The Association Between Maternal Education and Bottle-Feeding with Expressed Breast Milk Among Chinese Mothers: A Focus on Mediating Pathways

Background: Breastfeeding is the optimal infant feeding practice. However, bottle-feeding with expressed breast milk is increasingly prevalent, with the reasons for this practice being diverse and closely related to maternal educational level.

Objective: To explore the association between maternal educational level and expressed breast milk feeding among infants in China, and examine the underlying mediating pathway.

Methods: This study is a secondary analysis of data from a nationwide feeding survey in China. Child healthcare physicians enrolled infants aged 0–23 months and administered a standardized questionnaire to their mothers or caregivers. Data collected included demographic characteristics, perinatal information, breastfeeding practices, and the introduction of liquids other than breast milk. Logistic regression was used to identify factors associated with expressed breast milk feeding, and mediation analysis was performed to examine the pathways through which maternal education influences expressed breast milk feeding.

Results: A total of 2208 infants aged 0-23 months were included in the analysis. 18.4% of mothers regularly used expressed breast milk for feeding. Exclusive expressed breast milk feeding was practiced by 7.5% of mothers, comprising 7.15% who used bottle-feeding and 0.35% who relied solely on spoon-feeding. Higher maternal educational level was the strongest predictor of regular expressed breast milk feeding (OR = 3.211), followed by parity, maternal employment status, formula as the first non-breastmilk liquid, and early initiation of breastfeeding. Mediation analysis indicated that maternal employment, parity, early Initiation of breastfeeding, and formula as the first non-breastmilk liquid mediated the relationship between maternal education and regularly expressed breast milk feeding of infants aged 0-23 months, accounting for 24.73%, 17.45%, 6.18%, and 5.31% of the total effect, respectively. The stratified mediation analysis revealed distinct patterns across infant age groups and breastfeeding status. Among infants within the first six months of life, only parity (15.25%) and formula as the first non-breastmilk liquid (8.11%) mediated the relationship between maternal education and expressed breast milk feeding. For mothers who continued breastfeeding, maternal employment (56.21%) served as the sole mediator.

Conclusion: The prevalence of expressed breast milk feeding among Chinese infants warrants attention, which is closely associated with maternal educational level. Higher educated mothers may be more likely to use expressed breast milk feeding due to primipara, employment demands, lack of early initiation of breastfeeding, and formula as the first non-breastmilk liquid.