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Development and evaluation of a Chinese-language newborn feeding hotline: A prospective cohort study Janssen, Patricia A; Livingstone, Verity H; Chang, Bruce; Klein, Michael C Jan 29, 2009

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ralssBioMed CentBMC Pregnancy and ChildbirthOpen AcceResearch articleDevelopment and evaluation of a Chinese-language newborn feeding hotline: A prospective cohort studyPatricia A Janssen*1,2,3, Verity H Livingstone2, Bruce Chang2 and Michael C Klein2,3Address: 1School of Population and Public Health, University of British Columbia, Child & Family Research Institute, Vancouver, BC, Canada, 2Department of Family Practice, University of British Columbia, Child & Family Research Institute, Vancouver, BC, Canada and 3Faculty of Medicine, University of British Columbia, Child & Family Research Institute, Vancouver, BC, CanadaEmail: Patricia A Janssen* - pjanssen@interchange.ubc.ca; Verity H Livingstone - vlivings@shaw.ca; Bruce Chang - brucehchang@shaw.ca; Michael C Klein - mklein@interchange.ubc.ca* Corresponding author    AbstractBackground: Preference for formula versus breast feeding among women of Chinese descentremains a concern in North America. The goal of this study was to develop an interventiontargeting Chinese immigrant mothers to increase their rates of exclusive breastfeeding.Methods: We convened a focus group of immigrant women of Chinese descent in Vancouver,British Columbia to explore preferences for method of infant feeding. We subsequently surveyed250 women of Chinese descent to validate focus group findings. Using a participatory approach,our focus group participants reviewed survey findings and developed a priority list for attributes ofa community-based intervention to support exclusive breastfeeding in the Chinese community. Theauthors and focus group participants worked as a team to plan, implement and evaluate a Chineselanguage newborn feeding information telephone service staffed by registered nurses fluent inChinese languages.Results: Participants in the focus group reported a strong preference for formula feeding.Telephone survey results revealed that while pregnant Chinese women understood the benefits ofbreastfeeding, only 20.8% planned to breastfeed exclusively. Only 15.6% were breastfeedingexclusively at two months postpartum. After implementation of the feeding hotline, 20% of newChinese mothers in Vancouver indicated that they had used the hotline. Among these women, therate of exclusive breastfeeding was 44.1%; OR 3.02, (95% CI 1.78–5.09) compared to women inour survey.Conclusion: Initiation of a language-specific newborn feeding telephone hotline reached apreviously underserved population and may have contributed to improved rates of exclusivebreastfeeding.Published: 29 January 2009BMC Pregnancy and Childbirth 2009, 9:3 doi:10.1186/1471-2393-9-3Received: 19 August 2008Accepted: 29 January 2009This article is available from: http://www.biomedcentral.com/1471-2393/9/3© 2009 Janssen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 7(page number not for citation purposes)BMC Pregnancy and Childbirth 2009, 9:3 http://www.biomedcentral.com/1471-2393/9/3BackgroundPreference for formula versus breast feeding amongwomen of Chinese descent, remains a concern in NorthAmerica. Studies from the US, and Canada have reportedbreastfeeding rates after hospital discharge as low as 10–30% among Southeast Asian immigrant women com-pared to 65% in Caucasian women [1,2]. Studies of infantfeeding practices from countries of origin for Chineseimmigrants suggest that practices related to the hot-coldconcept (ying and yang), modesty regarding breastfeedingin public, need to return to employment within a fewweeks of giving birth, use of formula as a status symbol,and lack of knowledge about the benefits of breastfeedingcontribute to these low rates [3-7]. A recent survey offemale university students in Hong Kong indicated thatonly 63% wanted to breastfeed their future children [8].Rates of exclusive breastfeeding as low as 26% (Malaysia)[5] and 33% (Taiwan) [9] at six weeks postpartum havebeen reported in Asian countries. Other studies have indi-cated that breastfeeding rates among Southeast Asianwomen decline when they immigrate to North America[10,11].In Canada, the metropolitan area of Vancouver has thehighest proportion of persons of Chinese descent (17%)of all such urban areas in Canada, largely as a result ofimmigration trends in the past 20 years [12]. Vancouver,BC is home to BC Women's Hospital, the largest mater-nity centre in Canada. At discharge from BC Women's, therate of exclusive breastfeeding among new mothers ofChinese descent (Hong Kong, China or Taiwan) has beenreported anecdotally to be only 25–30% compared to70% among women overall.We engaged in a participatory action study in which wepartnered with mothers of Chinese descent and a regionalpublic health board to conceptualize, design, implementand evaluate a novel strategy to support breastfeeding.MethodsDesignOur project employed a participatory action methodologyin which the persons who stand to benefit from answeringresearch questions and to whom results will be general-ized play an active role in designing the research tool,interpreting results, and designing and evaluating anintervention [13]. Authentic participation in researchmeans sharing in the way research is conceptualized, prac-ticed, and brought to bear on the real world. Action meansthat groups of people can organize the conditions underwhich they can learn from their own experiences andmake this experience accessible to others.SampleThe largest community agency serving Chinese women inVancouver, SUCCESS (United Chinese CommunityEnrichment Services Society) [14], recruited a conven-ience sample of twelve women for a focus group to discusstheir preferences and experiences related to infant feeding.All participants had emigrated from Hong Kong duringthe previous ten years. Seven had given birth in Canada;five in Hong Kong. We conducted the focus group in Can-tonese then audiotaped and translated the proceedings.We summarized themes and presented them to partici-pants for confirmation of accuracy and completeness. Par-ticipants provided informed, written consent.MeasuresWe undertook a telephone survey to determine whetheror not preferences for formula feeding expressed in ourfocus groups would be validated in a representative sam-ple of Chinese women in Vancouver. In consultation withfocus group participants, we designed our survey to ascer-tain women's beliefs and practices related to infant feed-ing. Items were generated by the research team, includingthe authors and focus group members, and by a review ofrelevant literature. Face validity was evaluated by mem-bers of the focus group. The final survey was pilot testedon ten women to assess clarity. No additional revisionswere made. The survey consisted of 23 items in theantepartum component and 17 for the postpartum com-ponent in addition to socio-demographic items. Eachcomponent took approximately twenty minutes to com-plete. Items related to women's knowledge about advan-tages or disadvantages about feeding methods, theirintended and actual feeding practice and reasons for con-tinuing with their plan or not.We provided information pamphlets for prospective par-ticipants written in English and Chinese script to theoffices of 40 obstetricians and family medicine physicians(among whom 30 were also Chinese) providing antenatalcare to Chinese women pre-registered to deliver at BCWomen's hospital. Women indicating to their physicianthat they were agreeable to participation received a tele-phone call from a nurse who was fluent in English, Can-tonese, and Mandarin to explain the study and arrange a.time for the telephone interview. Interviews took placeduring the last trimester (after 30 weeks) of pregnancywith a follow-up call during the second postpartummonth. In the follow-up interview we ascertained whetherwomen were able to use their preferred method of infantfeeding and if not, what they perceived as facilitators orbarriers. Interviews were conducted in the preferred lan-guage of the participant and took approximately twentyminutes to complete. Participants in the telephone surveyPage 2 of 7(page number not for citation purposes)provided informed verbal consent prior to proceeding.BMC Pregnancy and Childbirth 2009, 9:3 http://www.biomedcentral.com/1471-2393/9/3We present survey findings as frequencies. Findings fromsubgroups within the survey were compared using the Chisquare statistic. A p-value of 0.05 or less was denoted asstatistically significant. We compared breastfeeding ratesamong women born in China vs. Hong Kong and amongwomen using the hotline vs. those in our pre-hotline sur-vey using odds ratios. We estimated the odds ratios andcorresponding 95% confidence intervals from a logisticregression model.We reconvened the focus group to review survey findings.After an initial review, we realized that the largest immi-grant group among our survey participants was fromChina. Our community partner, SUCCESS, subsequentlyrecruited three additional women to the focus group whowere new mothers and immigrants from China. The newmembers of the focus group supported the validity of thesurvey items for women who had immigrated fromChina. The group then brainstormed ideas based on sur-vey findings for interventions to support breastfeedingamong new Chinese mothers. Priority interventions wereidentified, implemented and evaluated.Prior to proceeding the study was granted ethical approvalby the University of British Columbia Behavioural EthicsReview Board, Certificate B95-0078.ResultsPrevalence of breastfeedingPreference for formula feeding predominated the discus-sion in the initial focus group and was associated with abelief that breastfeeding was messy, inconvenient, andsocially unacceptable. Participants stated that many Chi-nese women started breastfeeding to comply with theirphysician's advice, but most found it distasteful and quitwithin two weeks of giving birth. One participant, whowas a bank manager, said "I couldn't believe my eyes"when one of her clients breastfed her baby during a meet-ing.For the telephone survey, we identified 566 women whowere eligible and willing to participate, according to theirmaternity care provider. We were able to contact 373(65.9%) by telephone after a maximum of four attempts,including during weekends and evenings. At least 10% ofthe phone numbers on the hospital pre-registration listswere incorrect. Among those contacted, 77 were no longereligible, either because they had already delivered, n = 68(18.2%) or had a pregnancy loss, n = 9 (2.4%). Of the 296remaining eligible women, 250 (84%) agreed to partici-pate. At the postnatal survey 196 (78.4% of 250) mothersparticipated. Twenty-three had returned to Hong Kong orTaiwan. The whereabouts of another 31 were unknownOur survey study sample is described in Table 1. Partici-pants were mostly employed outside the home, evenlydistributed according to years lived in Canada (< 1 year,1–4.9, 5.0–9.9, ≥ 10) and roughly half were nulliparous.On average, women were 31 years of age and had 12 yearsof schooling. Most respondents were born in China(52.7%) and Hong Kong (32.8%), with 6.2% in Taiwan,4.6% in Canada, and 3.7% in other countries. The major-ity of participants were interviewed in Chinese languages;69% in Cantonese and 3.2% in Mandarin. All identifiedtheir ethnic origin as Chinese.Almost as many women (27%) had received prenataladvice to formula feed from their physicians as to breast-feed (34.8%). (Table 1) Most subjects (83%) thought thatTable 1: Characteristics of survey participants (n = 250)Mean SDAge [mean (SD)] 31.2 4.1Years of Education 12.6 3.6Spouse's years of education 13.6 4.1n %Employed outside of home n (%) 152 61%Years lived in Canada< 1 year 44 17.61 – 4.9 years 73 29.25 – 9.9 years 69 27.610 or more 64 25.6Country born inChina 127 50.8Hong Kong 79 31.6Taiwan 15 6.0Canada 11 4.4Other countries 18 7.2Language of interviewCantonese 172 68.8Mandarin 8 3.2English 70 28.0Parity – primiparous 122 48.8Planning to attend prenatal classes 58 23.2Advice from physician re infant feedingBreastfeed 31 34.8Formula feed 24 27Unsure of advice 34 38.2No answer to this question 161Planned infant feeding method:Breastfeeding in combination 126 50.4Breastfeeding exclusively 52 20.8Formula exclusively 67 26.8Page 3 of 7(page number not for citation purposes)but we were able to ascertain their choice of infant feedingfrom their hospital record.Unsure 5 2.0BMC Pregnancy and Childbirth 2009, 9:3 http://www.biomedcentral.com/1471-2393/9/3breastfeeding would be the best way to feed their infant.(Data not shown). Seventy-one percent planned to startwith exclusive breastfeeding. Among those planning tobreastfeed, 65.5% planned at some point to combinebreastfeeding with formula feeding. Overall, only 29% ofthe 178 (20.8% overall) planned to breastfeed exclusivelyuntil they weaned their baby. During the antenatal period,52.4% of women planning to breastfeed felt extremely orvery confident in their ability to breastfeed, 32.6% feltsomewhat confident and 15% felt not very or not at allconfident. Chinese vs. Hong Kong immigrants were sig-nificantly less likely to plan to breastfeed, odds ratio (OR)0.43, 95% confidence intervals (CI) (0.20–88). Adjust-ment for mother's age and years in Canada did not signif-icantly alter these odds ratios.The trend towards less breastfeeding among Chinese vs.Hong King immigrants continued for exclusive breast-feeding at hospital discharge, OR 0.36, 95% CI (0.20–0.64). Overall, rates of exclusive breastfeeding were 47.2%at hospital discharge and dropped to 15.6% within twomonths (Table 2). Rates at two months postpartum didnot differ by country of origin.The predominant reason for choosing formula exclusivelyor as a supplement while in hospital was a belief that therewas not enough breast milk. The majority of women seek-ing help for breastfeeding did so from hospital nurses,during the first 48–72 hours postpartum.Chinese language infant feeding telephone hotlineOn review of survey findings, focus group participantsdeveloped a list of attributes of an intervention that wouldpromote exclusive breastfeeding (Figure 1). As a priorityneed, they identified a Chinese language newborn tele-phone hotline. We then began to plan the implementa-tion of a Chinese language infant feeding telephonehotline in consultation with the regional Vancouver Rich-mond Health Board (VRHB). The VHRB was already oper-ating an English language hotline. We hired nineregistered nurses to staff the hotline. All were experiencedcommunity health nurses and six had worked in a perina-tal setting. Three were certified lactation consultants. WeTable 2: Breastfeeding experience of survey participants (n = 250)n %Infant feeding at hospital dischargeExclusive breastfeeding 118 47.2Combined breast and formula 70 28.0Formula feeding only 62 24.8Infant feeding at two months postpartumExclusive breastfeeding 39 15.6Combined breast and formula 58 23.2Formula feeding only 153 61.2Reasons for choosing formula feeding during hospital stay (n = 62)Believed they would not have enough milk 30 48.3Other persons could feed baby 8 12.9Returning to work 4 6.4Convenience 2 3.2No reason given 18 29.0Reasons for introducing formula after breastfeeding initiation(n = 79)Believed they did not have enough breast milk 35 44.3Convenience 6 7.6Belief that baby would be easier to wean 8 10.1No reason given 30 38.0Help seeking among women having breastfeeding difficulties (n = 49)Physician 12 24.5Hospital nurse 17 34.7Lactation consultant 3 6.1Family member 3 6.1Hospital drop in clinic 3 6.1Community health department drop-in clinic 2 4.0Friend 3 6.1Page 4 of 7(page number not for citation purposes)No one 6 12.2BMC Pregnancy and Childbirth 2009, 9:3 http://www.biomedcentral.com/1471-2393/9/3adapted protocols for responding to and documentingcalls from the VRHB hotline. The hotline operated from1800–2200 hours 7 days per week. Information about thehotline was included both in postpartum informationpackages distributed at Vancouver hospitals and in pack-ages distributed by public health nurses during routinepostnatal home visits to new mothers. The service wasadvertised through the Chinese language media.During the first five months of operation, use of the Chi-nese language hotline increased to 80 calls per month andremained at that level. Women called the hotline withquestions related to milk supply, babies spitting up andvomiting, engorgement, sore nipples and many otherfeeding problems (Table 3). Use of the existing Englishlanguage hotline did not change. A subsequent surveyamong women who had previously attended prenatalclasses at SUCCESS six months after implementation(unpublished) indicated that 63% of new Chinese moth-ers were aware of the hotline and 19.4% had used it.Among 365 individual women using the hotline, the rateof exclusive breastfeeding overall was 44.1%.(Table 3)This compares to 15.6% among women in our telephonesurvey at two months postpartum, odds ratio 3.02, 95%CI (1.78–5.09). Among 229 women who stated they werebreastfeeding, 36 (11.4%) were providing breast milk viafeeding hotline, there were many other areas of inquiry(Table 4).Interventions were undertaken by the hotline nurses inresponse to 490 (88%) of calls: advice provided by thehotline nurses 413 (84.3%); referral to a physician 63(12.8%); referral to community health nurses 7 (1.3%);breastfeeding drop-in clinics 4 (0.8%); and a nutritionist1 (0.3%). Two clients were directed to go immediately toa hospital emergency room. Six months after the conclu-sion of our study, the VRHB reopened the hotline as partof their services to the community on a permanent basis.DiscussionThe initial findings from our focus group, that culturallyspecific beliefs play an influential role in women's prefer-ences for infant feeding, were not supported by our surveyof 250 women. The primary reason for introducing for-mula reported in our survey was not unique to Chineseculture but common to many new mothers; that is, a con-cern that they would not have enough milk. Studies focus-ing on Asian women have reported similar concernsamong new mothers [5,15]. Concern about insufficientmilk supply, therefore can not explain entirely the differ-ence in breastfeeding rates observed in our populationprior to the study, unless women of Chinese descent donot receive the necessary teaching and support to addressthis misinformation. Of concern was the small proportionof women who had received encouragement to plan toAttributes of a health promotion program in the Chinese comm nityFigure 1Attributes of a health promotion program in the Chi-nese community.9Provided in Chinese languages 9Provided information that was supported by peer-reviewed and published research 9Available from one source 9Culturally specific 9Included preventative measures 9Open outside of office hours 9Accessible to extended family  Table 3: Characteristics of mothers using hotlinen %Age of mother in years (n = 365 women)20–25 20 5.526–30 97 26.631–35 130 35.636–40 86 23.641–45 32 8.8Weeks postpartum at time of call (n = 557 calls)0–1 109 20.02–3 147 27.04–5 72 13.26–7 38 7.08–9 44 8.110–19 83 15.220–29 36 6.630+ 16 2.9Not stated 12Method of Feeding at time of callBreastfeeding exclusively: 246 44.1Formula feeding exclusively: 121 21.8Combination feeding 190 34.1Page 5 of 7(page number not for citation purposes)a bottle; they were not putting the baby to the breast. Inspite of the fact that the service was specifically called abreastfeed. This barrier to breastfeeding has been reportedin other recent studies as well [6].BMC Pregnancy and Childbirth 2009, 9:3 http://www.biomedcentral.com/1471-2393/9/3Our findings of low rates or exclusive breastfeeding at hos-pital discharge (47%) and at two months postpartum(15.6%) are not different than other studies addressingthis population. Recent studies from Hong Kong reportbreastfeeding initiation rates as high as 60% [6] but onlyabout 22% at two months postpartum [16]. A study ofimmigrant Chinese mothers in Australia reported breast-feeding rates of 34% at three months and recommendedethno-specific services to support breastfeeding for thefirst six months postpartum [17].The Chinese Language Newborn Feeding Hotline enjoyeda rapid uptake. Requests for information were for general,as opposed to culturally specific information. Unchangedrates of usage of the English language hotline indicatedthat the hotline was addressing a previously underservedpopulation. Since most calls were received within the firstmonth of life, the hotline was supplementing care givenby family physicians, pediatricians, and communityhealth nurses.at two months postpartum in our pre-hotline survey. Ourfindings may be biased in that only women seeking helpwith feeding accessed the hotline and women determinedto breastfeed may preferentially use this service. The tele-phone service was never described, however, as a breast-feeding hotline, and women received assistance toformula feed if they so requested. Another potential limi-tation to our study is that our pre-intervention survey,unlike the Newborn Hotline, was hospital-based, ratherthan population-based. However, approximately 80% ofthe births in the City of Vancouver take place at BCWomen's Hospital.A report on multicultural perspectives on infant feeding inCanada described variation among Chinese womenaccording to country of origin[12]. In this report, womenwho had come from Hong Kong were more likely to beinformed abut the benefits of breastfeeding, and weremore likely to initiate and continue breast feeding com-pared to women from Mainland China and Taiwan. Oursurvey supports these findings. It is possible that womenfrom Hong Kong may have been more likely to access theNewborn Hotline, and if so, our findings may not be gen-eralizable to women of all Chinese immigrant groups. Ini-tiatives to target women from China specifically may bewarranted in future studies.It is worth noting that a variety of calls about issues notdirectly related to infant feeding indicate an unmet needamong this population for assistance with parentingissues other than breastfeeding.ConclusionWe utilized a participatory action approach in a commu-nity-based study to address disproportionately low ratesof exclusive breastfeeding among immigrant Chinesewomen. Our focus groups and a survey of Chinese womenbefore and after giving birth directed the development ofa Chinese-language telephone information service fornewborn feeding. Women using the hotline had a three-fold greater odds of breastfeeding exclusively. While wecannot attribute these increased rates in a causal fashionto the hotline due to the cross-sectional nature of our sur-veys, our results should encourage the implementationand evaluation of telephone-accessed language-specificservices in other public health settings serving new moth-ers.AbbreviationsCI: Confidence Intervals; OR: Odds Ratios; SUCCESS:United Chinese Community Enrichment Services Society;VRHB: Vancouver Richmond Health Board.Table 4: Mother's concerns precipitating a call to the hotlinen %Breastfeeding 226 40.4Inadequate milk supply 42Spitting up/vomiting 31Engorgement 28General information 22Supplementation 17Mother on medication 15Sore nipples 13Weaning 11Baby's appetite decreasing 10Hiccoughs 10Baby not satisfied 7Mastitis 6Baby sleepy at breast 5Use of vitamins 5Slow weight gain 2Latching problems 2Infant Health/Illness 102 18.3Infant Behaviour 49 8.8Infant Elimination 126 22.6Infant Sleep 12 2.2Formula Feeding 89 16.0Feeding Solids 44 7.9Infant Crying 27 4.8Infant Care 61 11.0Immunization 16 2.9Maternal Health 56 10.1Medication 14 2.5Community Resources 4 0.7Other 29 5.3Page 6 of 7(page number not for citation purposes)Rates of exclusive breastfeeding were threefold greater inwomen using the newborn hotline compared to womenCompeting interestsThe authors declare that they have no competing interests.Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central BMC Pregnancy and Childbirth 2009, 9:3 http://www.biomedcentral.com/1471-2393/9/3Authors' contributionsPJ contributed to the design of the study, participated infocus groups, undertook data analysis, organized the new-born hotline service, and wrote the first draft of the man-uscript. VL contributed to the design of the study, with amajor contribution to the design of surveys, interpretationof focus group findings, and development of the newbornhotline. BC originally outlined the need for the study andconceptualized the design. He assisted in interpretation ofstudy findings. MK participated in developing the studydesign, facilitated data collection, participated in interpre-tation of findings. All authors contributed to the writingof the manuscript and have read and approved the finalversion.AcknowledgementsThe authors would like to acknowledge funding from the British Columbia Medical Services Foundation. They would like also to thank the United Chi-nese Community Enrichment Services Society (SUCCESS) for their advice, and assistance with recruitment and provision of space for focus groups. The Vancouver Richmond Health Board shared their protocols for the Eng-lish language newborn feeding telephone service and provided space, man-uals, and phones for the implementation of the Chinese language newborn hotline.References1. Chute G: Breastfeeding.  Clinical Issues in Perinatal and Women'sHealth Nursing 1992, 3:717-722.2. Chan-Yip A, Kramer M: Promotion of breast-feeding in a Chi-nese community in Montreal.  Can Med Assoc J 1983,129:955-958.3. Wang X, Wang Y, Kang C: Feeding practices in 105 counties ofrural China.  Child Care Health Dev 2005, 31(4):417-423.4. Li L, Li S, Ali M, Ushijima H: Feeding practice of infants and theircorrelates in urban areas of Bejing, China.  Pediatr Int 2003,45(4):400-406.5. Chye J, Zain Z, Lim W, Lim C: Breastfeeding at 6 weeks and pre-dictive factors.  J Trop Pediatr 1997, 43(5):287-292.6. Tarrant M, Dodgson J, Choi V: Becoming a role model: thebreastfeeding trajectory of Hong Kong women breastfeed-ing longer than 6 months.  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McTaggart R: Principles for participatory action research.  AdultEduc Q 1991, 41:168-187.14. S.U.C.C.E.S.S Foundation   [http://www.successbc.ca/]15. Li L, Zhang M, Binns C: Chinese mothers' knowledge and atti-tudes about breastfeeding in Perth, Western Australia.Breastfeed Rev 2003, 11:13-19.17. Diong S, Johnson M, Langdon R: Breastfeeding and Chinesemothers living in Australia.  Breastfeed Rev 2000, 8:17-23.Pre-publication historyThe pre-publication history for this paper can be accessedhere:http://www.biomedcentral.com/1471-2393/9/3/prepubyours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 7 of 7(page number not for citation purposes)16. Khin P, Cheung S, Loh T: Support and promotion of breastfeed-ing. Where are we now?  Public Health and Epidemiology Bulletin2002, 11(3):25-32.


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