Postnatal women’s breastfeeding beliefs, practices, and support during the COVID-19 pandemic: a cross-sectional comparative study across five countries

A multi-country online cross-sectional study was conducted in five countries: Brazil, South Korea, Taiwan (Republic of China), Thailand, and the UK. Postnatal women were invited to participate in a survey concerning their infant feeding practices, experiences of postnatal infant feeding support received, and belief toward transmission and preventative measures for breastfeeding during the COVID-19 pandemic between July 2021 to November 2021.

Women up to six months postpartum, aged between 18 and 49 years (in Taiwan, between 20 and 49 years old), and literate in the country’s official language, were included in the survey. The exclusion criteria consisted of women who were not living in one of the countries under study during the survey period and those who could not read the questions. Since this study used convenience sampling online, no sample size was calculated. Based on the prevalence of infant feeding practices, the sample in each country was considered sufficient for this analysis.

The survey was developed in English and translated into the local languages of participating countries (Portuguese, Korean, Chinese, and Thai), and then back-translated into English. The researchers and some breastfeeding women from each participating country reviewed the content to identify any statements in the research instrument which were unclear, misleading, or highly sensitive and to verify the questions to ensure the validity and reliability of the survey prior to use in an online survey. Based on the results and comments from the data collectors, minor revisions were made to the wording.

Due to the preventative measures imposed to minimize the spread of COVID-19, data were collected using online Google Forms for web-based surveys. The survey information was distributed via e-mail, social media (Facebook, WhatsApp, Instagram, Twitter, etc.), personal networks, groups of health professionals, and not-for-profit organizations. In South Korea, a private company was used for recruitment.

All women who participated voluntarily signed an online informed consent form before starting the survey according to the Ethical Committee approval conditions of each country. In addition, prior to signing the informed consent, information on the study design and purpose were presented, including the assurance of confidentiality.

Descriptive statistics were used to measure the frequency and proportion of categorical variables, such as general characteristics, infant feeding practices, postnatal infant feeding support experience, questions relating to beliefs on breastfeeding during the COVID-19 pandemic, and mean and standard deviation (SD) for continuous variables, such as the total score for beliefs toward breastfeeding and COVID-19. The percentage of variables by country were compared using Chi-square tests or Fisher’s exact test as appropriate for categorical variables. T-tests or one-way analysis of variance (ANOVA) tests were performed to determine the significant associations between the mean belief scores and all examined variables. Bivariate and multivariate analyses of country comparison for infant feeding practice and breastfeeding status (never, stopped breastfeeding, and still breastfeeding) were assessed using binary and multinomial logistic regression, respectively. Associations between infant feeding practices and breastfeeding beliefs were assessed using binary logistic regression. In multivariate analyses, model 1 includes the infant’s age (and country in the total sample), while model 2 also includes the infant’s sex, mother’s age, education, working status, marital status, and type of residence (and country in the total sample) in model 1, with crude and adjusted odds ratios (COR and AOR, respectively) and 95% confidence intervals (CIs) presented. All analyses were conducted using SAS 9.3 (SAS Institute Inc., Cary, NC, USA).

In this study, the mean scores for belief toward breastfeeding in relation to COVID-19 transmission and preventative measures through infant feeding practices were significantly different among countries. A high rate of belief was expressed by the participants when asked about the “transmission of COVID-19 through breastmilk” (Question 1) and “Should women avoid breastfeeding if they are suspected of being infected with COVID-19?” (Question 2) were found in three Asian countries. One reason for this could be that information regarding the safety of breastfeeding during the COVID-19 pandemic was not widely disseminated in Asian countries compared to the UK and Brazil, despite recommendations from several international health agencies and medical societies. Furthermore, during the early stages of the COVID-19 pandemic, health professionals such as the American Academy of Pediatrics [27] and other associations [28] suggested that babies be temporarily separated from their mothers after birth and recommended that breast milk be expressed as a precautionary measure due to concerns about the risk of COVID-19 transmission through breastfeeding.

As soon as evidence was available that transmission of SARS-CoV-2 via breast milk was unlikely [29] and that the impact of breastfeeding would guarantee food safety for children [30], the recommendation to breastfeed grew, with most agencies and medical societies becoming unified in their views [31].

The participants expressed a low rate of belief when asked about “skin-to-skin and breastfeeding following delivery” (Question 3) in all three Asian countries compared to the others. Different postpartum practices in hospitals and maternity services which did not follow the WHO recommendations caused confusion among women about whether or not they should breastfeed their babies [32].

Regarding the practice of wearing a facemask when holding the baby, including during feeding (Questions 5 and 6), the findings reveal that fewer mothers in Brazil were in agreement with this practice during breastfeeding, touching, and holding their newborn baby. Despite the mothers being recommended to protect their nose and mouth with a mask during breastfeeding [10], they appeared to be less concerned about the transmission of COVID-19, preferring to focus on the importance of face-to-face interaction with the baby for brain development [33], nurturing, and bonding to forge a deep shared connection [34].

Global breastfeeding rates are generally low [8]. The results of this study reveal that 73% of the women in all the countries under study breastfed at the breast in the 24 hours preceding the survey. Brazil presented the highest breastfeeding rates at 91%, followed by the UK (85%) and South Korea (72%). Due to the difference in COVID-19 pandemic waves between countries, it has proven difficult to compare our results with other studies on the impact of breastfeeding. Despite the global breastfeeding rates being generally low, in the countries we analyzed [1‐6] , the rates were higher. A study carried out in April 2020 during a UK lockdown period identified that infant feeding was influenced by the mother’s negative emotions and anxiety when they had more than one child to take care of [35]. Around 27% of women faced barriers to continuing with breastfeeding due to the pandemic lockdown [36]. Another study in the UK, from May 27 to June 2020, showed that 59% of women who delivered during lockdown exclusively breastfed / mixed-fed their infants compared to 39% who delivered before the COVID-19 pandemic [37]. In Thailand, from July — October 2020 and December 2020 to February 2021, after the lockdown from April — June the same year, a slight decrease of 4.3% was exhibited in breastfeeding practice during the COVID-19 lockdown [38]. Furthermore, a study in Italy from March — May 2020 showed similar results, with a decrease in women exclusively breastfeeding compared to before the COVID-19 pandemic (2018) [39], and this was also the case in the United States of America for women who gave birth before 2020 [19]. Despite these findings, a study in China carried out from August to October 2020 to compare the infant feeding experiences of women who delivered before and during the COVID-19 pandemic in Beijing identified that breastfeeding practice rates were maintained during the pandemic [20].

Despite the benefits of breastfeeding and the recommendations made during the COVID-19 pandemic [10], concerns and fears about the infection being transmitted from mother to infant through breastfeeding could have affected infant feeding practice. Furthermore, mothers may have been influenced by various factors when deciding how to feed their infant since breastfeeding media and beliefs during the COVID-19 pandemic varied according to the government regulations, policies, socioeconomic status, and health inequity in each country [40]. Thus, further studies are needed to identify how breastfeeding beliefs toward COVID-19 transmission and prevention measures affect breastfeeding practices in various settings and populations. This study found that a positive breastfeeding belief was associated with the baby being breastfed at the breast and inversely associated with infant formula. All three Asian countries presented lower rates of breastfeeding at the breast and exhibited lower scores for belief compared to Brazil (16) and the UK (14.5), which both showed higher rates of breastfeeding at the breast. Asian women also have a similar or slightly lower rate of breastfeeding using expressed breast milk, while the UK and Brazil had a higher rate of breastfeeding at the breast. We found that 60% of women in Thailand express their breast milk, followed by 53% in Taiwan and 50% in South Korea.

Several factors may interfere with breastfeeding practice, such as educational level [41] and delivery experience [20]. Expressing breast milk may encourage continued breastfeeding [10, 23]. A study of Singaporean Chinese women showed the increased practice of expressed milk and combination feeding, defined as breast milk and non-breast milk fed via bottle and breast, while direct feeding at the breast showed a decreasing trend over time [42]. Women tended to express their breast milk when they did not want to breastfeed in public or had returned to work [23]. An increasing number of working mothers in Asia are changing their infant feeding practices due to increased participation in the labor force among Asian women (Thailand 59.2% and South Korea 53.2%) [43]. During the COVID-19 pandemic, women were more likely to have struggled with increased childcare demands [14]. Breastfeeding at the breast in public places or at work remains challenging for mothers, especially in Asia. In Korea, women who return to work after maternity leave stated that their work status directly affected their decision not to breastfeed. The primary reason given for not breastfeeding was that “it is not easy to express milk at work.” Furthermore, the expressed breastfeeding rate was higher than breastfeeding at the breast: breastfeeding mostly with an occasional bottle with expressed breast milk (44.2%) vs. breastfeeding only (26.9%) [44]. The women’s characteristics in this study showed little difference in work status, and no studies are currently available for comparison. Therefore, further research should be conduted to identify any differences.

Another study showed the influence of social policy on breastfeeding duration, such as the breastfeeding policy of the hospital and national parental leave, although social policy was not found to be statistically associated with the breastfeeding duration in a recent Korean study [45]. Furthermore, although women with a higher education level tend to know about the health benefits of breastmilk, they are more likely to be employed or involved in out-of-home activities. Thus, it is often difficult for women to feed their babies directly and instead use expressed breastmilk or combination feeding. In comparing the results, the participants in this study were found to have a high educational level (75.8% had a university or postgraduate degree), but 59.2% were on maternity leave. Infant feeding formula was used by 41% of women in the pooled sample, with the rate being higher in Taiwan at 73%, followed by South Korea at 57%. A high formula feeding rate was exhibited in Asian countries during the COVID-19 pandemic. Despite the benefits of expressed breast milk to support continued breastfeeding practice, women who exclusively expressed in early postpartum may not achieve long-term breastfeeding [46]. Using breast milk instead of formula feeding gives babies the benefits of human milk but can also reduce the practice of breastfeeding at the breast and result in increased formula feeding [47].

Face-to-face support for breastfeeding by professionals and / or peers improved breastfeeding rates [48]. Also, early breastfeeding support helped to increase breastfeeding by 24% [49]. In this study, postnatal feeding support was found to be mainly received from health professionals and peers / family through in-person contact in all countries. A systematic review showed that the views and experiences of family members toward breastfeeding support were multi-faceted [50]. Facilitators of exclusive breastfeeding (EBF) were, having good knowledge and skills among healthcare professionals and the support of healthcare services to improve breastfeeding practice [51, 52]. The provision of sufficient information with tailored, practical support is the main reason mothers continue to breastfeed [50, 53].

The COVID-19 pandemic interfered with women obtaining postnatal in-person follow-up care and in-person breastfeeding support [54]. A study that compared the postnatal experiences of women who delivered before and during lockdown in the UK identified a decrease in feeding support from 57% to 40% [36]. Despite the pandemic situation, our study revealed that more than 50% of women received professional support (67% in the pooled sample), ranging from 86% in Thailand to 47% in South Korea. The UK exhibited 57%, a similar rate before lockdown [36]. Meanwhile, a high number of women in South Korea and the UK reported receiving no support.

Health support was found to vary according to the restrictions and pandemic waves in each country. Some countries might face restrictive policies on services, with women receiving virtually no professional and / or peer support. A systematic review of remote support during the COVID-19 pandemic showed that remote breastfeeding support and education combined with support in hospitals reduced the risk of women stopping breastfeeding at three months by 25%, although it is less clear if such an intervention changes the chance of stopping breastfeeding at eight weeks, and three and six months [55]. In this study, 31% of women were found to receive online group support, 33% phone support, and 9% video breastfeeding support. The UK presented similar high rates of online group support (49%) and telephone support (41%) to Thailand (35% and 52%, respectively). Remote support, with online video calls and advice over the telephone, increased during the pandemic because it can help women with infections to self-isolate and receive breastfeeding support due to the COVID-19 control measures [56]. In our study, 59.3% of women who received online support via a video platform reported no difficulties, while 23.5% expressed concern that supporters were unable to clearly see their baby’s latching.

Access to breastfeeding support in hospitals and communities is also restricted due to the control measures in place during the COVID-19 pandemic. Some face-to-face breastfeeding support services by healthcare professionals and breastfeeding peer supporters were temporarily replaced by virtual support via telephone or virtual platforms [57, 58], which may be affected by national COVID-19 infection control measures. Although virtual breastfeeding support has the benefit of convenience, allowing women to receive support at home, a study conducted in the United States of America shows only moderate effectiveness for virtual professional support since it involves certain challenges such as the supporter being unable to assist with latching or analyzing the body language of the baby during the session [58]. How virtual and remote breastfeeding support can best be provided, to whom, and in what circumstances needs further investigation to facilitate the use of technologies for enhancing breastfeeding support.

On the other hand, with no internal support (spouse and family) and external support (professional health services, friends, and employers providing a room for pumping breast milk), women might decide not to continue with breastfeeding [59]. A systematic review shows the importance of community peer support in increasing the duration of exclusive breastfeeding in low- and middle-income countries, especially for infants aged three to six months [60]. Breastfeeding peer support is a good protection strategy since it increases the mother’s self-esteem and confidence [61]. Taiwanese women feel motivated to breastfeed when they have access to services provided by in-center care organizations that facilitate networking with other mothers [62], although during the COVID-19 pandemic, this may have presented a challenge.

The limitations of this study meant that only women who could access the internet could participate and were more likely to be young, have a higher education, and live in urban areas. In addition, recruitment using online nonprobability samples tends to be prone toward sampling participants leading certain lifestyles. Also, in the UK and Brazil, some infant feeding support organizations helped disseminate the online survey information. Such channels might attract women interested in infant feeding (breastfeeding or breastfeeding support) to complete the survey. Thus, the findings of the study cannot be generalized to other populations and settings.