Women’s experiences and views on early breastfeeding during the COVID-19 pandemic in Norway: quantitative and qualitative findings from the IMAgiNE EURO study

The COVID-19 pandemic has affected maternal and perinatal healthcare worldwide [1, 2]. New and continuously shifting government regulations had a large impact on the organization of hospital care, including restrictions that may have affected breastfeeding [3, 4]. Both the World Health Organization (WHO) and the International Confederation of Midwives (ICM) called the attention of the international community to women’s and newborn’s rights during the COVID-19 pandemic [5, 6]. However, a reduction in exclusive breastfeeding initiation during the first wave of the pandemic was observed [3, 7]. Further, European hospitals have differed in their interpretation of guidance around breastfeeding policies during the pandemic, with some advising formula feeding although no national or international guidelines recommended discontinuation of breastfeeding [8].

Breastfed children are less likely to die of infections [9], less likely to become overweight [10] and are less prone to diabetes and allergy later in life [11], while their intelligence quotients can be higher [12, 13]. Women who breastfeed have a reduced risk of a range of physical and emotional health problems, such as ovarian and breast cancers, postpartum depression and maternal excess of stress [14]. The multiple benefits of breastfeeding likely outweigh possible risk factors related to SARS-CoV-2 infection and should therefore be encouraged [15, 16]. In addition, while SARS-CoV-2 transmission from mother to baby via breastmilk seems to be unlikely, milk produced by infected mothers has been found to be a source of anti-SARS-CoV-2 IgA and IgG valuable for the baby’s health [16].

This study is part of the IMAgiNE EURO project, a multi-country survey conducted in 18 countries in the WHO European Region to collect views of women on the quality of maternal and newborn healthcare during the COVID-19 pandemic [17]. Similar to what occurred in other European countries, in order to prevent the spread of COVID-19, since 12 March 2020 the Norwegian government introduced strict social distancing regulations with major impacts on society [18]. During the COVID-19 pandemic in Norway, an increased use of formula, a reduction in exclusive breastfeeding and reduction in the average length of breastfeeding were documented [4]. However, little is known about women’s experience of care and views on early breastfeeding during the COVID-19 pandemic in Norway. More evidence on this topic may be of interest for researchers, policy makers and clinicians and support further improvements in the quality of maternal and newborn care.

The aim of this study was to investigate quality of care at facility level, and women’s experiences and views on early breastfeeding practices during different phases of the COVID-19 pandemic in Norway.

The study sample included answers from 2922 births, 2425 (83.0%) in 2020 and 497 (17.0%) in 2021 were included (Fig. 1). Characteristics of the study sample are shown in Table 1. Both in 2020 and 2021, few women had an immigrant background (n = 204) or answered the survey in a different language than Norwegian (n = 19). In both 2020 and 2021, most women were 25 to 35 years old; nearly four out of five had either a university or postgraduate degree; the number of instrumental births was similar (12.4% vs. 11.5%). When compared to 2021, the numbers of first-time mothers were statistically significant higher in 2020 (58.4% vs. 53.1%, P = 0.030); Cesarean sections were slightly but not statistically significant more frequent (14.3% vs. 11.3%); and the number of women born outside Norway and vaginal spontaneous births were slightly but not statistically significantly lower (7.2% vs. 5.8 and 73.3% vs. 77.3%, respectively).

Associations between year of birth (2020, 2021) and factors related to early breastfeeding (n = 13 factors) are shown in Table 2. When compared to the first year of the pandemic (2020), women who gave birth in 2021 reported higher odds of adequate breastfeeding support (adjOR 1.79; 95% CI 1.35, 2.38); immediate attention when needed (adjOR 1.89; 95% CI 1.49, 2.39); clear communication from healthcare providers (adjOR 1.76; 95% CI 1.39, 2.22); allowed companion of choice (adjOR 1.47; 95% CI 1.21, 1.79); adequate visiting hours for partner and / or relatives (adjOR 1.35; 95% CI 1.09, 1.68); adequate number of healthcare providers (adjOR 1.24; 95% CI 1.02, 1.52); and adequate professionalism of the healthcare providers (adjOR 1.65; 95% CI 1.32, 2.08). When compared to the first year of the pandemic (2020), women who gave birth in 2021 reported lower odds of reduction in QMNC due to COVID-19 pandemic (adjOR 0.73; 95% CI 0.60, 0.89). We found no difference by year of birth; in having skin-to-skin contact with the baby in the first hour after giving birth; early breastfeeding; exclusive breastfeeding at discharge; adequate number of women per room; or reduction in their general satisfaction due to COVID-19.

When compared to women who gave birth in Norway during the first year of the COVID-19 pandemic, women who gave birth the following year were more likely to experience adequate breastfeeding support; immediate attention when needed; clear communication from healthcare providers; being allowed a companion of choice; adequate visiting hours for partner and / or relatives; adequate number of healthcare providers; and adequate professionalism of the healthcare providers. Compared to 2020, in 2021, the women also experienced lower odds of reduction in QMNC due to COVID-19 pandemic. When comparing factors related to breastfeeding in 2020 vs. 2021, we found no difference in the opportunity to have skin-to-skin contact with the baby in the first hour after giving birth; early breastfeeding; exclusive breastfeeding at discharge; adequate number of women per room; or reduction in their general satisfaction due to COVID-19. In comments related to breastfeeding (2020 and 2021), women described understaffed postnatal wards; early discharge and highlighted the importance of breastfeeding support from healthcare providers and companion of choice; and concerns about long-term consequences such as postpartum depression.

Many factors contribute to successful breastfeeding in the early postpartum period, and we found a range of breastfeeding-related factors were improved for women giving birth in Norway in 2021, compared to the first year of the COVID-19 pandemic (2020). One UK study from the COVID-19 pandemic reported that face-to-face breastfeeding support was reduced during the pandemic and some women struggled to get breastfeeding support, while others found strict regulations positive because of increased time at home, less pressure and fewer visitors [33]. In the current study, answers to the open-ended question revealed some women were pleased with the calm atmosphere that followed the strict visitor restrictions. Our findings are in line with the UK study and suggest that the COVID-19 pandemic affected women’s breastfeeding experiences differently.

When comparing data from 2020 with data from 2021, we found little difference in early skin-to-skin contact, early breastfeeding within the first hour after giving birth or exclusive breastfeeding at discharge. Women’s satisfaction with the number of women per room stayed constant over the study period and women’s general satisfaction with care due to COVID-19 did not improve significantly from 2020 to 2021. One Italian study including 204 mothers and babies in the early stage of the COVID-19 pandemic (9 March to 8 May 2020) found a decrease in exclusively breastfeeding in the studied population [3]. Consistent with our findings, one study including 821 women who gave birth in Norway in the spring of 2020 found great reliance on breast-milk substitutes, which may imply that fewer women in Norway were exclusively breastfeeding during the initial phase of the COVID-19 pandemic [4]. Findings of a quantitative study including 3642 women giving birth in Norway during the pandemic adds support that one in three women experienced being discharged early due to COVID-19 related factors [34]. In our data, one in four women (23.2%) who underwent labor in Norway in the study period reported not exclusively breastfeeding at discharge [17]. In the current study, when comparing data from 2020 with data from 2021, we found no difference in early breastfeeding or exclusive breastfeeding at discharge. In 2020, a nation-wide Norwegian report showed that 97% of babies born in Norway in 2018 were breastfed before postpartum discharge [25]. To our knowledge, updated national data on exclusive breastfeeding at discharge has not been published. However, early discharge may be one explanation for why fewer women exclusively breastfeed their babies early in the pandemic [4]. The lack of improvement in exclusive breastfeeding during the study period should alert policy makers in postnatal care services to implement specific quality improvement actions. To better understand the reasons for a lack of improvement in exclusive breastfeeding at discharge and no change in women’s general satisfaction with care due to COVID-19 from 2020 to 2021, future studies with other designs are needed.

In comments related to breastfeeding, the open-ended question in our survey gave information on understaffed postnatal wards, the importance of breastfeeding support from healthcare professionals and companion of choice, and a concern for long term consequences, such as postpartum depression, due to insufficient breastfeeding support during the pandemic. Our findings related to understaffed postnatal wards and the importance of partner are supported by a qualitative study exploring women’s experiences with giving birth in Norway during the pandemic [30]. Further, studies from Norway and the UK support the concern for the occurrence of postpartum depression, as they found an increase in maternal depression and anxiety postpartum, during the COVID-19 pandemic [34, 35]. A Norwegian national report on parental experience of QMNC published before the COVID-19 pandemic (2018) found that new parents in Norway were well satisfied with the care given on labor wards, however, postnatal care scored lower than other areas [36]. Findings in the Norwegian report suggest that our results related to QMNC in Norway during the first year of the Covid-19 pandemic cannot be attributed to the pandemic alone and must therefore be interpreted with caution. The qualitative findings in the current study support the concerns arising from the quantitative data, such as those related to women experiencing inadequate breastfeeding support, lack of attention when needed, not being allowed companion of choice, or a low number of healthcare providers.

In the second year of the COVID-19 pandemic, several but not all breastfeeding-related factors improved for women giving birth in Norway compared to the first year of the pandemic. Women’s general satisfaction with care during COVID-19 and rates of exclusive breastfeeding did however not improve significantly from 2020 to 2021. The findings should alert researchers, policy makers and clinicians in postnatal care services to improve future practices.