Social Support During COVID-19: Perspectives of Breastfeeding Mothers

Abstract

Introduction:

Effective social support can have a critical influence on a mother's ability to initiate and continue breastfeeding. Coronavirus disease (COVID-19) has created unprecedented barriers for breastfeeding mothers to obtain various types of support: emotional, instrumental, informational, and appraisal. However, no research has evaluated the influence the pandemic has had on breastfeeding supports. The purpose of this study was to explore perceptions of social support among breastfeeding mothers during the COVID-19 pandemic.

Materials and Methods:

A cross-sectional phenomenological approach was taken utilizing semistructured interviews (March–June 2020) with currently breastfeeding mothers (n = 29). Data were analyzed through a process of immersion and crystallization.

Results:

Mothers are still able to obtain each type of support, however, support has been negatively influenced by the pandemic. Mothers reported experiencing increased stress and isolation and had an immense desire to receive in-person support from peers, family, childcare providers, and lactation specialists. Furthermore, mothers of multiple children felt if they did not already have breastfeeding knowledge from previous experiences they would be unsuccessful in breastfeeding due to their current lack of support. Conversely, a majority of mothers felt the pandemic had positively influenced their breastfeeding journeys due to concerns of formula shortages and extended maternity leaves. Finally, mothers were concerned about safely expressing breast milk on their return to work.

Conclusion:

Mother's ability to obtain breastfeeding support has been negatively impacted by the pandemic due to the inability to engage with individuals in-person and the lack of access to childcare. First-time mothers may be at higher risk of early breastfeeding cessation due to lack of support. However, breastfeeding journeys have also been positively influenced by allowing mothers more time at home with their child. Resources are needed to support expressing breast milk in the workplace during COVID-19.

Introduction

Despite the tremendous benefits associated with breastfeeding for mother and child, breastfeeding rates remain at suboptimal levels.¹ Social support has been identified as a key influence with support from peers and/or health care providers positively affecting breastfeeding.² Specifically, there are four types of social support found to be influential: emotional, instrumental, informational, and appraisal.³ In the context of breastfeeding, emotional support might include providing empathy to a breastfeeding mother. Instrumental support may include elements such as childcare or grocery shopping to allow the mother time for nursing. Informational support would be advice or education on breastfeeding. Finally, appraisal support would involve providing encouragement or feedback to a breastfeeding mother.⁴ It has been recommended that social support be continuous, frequent, and in-person throughout a mother's breastfeeding journey.²

The coronavirus disease (COVID-19) has created unforeseen challenges for health care on a global scale. This is especially true for new mothers when attempting to access resources and education.⁵ Importantly, the World Health Organization has stated mothers with COVID-19 or suspected COVID-19 can and should breastfeed their child while taking appropriate precautions.⁶ Furthermore, due to what is known about breast milk's antimicrobial properties and immune system development, breastfeeding should be widely encouraged for all new mothers.⁷

The previous recommendations of in-person lactation support are likely difficult due to new COVID-related policies. Thus, mothers may be struggling to receive the support they need. This lack of support could have devastating impacts on breastfeeding initiation and duration if not properly addressed.² As COVID-19 cases continue to climb globally, timely research is needed to understand how the pandemic has influenced mothers' social support networks. Thus, the purpose of this study was to explore perceptions of social support among breastfeeding mothers during the COVID-19 pandemic.

Materials and Methods

Research design and participants

This was a cross-sectional phenomenological qualitative study that took place from March through June 2020 in Nebraska. This study was approved by a university-affiliated institutional review board. Participants were recruited through purposive sampling by posting study information on four breastfeeding-friendly Facebook pages. These organizations included the Nebraska Breastfeeding Coalition page with 2,789 followers, an Omaha breastfeeding support group with 8,716 members, an Omaha pediatric clinic's Facebook group with 1,773 followers, and the Grand Island Women and Infant Clinic (1 of 12 Special Supplemental Nutrition Program for Women, Infants, and Children [WIC] clinics in the state) with 232 followers.⁸ Women interested in participating were invited to text a phone number stating that they were over the age of 19 (age of legality in Nebraska) and currently providing their child breast milk in any form (i.e., breast or bottle). A total of 39 women noted interest in participating, with 29 participating in the interview and 10 unreachable at follow-up. Of the 29 participants, 11 were recruited from the Grand Island WIC Facebook page, 11 from the Omaha breastfeeding support group, 6 from the Nebraska Breastfeeding Coalition page, and 1 from the pediatric clinic. Women resided in Omaha (n = 15), Grand Island (n = 11), and Lincoln, Nebraska (n = 3). For geographic reference, the United States census reports the city of Grand Island has a population of 51, 478 compared with Lincoln with a population of 287,401 and Omaha with a population of 468,262. See Figure 1 for additional geographic details; Omaha = A; Lincoln = B, Grand Island = C. Women received a $25 e-gift card for participating.

FIG. 1.

Geographic representation in Nebraska.

Data collection and analysis

Upon confirmation of eligibility women scheduled a telephonic interview. Before the interview took place a summary of the study was read aloud with the potential risks of participation (i.e., loss of private information). Women were asked to verbally assent to participate before the interview started. The interview lasted ∼15 minutes and was audio recorded. The interviewer first obtained the following demographic information: age of child being breastfed, age, race/ethnicity, occupation, and highest level of education received. The interviewer then asked 12 semistructured questions focused around the constructs of social support theory (emotional, instrumental, informational, and appraisal). Questions were developed by an expert trained in qualitative methodology (PhD) and reviewed by another qualitative expert (PhD) before being deemed complete. The interview guide can be found in its entirety in the appendix of this article. Two pilot interviews were conducted to determine if any wording changes were needed or further clarification was required. After the two interviews took place only small grammatical changes occurred to enhance clarity.

Data analysis occurred concurrently as the interviews were taking place to better determine when saturation of data occurred. All interviews were transcribed verbatim by the interviewer into word documents. These documents were then uploaded into NVIVO qualitative analysis software.⁹ A trained qualitative expert (PhD) then began an analysis process of immersion and crystallization.¹⁰ The researcher first read through the transcripts several times and identified common words and phrases related to each construct of social support: emotional, informational, instrumental, and appraisal. All interviews were coded into each construct category. After this analysis was complete an additional analysis was conducted for overarching themes commonly found within each of the support constructs. A total of four overarching themes emerged. These were then discussed with the interviewer and codes were reanalyzed within each theme until consensus was reached. Finally, sociodemographic classifications were added (e.g., number of children) to allow for response comparison of first-time mothers (n = 10) versus mothers of multiple children (n = 19). A thematic comparison of the two groups was completed.

Results

A total of 29 women completed the semistructured interview. Seventy-nine percent of women identified as Caucasian followed by 10% identifying as Hispanic. The average age of participant was 29.93 (29.9 ± 5.28). A total of 31% reported working in the health care industry followed by 24% reported being unemployed. Finally, 38% of mothers were participants of the Special Supplemental Nutrition Program for WIC. For additional details see Table 1.

Table 1.

Sociodemographic Information of Participants

Age	Education	Race/ethnicity	Occupation	Child age (months)	No. of children	WIC participant
40	Masters	Asian-Indian	Unemployed	8	1
23	Some college	Caucasian	Unemployed	6	2	X
27	High school	Caucasian	Church director	4	1	X
30	Some college	Asian	Unemployed	3	2	X
31	Bachelors	Caucasian	Nurse	6	1
29	Associates	Caucasian	Certified medical assistant	4	2
22	Some college	Caucasian	Medical support assistant	2	3	X
33	High school	Hispanic	Unemployed	3	1	X
25	Masters	Caucasian	Teacher	6	1
29	Bachelors	Caucasian	Unemployed	1	4	X
30	Doctorate	Caucasian	Physical therapist	3	2
35	High school	Hispanic	Grocery manager	3	4	X
42	Bachelors	Caucasian	Unemployed	4	3	X
37	Some college	Caucasian	Unemployed	5	4	X
33	Masters	Caucasian	Nurse	3	3
25	Associates	Caucasian	Nurse	5	1
35	Doctorate	Caucasian	Physical therapist	3	3
32	Bachelors	Hispanic	Nurse	6	1
30	Masters	Asian	Occupational therapist	5	2
25	Some college	Caucasian	Office support assistant	2	3	X
26	Associates	Caucasian	Property manager	1	1	X
19	Some college	Caucasian	Nanny	3	1
31	Masters	Caucasian	Teacher	3	2
28	Masters	Caucasian	Teacher	1	2
32	Bachelors	Caucasian	Realtor	2	2
36	Masters	Caucasian	Professor	5	1
27	Bachelors	Caucasian	Nurse	4	3
25	Some college	Caucasian	Customer service	6	2
31	Some college	Caucasian	Customer service	5	3

WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

Social support

Women were asked to describe who provides them with each type of support and how that support is provided. In addition, they were asked what they desired in terms of support. Table 2 provides additional information.

Table 2.

Current Supports

Support type	Who provides support	How support is provided	How support is desired
Emotional support	Husband and family	In-person listening, telephonic/online discussions	In-person listening and peer-to-peer support
Informational support	Family members, Facebook, Pinterest, and lactation counselors	Facebook groups and telephonic	In-person lactation support and reputable online resources
Instrumental support	Family, friends, and workplace	Assistance with errands and time for pumping	Access to childcare and ability to run errands with child
Appraisal support	Friends, coworkers, family, and lactation counselors	Telephonic encouragement and workplace support	Greater in-person discussions

Emotional support

Related to emotional support, husbands and boyfriends were the most common current source of emotional support through in-person listening followed by family members providing support telephonically or over the Internet. Almost all mothers reported they were unable to see family and friends in-person to the extent they desired and wanted more in-person opportunities for emotional support. For example, “you can't really go anywhere, it's one thing to talk over the phone or on the computer it's just more difficult that way” (35, Hispanic, Grocery Manager).

Informational support

When asked where they obtained informational support the most common responses focused on social media (i.e., Pinterest and Facebook) followed by lactation counselors. Related to social media use one mother noted, “Um honestly I look up a lot on Pinterest just for articles. I know that's probably not the most reliable” (27, Caucasian, Church Director). All women using lactation services reported using only telelactation after being released from the hospital postdelivery. Furthermore, some mothers were uninterested in using telelactation. For instance,

I've been wanting to, like, talk to a lactation consultant again but, like, with the pandemic it's been so hard because you know like everything, everybody, is obviously shut down and it's just like I want to be able to talk to someone but I can't. Like it would be easier to have someone be there and physically be like right now try moving him this way now try this way like (23, Caucasian, unemployed)

Although the majority of women stated they wanted access to in-person lactation information, two first-time mothers did not feel it made a difference. For example, “Everyone has still been available via telehealth options or via phone conferences so I don't think those resources have lessened at all” (25, Caucasian, teacher). Conversely, another mother noted, “The face to face meetings because of COVID. I really miss those” (36, Caucasian, educator). Furthermore, one third of mothers reported concerns about being unable to obtain effective support for latch issues through telehealth.

Instrumental support

Husbands and significant others were the most common form of instrumental support. Mothers reported they would like more support from family members but were unable to be around them due to COVID-19. One mother explained, “You don't always feel comfortable asking someone to come here to help, always just a little worried” (29, Caucasian, unemployed). More than half of mothers also reported that they were unable to utilize their previously arranged childcare due to the pandemic and reported needing childcare support. One mother stated, “if I wanted to go back to work right now one I can't because of the baby and none of the daycares are taking new babies so that part is really frustrating” (23, Caucasian, unemployed).

Appraisal support

Mothers receive encouragement and appraisal from their family, friends, and coworkers. Two women who worked in health care were able to receive this support in-person from coworkers; however, the remaining women reported primarily receiving this over the phone. Most mothers reported being unsatisfied with the amount of appraisal support they received. One mother noted, “I just feel really isolated so that kind of discourages me from breastfeeding because I'm just so exhausted because like I have formula to make his food I could just pour him some formula and like be done even though I know that's not what's best for him” (23, Caucasian, unemployed).

Impact of the Pandemic

Five key themes emerged from evaluating commonalities seen across support constructs: smaller networks for support, increased stress, a silver lining, previous knowledge, and concerns for the workplace.

Smaller networks for support

Overall, mothers reported that the pandemic had decreased their support networks. This has led to increases in feelings of frustration and isolation. Support networks decreased from the time of delivery with mothers reporting a decrease in lactation support within the hospital. For example, “It was hard for me to know if it was because of like COVID but I really didn't get help at all at the hospital. She did latch on pretty easily but no one came in to help or you know anything like that. I never got any support at the hospital” (31, Caucasian, teacher). Another mother reported similar lack of support once home from the hospital, “I want to be able to share it with like people that I know and love and like my friends but like you can't go anywhere and it's just like you just feel really isolated and then it's exhausting” (22, Caucasian, Medical Assistant). Elements related to a desire for increased emotional support networks were most common. This was frequently related to a desire for in-person peer-to-peer support, especially from mothers who had multiple children. One mother reported missing her weekly breastfeeding support group, “Having that community of women of being able to sit down every week and talk about how things are going or just someone that's in a similar situation” (31, Caucasian, nurse). First-time mothers were more likely to desire emotional support from family and friends than peers.

Increase in stress

Mothers report a heightened stress related to their breastfeeding journey due to the inability to receive in-person lactation support as well as stress related to how COVID-19 could influence themselves or their baby. This stress was common for both new mothers and mothers with multiple children. For instance, one mother stated,

Mainly it was probably a lot more stressful um I don't know if that has to do anything with my supply going down and like work all included in there, I'm not sure how that affected it but it's a lot more stressful I know that. Because for the longest time I was just really like not wanting to leave the house and if I had to like any kind of symptom like if I had a little itch in my throat I'm like oh my goodness do I have something? Am I going to pass it on to her through breastfeeding?

A silver lining

The next theme that emerged was a silver lining related to the COVID-19 epidemic. More than half of mothers reported that the pandemic increased the duration of their maternity leave, which they credited with positively influencing their breastfeeding journey. One mother explained,

To be very honest the pandemic really started at the end of my maternity leave and so it's been somewhat of a blessing in disguise because my job allowed me to work from home and so it just feels like it's been a maternity leave and I feel like it's given me a lot of time to be home and to be at a slow pace and have a longer period of time to figure out you know my baby and nursing has become so much more easier and I think it helped just having so much time just to practice instead of having to figure it out in the workplace at such a quicker pace and so I've honestly enjoyed the time that I've had at home these last few months just because of that (27, Caucasian, Church Director).

Another mother shared a similar sentiment by saying, “it's impacted me personally for the better just because I haven't been able to return back to work and I've been able to breastfeed on demand which is easier than pumping and trying to come up with milk to feed” (37, Caucasian, unemployed). In addition, some mothers credited the early fear of formula shortages as their motivation for continuing to breastfeed. For instance,

I think you know being able to put him to breast as often as I can to maintain that supply so we didn't have to leave the house. I think that's just kind of what kept me going you know like people were really struggling to find formula there for a couple weeks (31, Caucasian, nurse).

Previous knowledge

The majority of mothers had more than one child (n = 19). Many mothers believed that if the pandemic had occurred during their first breastfeeding journey they would have experienced even more challenges. For example, “If this was my first baby I definitely think it would've been a lot harder and just with the whole pandemic in general. I mean it's been challenging because of the pandemic but it would've been a lot more challenging if it would have been our first baby” (31, Caucasian, teacher). Another mother echoed a similar sentiment noting, “With my other one, having that support and weekly consultation with a lactation consultant and everything was really what probably got me through our journey and kept me nursing um if I would have had that problem with my one now and not having that support then I we probably would've stopped by now to be honest” (35, Caucasian, physical therapist)

Concerns for the workplace

Mothers were also concerned about what their return to work would look like in the COVID-19 era. Mothers reported concerns with new policies hindering their ability to express breast milk while at work. Furthermore, mothers who had already returned to work reported being concerned about pumping safety. One mother working in the health care industry reported,

Since I do work with COVID positive patients it's given me a lot of anxiety you know what happens if I get it and is it going to go through my breast milk things like that and then you know when I'm pumping there it's hard to get regular pump times in because things are pretty strict so it's hard to make sure that I actually can pump enough as I need to so I can keep my supply up and then of course you don't want to contaminate the milk either so it's hard for me to pump and then store because I'm worried about what if I touch something or you know things like that (25, Caucasian, Registered Nurse).

Discussion

The COVID-19 pandemic has changed how breastfeeding women can obtain support related to their breastfeeding journey. Furthermore, women are experiencing an unprecedented level of stress. Not only are they now concerned with how COVID-19 could impact the health of themselves and their child, but they are also concerned with how this will influence their ability to pump in the workplace. Interestingly, only one mother noted a concern for passing the virus through breast milk suggesting mothers have seen communications promoting breastfeeding during the pandemic.^11,12

Women are reliant on telelactation services and online support group resources like never before. Our findings suggest that although support from their significant other remains consistent and effective, peer-to-peer support, childcare, and familial support have been reduced and women consider this a detriment to their breastfeeding experience. Furthermore, first-time mothers may be especially at-risk of early breastfeeding cessation due to the lack of emotional in-person support from family and friends. Although first-time mothers did not discuss a lack of peer-to-peer support this could be due to not being able to attend breastfeeding support groups and mothers being unaware of the benefits related to this. More research is needed specific to first-time mothers breastfeeding experience during the pandemic.

Mothers appear to have mixed feelings on the utilization of online and telehealth resources and more prefer in-person support, especially related to latch issues. Interestingly, although women reported receiving help from lactation counselors frequently no women reported utilizing their pediatrician for in-person breastfeeding support. This is despite the fact that many pediatric and family medicine clinics have remained open throughout the pandemic. Primary care physicians have the unique advantage of frequent contact with the mother/infant dyad in the first few months of life. This is especially crucial right now when access to other in-person resources such as community lactation counselors and mother support groups are limited. Physicians should ensure their clinics are following evidence-based recommendations for breastfeeding-friendly practices as well as reviewing their policies and procedures to ensure all are still currently relevant.¹³ For example, if a physician refers a patient to a community-based breastfeeding group or lactation service, they should determine if that organization has made any pandemic-related changes as well as prepare the patient for what those changes in service may look like.

Additional considerations for health care providers based on study findings can be seen in Table 3.

Table 3.

Implications for Support

Support type	Pandemic impact	Considerations for health care providers
Emotional	Lack of in-person support from family and friends other than significant otherIncreased stress	Ask questions to determine where emotional support is receivedBe sympathetic to the mother's lack of in-person supportProvide empathy and reflective listeningEducate mothers on early signs of postpartum depression¹⁴
Informational	Lack of in-person support from family, friends, peers, and health care providersUtilization of social media for resources and educationConcerns for return to workHeavy reliance on tele-support	Educate mothers on the availability of helpful mobile and wireless technologies (e.g., mHealth) to support breastfeeding^15,16Inform mothers on the concerns of utilizing anecdotal evidence seen on social media^17,18Educate on pumping safety and pumping rights in the workplace^19,20
Instrumental	Lack of support from family members other than significant otherLack of childcare	Discuss other opportunities for tangible support such as grocery delivery and social services (if applicable)Strategize ways to manage other children while breastfeeding²¹
Appraisal	Lack of in-person support from family, friends, health care providers, and coworkersHeavy reliance on tele-support	Provide ample encouragement to mothers especially during in-person encounters²²Address and discuss the lack of encouragement mothers may be receiving

Finally, this study once again highlights the critical need for extending maternity leaves beyond the typical 6–12 weeks. Women reported having improved breastfeeding journeys because the pandemic extended their maternity leaves and allowed them to better establish breastfeeding. This is a common finding in previous literature as longer maternity leaves are associated with longer breastfeeding duration.²³ Amidst the pandemic, organizations should continue to develop family-friendly policies that allow for more flexible scheduling and telecommuting, especially for new mothers early in their breastfeeding journey.

This study was limited by its cross-sectional nature and that it took place in only one Midwestern state. At the time of the study this state was 10th in the nation for COVID-19 cases per capita.²⁴ In addition, participation was voluntary and incentivized, which could have biased the sample. This study was strengthened by a geographically diverse sample and the inclusion of WIC participants.

Conclusion

COVID-19 has altered how mothers obtain various types of social support. Specifically, mothers greatly desire more in-person support from family, friends, and lactation medicine providers. The lack of opportunity for in-person support has led to greater feelings of stress and smaller social support networks. As the ability to provide in-person support through community efforts (e.g., breastfeeding during the pandemic remains unknown more support types should be addressed during infant well checks. Further research is needed to determine how to best provide emotional and appraisal support virtually.

Surprisingly, COVID-19 has had a positive influence on breastfeeding by motivating women to continue breastfeeding due to formula shortage concerns and allowing women more time at home with their child to establish breastfeeding. It is crucial that health care providers and public health experts continue to find innovative ways to support breastfeeding mothers during these unprecedented times.

Footnotes

Disclosure Statement

The authors have nothing to disclose.

Funding Information

This research was funded by Creighton University.

References

Stuebe

, Jegier

, Schwarz

, et al. An online calculator to estimate the impact of changes in breastfeeding rates on population health and costs. Breastfeed Med, 2017; 12:645–658.

Renfrew

, McCormick

, Wade

, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev, 2012; 5:CD001141.

House

JS.

Work Stress and Social Support. Reading, MA: Addison-Wesley, 1981.

Heaney

, Israel

. Social networks and social support. Health Behav Health Educ Theory, Res Pract, 2008; 4:189–210.

Ranganathan

, Khan

, Chhabra

. Antenatal care, care at birth, and breastfeeding during the coronavirus (COVID-19) pandemic. Indian J Commun Health, 2020; 32.

Williams

, Namazova-Baranova

, Weber

, et al. The importance of continuing breastfeeding during coronavirus disease-2019: In Support of the World Health Organization Statement on Breastfeeding during the Pandemic. J Pediatr, 2020. [Epub ahead of print]; DOI: 10.1016/j.jpeds.2020.05.009.

Goldman

AS.

The immune system in human milk and the developing infant. Breastfeed Med, 2007; 2:195–204.

Tongco

MDC.

Purposive sampling as a tool for informant selection. Ethnobot Res Appl, 2007; 5:147–158.

QSR International Pty Ltd. (2020) NVivo (released in March 2020). https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home (accessed June 15, 2020).

10.

Borkan

Immersion/crystallization. Doing Qual Res, 1999; 2:179–194.

11.

Moro

, Bertino

. Breastfeeding, human milk collection and containers, and human milk banking: Hot topics during the COVID-19 pandemic. J Hum Lact, 2020; 0890334420934391.

12.

Kendall-Tackett

Lactation in the time of global pandemic. Clin Lact, 2020; 11:54–58.

13.

Meek

, Hatcher

. The breastfeeding-friendly pediatric office practice. Pediatrics, 2017; 139.

14.

Stewart

, Vigod

. Postpartum depression. N Engl J Med, 2016; 375:2177–2186.

15.

mHealth. https://www.who.int/goe/publications/goe_mhealth_web.pdf (accessed July 29, 2020).

16.

Schindler-Ruwisch

, Roess

, Robert

, et al. Social support for breastfeeding in the era of mHealth: A content analysis. J Hum Lact, 2018; 34:543–555.

17.

Regan

, Brown

. Experiences of online breastfeeding support: Support and reassurance versus judgement and misinformation. Matern Child Nutr, 2019; 15:e12874.

18.

Alianmoghaddam

, Phibbs

, Benn

. “I did a lot of Googling”: A qualitative study of exclusive breastfeeding support through social media. Women Birth, 2019; 32:147–156.

19.

Tahra Johnson

. Breastfeeding State

Laws

. https://www.ncsl.org/research/health/breastfeeding-state-laws.aspx (accessed July 29, 2020).

20.

Coronavirus Disease (COVID-19) and Breastfeeding—CDC. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/covid-19-and-breastfeeding.html (accessed July 29, 2020).

21.

Managing Older Siblings While Breastfeeding—HealthyChildren.org. https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Managing-Older-Siblings-While-Breastfeeding.aspx (accessed July 29, 2020).

22.

Primary Care Interventions to Promote Breastfeeding—AHRQ. https://www.ahrq.gov/ncepcr/tools/healthier-pregnancy/fact-sheets/breastfeeding.html#tools (accessed July 29, 2020).

23.

de Lauzon–Guillain

, Thierry

, Bois

, et al. Maternity or parental leave and breastfeeding duration: Results from the ELFE cohort. Matern Child Nutr, 2019; 15:e12872.

24.

Cases in the

U.S

. Centers for Disease Control and

Prevention

. 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html (accessed June 29, 2020).