practices among rural mothers, North West Nigeria. Int Breastfeed J. 2019;14:38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacDonald CA, Aubel J, Aidam BA, Girard AW. 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Contemp Nurse. 2013;45(2):234\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"grandmother, breastfeeding, knowledge, attitude","lastPublishedDoi":"10.21203/rs.3.rs-4197645/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4197645/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThe study aimed to scan the status of grandmothers\u0026rsquo; breastfeeding knowledge and attitudes, explore the relationship between grandmothers\u0026rsquo; knowledge, attitudes, and the mother's breastfeeding support perception, and further study whether those factors have a direct impact on breastfeeding practices.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA quantitative, prospective cohort study was set in an obstetrics and gynecology specialist hospital. 310 mother-grandmother dyads completed structured questionnaires, and 282 mothers were followed up to 6 weeks postpartum to investigate breastfeeding practice.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e \u003cb\u003eT\u003c/b\u003ehe grandmother\u0026rsquo;s breastfeeding knowledge score was 9.32 (SD\u0026thinsp;=\u0026thinsp;2.33). The grandmothers\u0026rsquo; breastfeeding attitude score were 62.03 (SD\u0026thinsp;=\u0026thinsp;4.46) at a positive level. The mother\u0026rsquo;s perception of the grandmother\u0026rsquo;s support score was 27.77 (SD\u0026thinsp;=\u0026thinsp;3.40) at a positive level. There were positive correlations among grandmothers\u0026rsquo; breastfeeding knowledge, grandmothers\u0026rsquo; breastfeeding attitudes, and mothers\u0026rsquo; perception of breastfeeding support of grandmothers. Mother's breastfeeding plan (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02), mother's perceived breastfeeding support (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04), grandmother's education level (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and attitude towards breastfeeding (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) were independent influencing factors of breastfeeding practice.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eGrandmothers' breastfeeding knowledge and attitudes and mothers' breastfeeding support perceptions of grandmothers were positive, but there is a vast scope for betterment. Healthcare professionals must identify the factors that impact breastfeeding practice and create interventions to improve it.\u003c/p\u003e","manuscriptTitle":"Grandmothers’ breastfeeding knowledge, attitudes, maternal support perception, and breastfeeding practice: A prospective cohort survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-04 18:10:50","doi":"10.21203/rs.3.rs-4197645/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9887c072-e10c-41d4-81f2-925e70ef9ddf","owner":[],"postedDate":"April 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-03T01:08:59+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-04 18:10:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4197645","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4197645","identity":"rs-4197645","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}