Participants
The research included all mothers who gave birth while hospitalized in the ward. The sample size was determined based on a previous study by Harris Luna et al., considering (p1 = 0.45, p2 = 0.13, 80% power and 95% confidence) 32 participants per group, accounting for a 15% drop-out rate. The final sample size included an additional 37 participants in each group [
21].
The inclusion criteria of mothers include the desire to participate in the study, having a smartphone with the ability to use WhatsApp, having a definite infection with COVID-19 based on a positive PCR test or CT scan result, the general condition of the mother being favourable to start feeding the baby after delivery, hospitalization in the ward at least 24 h after delivery. The criteria for the inclusion of newborns included a healthy newborn the ability to feed with breastmilk and a gestational age at birth of more than 34 weeks. Exclusion criteria included delivery less than 34 weeks of pregnancy, maternal or infant contraindications for breastfeeding, hospitalization of the infant or mother in the intensive care unit, and unwillingness to continue cooperation.
Procedure
The eligible participants for the study were selected using an available sampling method. After verifying the inclusion and exclusion criteria, they were divided into two intervention groups, namely continuous counselling and intermittent counselling through a coin toss.
The content of the breastfeeding counselling was adjusted based on the protocol and guidelines of the Ministry of Health, as well as the previous study conducted by the research team [
16]. In Iran, breastfeeding counselling was routinely provided in hospitals during the postpartum phase to all mothers, regardless of whether they had COVID-19 infection. However, ongoing counselling after discharge was not included in the standard practice. Following the World Health Organization’s recommendations (March 18, 2020) to initiate breastfeeding within the first hours after birth for women with COVID-19, while observing proper respiratory precautions, this protocol was also adopted in Iran for mothers and babies in good general health. Nevertheless, in practice, some doctors and parents opted out of this practice. In this study, “counselling” refers to personalized interactions between women and midwives, focusing on tailored support and guidance.
In Iran, as in many other countries, standard postpartum care includes breastfeeding education programs immediately after childbirth in a hospital. Postpartum routine care at health centers involves three visits on days 3, 15, and 40 after birth. The key counseling topics cover personal hygiene, breastfeeding, immunization, vitamin use, postpartum hemorrhage or infection examinations, baby care, family planning, and nutrition. However, due to the COVID-19 pandemic, face-to-face visits were limited, following COVID-19 health protocols. Additionally, at the onset of the pandemic, mothers and newborns were separated after childbirth.
The first author, who had completed relevant courses on breastfeeding at Ayatollah Mousavi Hospital in Zanjan, was responsible for implementing the counselling protocol. This ensures that the counselling sessions are conducted by a trained professional with expertise in breastfeeding support. In both groups, the first session of breastfeeding counselling was conducted face-to-face and individually. This session took place in the hospital, following the health protocols for COVID-19, and lasted for 45 min. The counselling session was held at the patient’s bedside. Following the initial session, the continuous supportive counselling group received daily counselling for 14 days. This counselling was conducted through phone calls and the delivery of educational content via WhatsApp. In the intermittent supportive counselling group, counselling sessions occurred once a week for a total of four weeks. Similar to the continuous group, counselling in this group was also delivered through phone calls and the transmission of educational materials via WhatsApp. Additionally, as part of the counselling process, mothers in both groups had the opportunity to ask questions and receive answers by sending messages on WhatsApp.
During the first session of breastfeeding counselling, the following activities were conducted:
(1) Self-introduction and getting to know the patient, (2) Explanation of the objectives of the study, (3) Definition of exclusive breastfeeding and its benefits for the baby, (4) Explanation about the new coronavirus disease and concerns of mothers with COVID-19 regarding breastfeeding, (5) Health recommendations for infected mothers with COVID-19 during breastfeeding, (6) Explanation about the number and frequency of breastfeeding throughout the day, (7) Explanation of how to breastfeed and observing mothers breastfeeding based on the Latching-on Checklist, (8) Answering mothers’ questions regarding breastfeeding or COVID-19. In this study, emotional support was provided to mothers who expressed fears and concerns about COVID-19 transmission through breastfeeding.
The counsellor collected the mothers’ contact information for future counselling sessions and conducted a pre-test.
During the subsequent phone call sessions and the delivery of educational content via WhatsApp, the focus of the counselling and educational materials was on the following topics:
(1) Discussing fears and concerns of breastfeeding mothers in the era of COVID-19, (2) Explaining misconceptions of breastfeeding in the era of COVID-19, (3) Explaining the benefits of breastfeeding for babies, (4) Explaining the assessment of breast milk adequacy, (5) Explaining the risks of formula feeding, cow’s milk and milk alternatives, (6) Health recommendations for mothers with COVID-19 while breastfeeding, (7) Teaching various correct breastfeeding techniques, (8) Strategies to increase breast milk production, including recommendations for adequate nutrition, hydration, and breastfeeding frequency, (9) Preventing and solving breast problems such as engorgement or mastitis, and guiding prevention and management, (10) The importance of breastfeeding during the night and its role in maintaining milk supply, 11. How to use supplements for the baby such as vitamin D, 12. Encouragement to take care of the baby with the support and participation of the family.