Exclusive breastfeeding, even and possibly especially during the COVID-19 pandemic, is beneficial for mothers and infants. Yet, evidence from the study indicates declining rates and identifies factors that are barriers to exclusive breastfeeding during the pandemic. According to the socio-ecological model, intrapersonal, interpersonal, organizational, community and society factors were significantly associated with exclusive breastfeeding during the pandemic, as breastfeeding practices are multifactorial. In our study, several intrapersonal factors were associated with exclusive breastfeeding, including maternal age, parity, education, health insurance, and mode of birth. Older mothers were less likely to exclusively breastfeed compared to younger mothers, which is supported by a population-based study in Spain conducted prior to the pandemic [14], but differed from a study Poland where older mothers were more likely to exclusively breastfeed [27]. In our study, multiparous mothers were more likely to exclusively breastfeed at discharge, similar to an online study conducted during the pandemic in the United Kingdom which found that multiparous women were more likely to breastfeed [28]. Health insurance is one of the variables representing socioeconomic status relevant to the individual intrapersonal factors [25], although mechanisms of payment for healthcare services differs among European countries. Consistent with previous research conducted in Italy [29], Croatia [30], and Romania [31], higher maternal education was associated with higher likelihood of exclusive breastfeeding, whereas cesarean birth was associated with non-exclusive breastfeeding at discharge.
The interpersonal factor significantly associated with exclusive breastfeeding was maternal perception of adequate breastfeeding support. In a sub-analysis from one participating country in the larger European study, over 36% of mothers reported inadequate breastfeeding support during the pandemic [32]. The employment of lactation professionals has consistently contributed to improved breastfeeding outcomes [24], but their availability may have been limited during the pandemic. Other social factors were not significantly associated with exclusive breastfeeding in our study, which may relate to the pandemic circumstances that restricted family members from visiting and attending to the mother and her infant, thereby placing more importance on the support from healthcare providers.
The organizational factors of rooming-in and early breastfeeding were significantly associated with exclusive breastfeeding outcomes. Similarly, in a sub-analysis of the original study’s participants in Sweden, over 16% reported not having full rooming-in [32]. Type of healthcare provider at birth, professionalism, and immediacy of attention were associated with exclusive breastfeeding in the multivariable model, suggesting the important role of healthcare providers in breastfeeding practices. This may be explained by the critical role of trained professionals in providing breastfeeding support during the early postpartum period, as found among mothers giving birth in Italy [28] and in Croatia [30]. A multi-country meta-synthesis pointed to the organizational factors positively influencing breastfeeding support and outcomes such as midwifery care and person-centered communication [33]. A qualitative study in Belgium found that midwives perceived their roles as providing mothers with breastfeeding education and support, although they faced barriers in the facility setting [34].
An additional organizational factor was the association between maternal perception of room cleanliness and exclusive breastfeeding, which was a novel finding. Clean lactation space in the workplace has been shown to influence continued breastfeeding [35], suggestive of a similar organizational factor. Furthermore, during the pandemic, there was a heightened need for cleanliness and hygiene in health facilities.
In a previous study that employed the socio-ecological model, breastfeeding supportive policies and practices were identified as organizational level facilitators [24]. Early breastfeeding and full rooming-in are BFHI practices associated with exclusive breastfeeding. Rooming-in is foundational in minimizing maternal-infant separation [36]. Separating mothers and their infants who had tested positive or were suspected of COVID-19, negatively influenced breastfeeding and was associated with maternal distress [18]. Giving birth during the pandemic in BFHI accredited facilities was associated with higher exclusive breastfeeding rates, higher likelihood of skin-to-skin contact, and lower rates of maternal-infant separation [37]. Less than half of the participating countries reported at least 50% of their maternity care facilities had been BFHI designated, similar to findings in another WHO European Region multi-country study [38], suggesting a need for increasing implementation of the global effort to promote breastfeeding.
Community and society factors were represented by timing of breastfeeding guidelines and country of birth. Data collected prior to the pandemic in the WHO European Region highlight differences in early initiation of breastfeeding and exclusive breastfeeding rates among the member countries [38]. In the early weeks of the pandemic, guidelines were continually being revised based on updated findings. On 23 June 2020, the WHO released its second set of guidelines regarding clinical management of infants and mothers with COVID-19 infection which were more protective of breastfeeding than previous guidelines published during the pandemic [8]. A study in Spain found that exclusive breastfeeding rates at discharge among mothers who had COVID-19 infection at birth were higher in BFHI accredited facilities, where the implementation of skin-to-skin and rooming-in practices was higher than in other facilities [37]. Our study supports previous findings showing differences in exclusive breastfeeding rates specific to particular countries, of which there are varying levels of BFHI accredited facilities and adherence to BFHI policies [23, 26].
A concerning finding of the study is the declining trend in exclusive breastfeeding at discharge, despite the WHO recommendations. This phenomenon was observed by other researchers in Europe who found that facilities restricted breastfeeding support early in the pandemic, resulting in inadequacy and inaccessibility of breastfeeding support [39]. Our study adds to the literature by tracking the continued decline in exclusive breastfeeding rates extended over time, even after the updated WHO recommendations. In a survey of 124 European healthcare facilities who reported BFHI practices during the pandemic, 6% recommended formula rather than breastfeeding for mothers infected with COVID-19 [40] which may contribute to the overall decreased exclusive breastfeeding rates in the European Region. Additionally, with the outbreak of the pandemic, many professionals adapted their lactation services to offer virtual support which facilitated remote access although there were challenges with connection, communication, reading body language, accuracy of assessment, and providing assistance [41].
Limitations and strengths
Limitations of the study include voluntary maternal self-report with possible selection and reporting biases. Additionally, the survey did not inquire into the infant sex, birth weight, and gestational age, as the focus of the original study was on the maternal perception of quality of care. Gestational age is often a significant factor in breastfeeding outcomes [42], but considering the association of rooming-in on early exclusive breastfeeding [43], singleton infants who were not admitted to the NICU or SCBU served as a proxy for “low risk” infants which would exclude preterm or sick infants. The survey question regarding COVID-19 infection or suspected infection did not inquire into the timing of the infection during pregnancy, birth, or early postpartum which precluded an in-depth analysis of the association of timing of COVID-19 status and exclusive breastfeeding outcomes. Finally, the survey did not inquire into the current or previous BFHI accreditation status of facilities, so we accounted for BFHI status through country-level reporting. Despite the limitations, this study provides a multi-country analysis of exclusive breastfeeding at discharge over the first two years of the COVID-19 pandemic in 17 countries of the WHO European Region. The survey was developed according to the WHO Standards and therefore allows for comparison across countries and sub-groups and the large sample size provides confidence in the findings.
