Methods
We conducted a narrative review of publications exploring how the pandemic restrictions, and positive COVID-19 status of the mother, impacted breastfeeding initiation, duration, and mothers’ self-reported breastfeeding experiences in Australia, N.Z., Canada, the U.K., and the U.S. Four literature searches were completed on PubMed using the key words, “breastfeed*”, “pandemic OR COVID-19” and either “Australia OR New Zealand”, “Canada”, “United Kingdom”, or “United States”. Results were limited to publications in 2020 and 2021. Inclusion criteria were as follows: original research study (i.e., not a commentary or review paper), participant population living in Australia, N.Z., Canada, the U.K., or the U.S., and included the outcome of breastfeeding initiation, duration, or mothers’ experiences of breastfeeding during the pandemic. The Australian and N.Z. search returned 28 results, of which two met inclusion criteria [42, 43], the U.K. search returned 26 articles, of which two met inclusion criteria [44, 45], the U.S. search returned 63 articles, of which six met inclusion criteria [5, 46,47,48,49,50], and the Canadian search returned 29 articles, of which two met inclusion criteria [51, 52]. Two additional articles on breastfeeding initiation and duration in the U.S. were identified through searching the references of the identified publications and through RSS alerts of newly published articles of breastfeeding during the pandemic [12, 53].
Results
Seven studies from the U.S. and one study from the U.K. showed that the COVID-19 pandemic was related to changes in breastfeeding initiation and duration [5, 45,46,47, 49, 50, 53]. No Australian, N.Z. or Canadian data on breastfeeding initiation or duration during the pandemic was found. In studies including COVID-positive mothers (all from U.S. samples) a reduction in breastfeeding initiation and duration was observed. Similarly, in a low-income U.S. sample not limited to COVID-positive mothers, breastfeeding exclusivity and duration declined during the pandemic. However, breastfeeding rates remained comparable to pre-pandemic rates in a general U.K. sample.
Among the studies including COVID-positive mothers, mother-infant separation emerged as the main barrier to establishing breastfeeding. In a U.S. study of 85 COVID-positive mothers in New York City, 58% were separated from their infants after birth [12]. None (0%) of the mothers who were separated from their infant were able to initiate breastfeeding in hospital, and only 12% were able to breastfeed when they arrived home. This is in contrast to 22% of non-separated mothers initiating breastfeeding in hospital, and 28% being able to breastfeed after arriving home. Among those who were separated from their infant at birth, 35% of mothers reported changing their feeding plan because of their illness, specifically due to separation and difficulty with latch [12]. Similar results were reported in another U.S. study that reviewed the neonatal and maternal outcomes of 70 COVID- positive mothers from 16 U.S. hospitals [50]. In this population, 51% of the dyads were separated after birth. Among those separated, 84% were feeding infant formula or donor milk exclusively, with only 14% feeding either exclusive expressed mother’s own milk, or expressed mother’s own milk with supplementation. None (0%) of these mothers were feeding directly at the breast. Among those who were allowed to room in, 85% were able to initiate direct breastfeeding (with or without supplementation), with only 18% providing infant formula or donor milk exclusively [50]. Similar trends were also observed in a study examining breastfeeding from one New York City hospital [47]. The authors compared the prevalence of separation and breastfeeding initiation between COVID-positive (n = 15) and COVID negative mothers (n = 64). All of the COVID-positive mothers were separated from their infant at birth, with only 33% direct breastfeeding to some degree. Among COVID-negative patients, 23% were separated from their infant, with 67% direct breastfeeding [47]. In contrast to the high separation rates stated above, a different U.S. sample of 82 neonates born to COVID-positive mothers from four hospitals in New York City, reported 83% of infants were allowed to room in with their mothers [46]. However, infants were kept in a closed isolette, which does not meet the WHO definition of rooming in [34]. At 5–7 days post-partum, 78% of the 82 infants were receiving at least some breastmilk.
In studies not limited to COVID-positive mothers, the prevalence of breastfeeding initiation and duration remained mostly stable aside from one study including a low-income sample from the U.S. [53]. This study included a sample of 2426 low-income mothers who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Southern California. The authors found that the prevalence of any breastfeeding at 6 months decreased from 48.7% before March 2020 to 38.6% after March 2020 [53]. Alternatively, in a large study of 1344 hospitals from across the U.S., 68% of hospitals reported that their exclusive breastfeeding rates during hospitalization stayed the same, while 11% reported an increase and 12% reported a decrease [5]. Using an online survey, Burgess et al. recruited 258 pregnant people from the U.S. and asked them if the COVID- 19 pandemic changed their infant feeding plans [49]. Only 3.1% indicated their infant feeding plan had changed, with 83% indicating they were now planning to breastfeed to provide better immune protection and due to fears of formula shortage. A single U.K. study of 316 mothers, reported that 72% of mothers who gave birth during the COVID-19 lockdown initiated breastfeeding; a proportion that was comparable to mothers who gave birth before the lockdown (76%) [45].
While quantitative evidence from the U.S. indicates that the pandemic has altered the prevalence of breastfeeding initiation and duration, especially for dyads who were separated at birth, it is important to also consider mother’s experiences of breastfeeding during this time. Our search strategy returned two Australian and/or N.Z. studies [42, 43], two studies from the U.K. [44, 45], one study from the U.S. [48], and two Canadian studies [51, 52] that examined maternal experiences of breastfeeding during the pandemic.
In one Canadian province, a sample of 335 mothers with infants less than 6 months of age completed an online survey with open and close-ended questions [52]. Mothers in this sample reported negative experiences related to the pandemic such as no social support, difficulty receiving professional help with breastfeeding techniques over the phone, trouble accessing specialized infant formulas, and fear of developing low milk supply due to the stress of living in the pandemic. These experiences are similar to another Canadian study that analyzed interviews with 57 post-partum mothers [51]. Mothers in this sample reported challenges with the lack of care provided in the hospital, absence of social support, and poor mental health, leading some to stop breastfeeding sooner than desired.
These themes are reflected in studies from the U.S., the U.K., Australia and N.Z. as well. In the U.S., mothers reported similar challenges of inadequacy of online breastfeeding support, as well as less social support, feelings of isolation, and challenges caring for an infant and older child at home at the same time [48]. In addition, U.S. mothers reported concerns about returning to the workplace while expressing breastmilk and finding a safe, non-contaminated place to do so. Two large online samples from the U.K. also found that many mothers struggled with having enough support to continue breastfeeding [44, 45]. An online survey of 316 mothers who gave birth during the lockdown found that 45% felt they were not receiving enough support with feeding [45]. A separate online survey of 1219 breastfeeding mothers, found that 27% experienced barriers with infant feeding such as lack of support, leading some to stop breastfeeding before they were ready [44]. These mothers also noted concerns with trying to juggle caring for older children without family support, lack of experience with breastfeeding in public and stress of pumping at a busy workplace for those who worked as health professionals. Finally, in Australia, a large online survey returned responses from 3364 women who were pregnant or had given birth since March 2020 [42]. Mothers reported concerns about lack of social support, having to ‘do it all alone’, and being deprived of antenatal classes, leaving them without the necessary information to feel prepared for the transition to parenthood. A sample of 364 mothers from Australia and N.Z. who were all breastfeeding at the time of data collection, reported concerns about lack of social interaction for their child, concerns about returning to work, and not being able to see family members [43].
Mothers from all five countries also reported positive experiences with breastfeeding during the pandemic lockdown, however, these were mentioned less frequently than negative experiences [42,43,44, 48, 51, 52]. Commonly cited positive factors included more time to focus on breastfeeding, bonding with baby without distractions, fewer visitors, greater partner support and delay of return back to work. These ‘silver linings’, provided some mothers the uninterrupted time they needed to establish breastfeeding without pressure to host visitors or busy schedules. However, two studies further explored subgroups of mothers with positive experiences, and found that these were mostly reported among mothers with higher income, fewer pre-existing mental health challenges, and less complicated births [44, 51].