This study complemented the existing literature regarding the barriers and facilitators of breastfeeding by identifying three factors associated with successful six-month PBF, namely giving birth in a public hospital, the self-rated impact of COVID-19, and the support from family and friends. Such factors could be targeted by policymakers for designing breastfeeding interventions.
Breastfeeding assistance offered by hospitals
Both descriptive statistics and open-ended responses regarding the perinatal experience of participants indicated a high prevalence of breastfeeding problems in both public and private maternity wards, suggesting that neonatal support for breastfeeding in both public and private hospitals was generally insufficient and ineffective. In particular, giving birth in private hospitals was associated with a lower likelihood of successful six-month PBF, both in general and during the pandemic period. There are four potential reasons why private hospitals discourage EBF. First, the inappropriate recommendation of formula supplementation by staff in private hospitals likely reinforced perceived insufficient milk supply amongst mothers, hence discouraging them from in-hospital EBF (BFHI Step 6) and responsive breastfeeding (BFHI Step 8) [21]. As demonstrated in both our study and other international studies, perceived insufficient milk supply is a major factor for discontinued breastfeeding and EBF cessation [22,23,24]. Moreover, while in-hospital EBF has been demonstrated to be positively associated with continued breastfeeding or EBF in both local and international studies, in-hospital formula supplementation is a risk factor for early breastfeeding cessation worldwide [25,26,27,28]. Second, compared to public hospitals, private hospitals were less supportive of early in-hospital breastfeeding initiation (BFHI Step 4), a finding consistently implied from both local and international studies [5, 21, 29]. Yet, early in-hospital breastfeeding initiation is a factor strongly positively associated with breastfeeding establishment, in-hospital EBF, and continued breastfeeding worldwide [21, 28, 30]. Third, private hospital staff tended to offer conflicting and incomprehensive breastfeeding advice to mothers. This is likely due to the relatively poor communication of hospital breastfeeding policies (BFHI Step 1) and insufficient staff training (BFHI Step 2) in private hospitals as compared to public hospitals [5, 21]. Fourth, private hospitals were generally unsupportive of rooming-in practice (BFHI Step 7), a factor significantly positively associated with in-hospital EBF [21, 31]. The poor rooming-in practice of private hospitals, as compared to public hospitals which all practised rooming-in, was observed in another local survey [5]. Overall, our results suggested that private hospitals were less supportive of in-hospital EBF and less committed to the BFHI than public hospitals, although public hospitals had a shortage of staff and lacked breastfeeding support in special care baby units (SCBUs) and neonatal intensive care units (NICUs). Further investigation is needed to assess whether similar trends are observed internationally.
Impact of COVID-19
We also found the pandemic in Hong Kong to have a generally positive self-rated impact on breastfeeding, which was positively associated with successful six-month PBF. Our linear regression results suggested that this is likely due to the work-from-home arrangements implemented and the perceived benefits of breastfeeding in improving children’s immunity. In contrast, a study in Italy found lockdown and home confinement measures during COVID-19 to reduce EBF [15]. Such contrasting findings were likely due to two reasons. First, the more severe COVID-19 situation in Italy and uncertainties around vertical transmission of SARS-CoV-2 during the study period (March—August 2020) at the early stages of the pandemic made mothers and healthcare workers alike wary of breastfeeding [32, 33]. Second, due to stringent lockdown restrictions in Italy that resulted in complete home confinement and reduced transportation, new families could not access breastfeeding support easily, including those from family and friends [34]. Meanwhile, the pandemic also presented unique difficulties to breastfeeding. Mothers may avoid breastfeeding and expressing breast milk in public premises to reduce children’s risk of infection. Moreover, the temporary suspension of postnatal services in MCHCs during pandemics could deprive mothers of critical breastfeeding support, hence negatively impact breastfeeding practice amongst mothers. Furthermore, during the pandemic, most antenatal classes and breastfeeding coaching services were cancelled, while some were moved online with the implementation of social distancing measures. Some participants further complained that online antenatal classes did not facilitate interactive teaching and effective learning; similar findings were observed in the UK [35].
Breastfeeding support
Results of logistic regression models further indicated that breastfeeding support from family and friends was positively associated with successful six-month PBF, both in general and during the pandemic period. This is consistent with previous studies that emphasised the importance of the husband’s preference for EBF and having peers who have had breastfeeding experience, as well as the positive impact of paternity leave on breastfeeding duration [36,37,38,39]. In Chinese society, it is traditional for the grandparents to assist new mothers during the first month postpartum and as such, the attitude of grandparents strongly influences feeding practices [38]. The notion that EBF is not enough for the baby’s satiety is strong amongst the older generation and reinforces perceived insufficient milk supply in new mothers, a circumstance that often convinces new mothers to supplement with or switch to formula feeding [40, 41].
Socioeconomic status
Both local and international studies have demonstrated that the exclusivity of breastfeeding and the duration of EBF are positively associated with maternal education level and household income [42, 43]. However, due to our purposive sampling approach, our participants had a higher education level and socioeconomic status compared to the general population, and were more committed to breastfeeding [44]. As such, these associations were not observed in this study.
Strengths and limitations
Our study adopted a purposive sampling approach and targeted members of breastfeeding support groups and organisations, who were committed to breastfeeding, experienced with breastfeeding, and exposed to a wide range of breastfeeding services provided by different health care providers, organisations, and professionals. This allowed wide-ranging exploration on the barriers and facilitators of breastfeeding to help inform future research efforts. In addition, this is the first study undertaken to explore the impact of COVID-19 on breastfeeding practice in Hong Kong.
However, our study had some limitations. Due to the voluntary nature of this study, it was possible that those who participated had more positive attitudes towards breastfeeding, subjecting it to volunteer response bias. In addition, the purposive sampling approach limited the generalisability of our findings. Moreover, the inductive method adopted in the qualitative content analysis could oversimplify the individual breastfeeding experience of participants. Furthermore, self-reporting responses of participants were subject to recall bias. Lastly, responses regarding participants’ perceived helpfulness of different health organisations and professionals might be influenced by the reduced accessibility of antenatal classes and MCHC services during the COVID-19 pandemic.
Recommendations
In view of our findings, we propose six areas which the government and hospitals should address to further promote breastfeeding in Hong Kong.
First, staff training in private hospitals should be strengthened. Written notice of breastfeeding policies should be well-communicated to all staff (BFHI Step 1), while standard training should be mandated for staff (BFHI Step 2), especially for nurses and midwives in private maternity wards [21].
Second, a postpartum home-based programme should be implemented, as recommended by other local studies [17, 45]. Although open-ended responses suggested that practical, comprehensive, extensive, and interactive antenatal classes were welcomed by the mothers, the evenly divided rating of participants suggested that the helpfulness of existing antenatal classes was controversial. Results from other high-income countries consistently suggest that the efficacy of antenatal classes is uncertain [46]. In addition, mothers in Hong Kong may find it difficult to leave home during the early postpartum period due to the overwhelming workload and the cultural practice of “doing-the-month” [17]. Hence, the practical challenges of breastfeeding should be addressed postnatally in a home setting.
Third, breastfeeding support in SCBUs and NICUs of public hospitals should be strengthened. SCBUs and NICUs of public hospitals should offer clear breastfeeding guidance and support milk expression, bottle-feeding, and breastfeeding as appropriate.
Fourth, MCHC services should be continued during pandemics and be further promoted on discharge. The provision of information regarding breastfeeding support on discharge (BFHI Step 10) was associated with continued breastfeeding both locally and internationally [21, 26, 28]. While most public and private hospitals in Hong Kong self-reported that they provided such support, open-ended responses indicated that some participants were unaware of such services [5], suggesting a communication gap which should be addressed through active promotion.
Fifth, the spouse and the grandparents should be included in breastfeeding education and antenatal classes. Since family members play a significant role in the choice and duration of EBF, it is important to cultivate their knowledge on breastfeeding through family-centred breastfeeding education [47, 48].
Sixth, flexible work-from-home arrangements should be provided to parents following the end of existing parental leave. Descriptive statistics of this study indicated that the return to work from maternity leave is a common reason for EBF cessation among participants, while other studies indicated that parents’ return to work was significantly associated with early weaning [39, 45, 49]. Yet, the recent extension of statutory maternity leave to 14 weeks in Hong Kong still falls short of the six-month target, while statutory paternity leave lasts for 5 days only [4, 50]. With the experience of large-scale work-from-home arrangements during COVID-19, similar arrangements could be considered as an alternative to extending existing parental leave.
