This study to our knowledge is the first study to examine breastfeeding belief, practice, and postnatal infant feeding support during the COVID-19 across 5 countries. This multi-country study revealed some differences in belief towards breastfeeding during the COVID-19 in Asian countries, compared to Brazil and UK. Compared to women in the UK and Brazil, a higher proportion of women in the Asian countries believed women with suspected or infected with COVID-19 infection can transmit COVID-19 virus during breastfeeding, including through breastmilk, and skin-to-skin. Compared to the other counties, women in Brazil presented lowest rate of believing that wearing face mask should always be worn when breastfeeding and when they are touching and holding her baby. Postnatal women’s belief towards breastfeeding may affect breastfeeding practice. Women breastfeeding at breast had high score of belief towards breastfeeding meanwhile those feeding infant formula had a lower score. Women reported that postpartum infant feeding support was received mostly from health professionals and peers/family through in personal contact in all countries, while the support via online group wasalso relatively higher in Thailand and UK compared to the rest of the countries. More than 10% of the women in Brazil and the UK reported receiving Lactation support via a video contact.
Belief towards breastfeeding
A cultural beliefs and practices impact in breastfeeding practices [27]. Despite a lot of scientific evidence of the benefits of breastfeeding [1], women in different countries have their culture beliefs, myths and misconceptions that can have negative impact on their breastfeeding practice [28].
In our study, the mean of the belief towards breastfeeding score in relation to COVID-19 transmission and preventative measures by infant feeding practice were significantly different among countries. A high rate of belief of “transmission of COVID-19 through breastmilk” (#1) and “should avoid breastfeeding if women is suspected or infected with COVID-19” (#2) were found in three Asian countries. A reason could be that the safety of BF during COVID-19 is not widely disseminatied by Asian countries than UK and Brazil, despite the recommendation from several international health agencies and medical societies. Furthermore, at the early stage of the COVID-19 pandemic, professional health support temporary separate babies from their women after birth and suggest expressed breastmilk as an initial recommendation, because of concern for COVID-19 transmission risk by breastfeeding, as American Academy of Pediatrics and Royal College Society of Neonatology [29].
Once evidence shows that SARS-CoV-2 is not likely to be transmitted via breast milk [30] and the impact of breastfeeding to guarantee food safe to children [31], the recommendation to breastfeed grow and became unified from most of agencies and medical societies [32].
Our results showed a low rate of belief in “proper skin-to-skin and breastfeeding following delivery” (#3) were seen in all three Asian countries compared to the others. Different postpartum practice in hospitals and maternity services which did not followthe WHO recommendation can bring confusion to women whether they should or not breastfeeding their babies [28].
Our finding in belief about practice of facemask use when holding your baby, including during feeding (#5-6), women from Brazil reported a lower rate of respondents agreeing to wear a mask when breastfeeding and to touch and hold her newborn baby. Despite the recommendation protect nose and mouth with a mask during breastfeeding [11], a reason could be less concerns about transmission of COVID-19 and the importance of visual face-to-face interaction with their babies to development brain [33], nurturing and bounding in a deep share connection [34].
Also, we found that the beliefs towards breastfeeding were associated with BF practices, which we discuss next.
Breastfeeding practice
Breastfeeding rates are low in the world [1]. Our results showed 73% of women in all countries brestfed at breast in the last 24 hours. Brazil presented the highest rates with 91% of their babies follow by UK (85%) and South Korea (72%). Because of different COVID-19 waves between countries, it is difficult to compare with other studies how BF was impacted. A study, carried in April 2020 in a lockdown UK period, identified that infant feeding is influenced by women negative emotional and anxiety symptoms when they had more than one child to take care [35]. Around 27% women had barriers stemming from lockdown to continue breastfeeding [36]. Another study in UK, in 27th May to 3rd June 2020, showed 59% women who delivered during lockdown had infants exclusively breast-fed/mixed fed compared to 39% who delivered before COVID-19 pandemic [37]. In Thailand, in July to October and December 2020 to February 2021, after lockdown from April to June same year, showed a slight decreased in 4.3% BF practices during the pandemic COVID-19 lockdown (38). Also, in Italy a study conducted in March to May 2020 showed similar results, a decrease of EBF than women before COVID-19 pandemic (2018) (39) as in USA Rates with women that gave birth before 2020 [20]. Despite of those findings, a study in China carried in August to October 2020 to compared the infant feeding experiences of women, who delivered before and during COVID-19 pandemic in Beijing, identified BF practice rates was maintained during pandemic situation [21].
Evidence of breast milk from women infected by COVID-19 contains antibodies against SARS-CoV-2 and can protect infants [40]. Despite the benefits and breastfeeding recommendation during COVID-19 infection, concerns, and fear about COVID-19 transmission from mother to infant through BF may affect to infant feeding practice. Further, women maybe have influenced by multifactor to decide how feed their infant, since breastfeeding media and belief during COVID-19 pandemic varies according government, polities, socioeconomic status, health inequities in each countries [41]. Thus, further studies are needed to identify how breastfeeding belief regarding covid-19 transmission and prevention measures affect breastfeeding practices in various settings and populations. Our study found the positive breastfeeding belief was positively associated with baby breastfeed at breast, and inversely associated with infant formula. All three Asian countries presented lower rates of breastfeeding at breast and had a lower belief score, when compared with Brazil [16] and UK [14.7] that presented higher rates of breastfeeding at breast. Also, Asian women have a similar or slightly lower rate of breastfeeding using expressed breast milk, while UK and Brazil had a higher rate of BF from breast. We found breastfeeding women use to express breast milk, 60% in Thailand, followed by 53% in Taiwan and 50% in South Korea.
Any factors may interfere in breastfeeding practice, as marital status, educational level and place of birth [21]. Expressing breast milk may protect continue breastfeeding. A study with Singaporean Chinese women showed an increased practice of expressed milk and combination feeding, defined as breast milk and non-breast milk fed via bottle and breast, while direct feeding from breast were in decreasing trend over time [42]. Women use to expressed breast milk when they don’t want to breastfeed in public or went back to work. There is an increasing number of working moms in Asia, that cause a changing to infant feeding practice due to participation rate in the labor force among Asian women (Thailand 59.2%, and South Korea 53.2%) [43]. Breastfeeding at breast in public places or at work is still challenging for all women, maybe worst in Asia. In Korea, women who return to their work after maternity leave stated that their work status directly affected their decision not to breastfeed their babies. The primary reason given for not breastfeeding was that “it is not easy to express milk at work”. Further, the expressed BF rate was higher than breastfeeding at breast: “Breastfeed mostly with an occasional bottle with expressed breastmilk (44.2%) vs. Breastfeed only (26.9%) [44]. Once our women characteristics showed work status are not very different, there is no study found that we can compare with results, and more studies need to be explored to find those differences.
Another study showed the influence of social policy on breastfeeding duration, such as breastfeeding policy of hospital and national parental leave, although social policy was not statistically associated with the BF duration in a recent Korean study [45]. Further, women with high education are more likely to know the health benefits of breastmilk but they are more likely to involve in out-of-home activities or be employed. It thus made women difficult direct feeding but expressed breastmilk or combination feeding. Comparing those results our participants had high educational level (64.4% of women having a university or a postgraduate degree) but 59.2% were on maternity leave. We found that infant feeding formula was 41% in pooled sample, higher in Taiwan with 73%, followed by South Korea with 57%. A high formula feeding rate in Asian countries during the covid-19 pandemic. Despite the benefits of expressed breast milk to support continue BF practice, women who exclusive expressing in early postpartum may not achieve long-term BF duration [46]. Using breast milk instead of formula feeding gives to babies the benefits of human milk but can also reduce the breastfeeding at breast and increase formula feeding [47].
Postnatal feeding support
Breastfeeding face-to-face support by professional and/or peer support improved breastfeeding rates [48]. Also, early breastfeeding support was related to increased breastfeeding by 24% [49]. Our study found postnatal feeding support was mainly received from health professions and peers/family through in person contacts in all countries. A systematic review showed partner’s and family members’ views and experiences of breastfeeding support reflected multi-faceted factors of their support [50]. Facilitators to EBF are good knowledge and skills among healthcare professionals and support of health care services to improve breastfeeding practice [50-52]. Sufficient information and support received with tailored and practical are reasons breastfeeding women continue breastfeeding [50, 53].
COVID-19 pandemic interfered in women getting postnatal in-person follow-up care and in-person breastfeeding support [15]. A study that compare postnatal experiences of women who delivered before and during lockdown in UK identified a decreased feeding support from 57% to 40% [37]. Despite the pandemic situation, our study found more than 50% of women with professional support (67% in pooled sample), ranging from 86% in Thailand to 47% in South Korea. UK presented 57%, similar rate before lockdown [37]. Meanwhile, women reporting no support given were high in South Korea and UK.
Health support can vary according to countries restriction and pandemic waves. Some countries might face policies restricted services and women received virtual professional and/or peer support. Remote support has been considered during COVID-19 pandemic. A systematic review showed that remote breastfeeding support and education combined with support in hospital reduce the risk of women stopping breastfeeding at 3 months by 25%, although it is less clear if that intervention change of stopping any breastfeeding at 8 weeks, 3 and 6 months [54]. We found 31% receiving online group support, 33% of women receiving phone and 9% by video breastfeeding support. UK presented higher rates of online group support (49%) and phone support (41%) as Thailand (35% and 52% respectively). Remote support, with online videos calls and phone, increased during the pandemic, also because it helps women with infection to be in self-isolation and receive breastfeeding support due to COVID control measures [55]. In our study 59.3% of women who received online video platform support reported experiencing no difficulties, and 23.5% supporter was unable to clearly see their baby’s latching.
Access to breastfeeding support in hospitals and communities are also restricted because of control measures of 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 [56, 57], which may be affected by a nation’s covid-19 infection control measures. Although virtual breastfeeding support has benefits of being convent for women to stay at home and receive support, a study conducted in United States shows moderate effectiveness of virtual professional support with challenges including assisting with latching or analyzing body language of the baby during the session [57]. How virtual and remote breastfeeding support can be best provided, to whom, and in what circumstances need further investigation to enable technologies to enhance breastfeeding support.
On the other hand, with no internal support (spouse and family) and external support (professional health, friends, and employers providing room for pump breast milk) women might decide do not continue to breastfeed [58]. A systematic review shows the importance of community peer support to increase exclusive breastfeeding duration in low- and middle-income countries, specially for infants with 3 to 6 months (59). BF peer support is a good strategy to protect BF because it increased women’s self-esteem and confidence [60]. Taiwanese women feel motivating to breastfeeding in many ways when they have services provided by in-centre care organizations, that facilitate networking with other mothers women [61], but in COVID-19 pandemic it can be a challenge.
Limitations
Limitations considered were that since only women who can access to the internet could participate in the study, participants were more likely to be young, to have high education and to live in urban areas. In addition, recruitment using online nonprobability samples tend to be prone to have certain lifestyles. Also, in UK and Brazil, some infant feeding support organization helped disseminate the online survey info. These requirement channels might attract women who were interested in infant feeding (breastfeeding or breastfeeding support) to complete the survey. Thus, the finding of the study cannot be generalized to other population and settings.