The Impact of COVID-19 on Breastfeeding Rates in a Low-Income Population

Abstract

Objective:

To examine the impact of the coronavirus disease 2019 (COVID-19) pandemic on breastfeeding outcomes among participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Southern California.

Materials and Methods:

Data from the 2020 Los Angeles County triennial WIC Survey were used to examine the impact of COVID-19 on breastfeeding outcomes among WIC participants. Chi-square tests were used to explore the association between the COVID-19 pandemic and breastfeeding outcomes along with hospital-friendly practices.

Results:

Compared with infants born before March 2020, the percentage of infants who received any breastfeeding at 1 month decreased from 79.66% to 76.96% (p = 0.139). The percentage of infants who received any breastfeeding at 3 and 6 months significantly decreased from 64.57% to 56.79% (p = 0.001) and from 48.69% to 38.62% (p = 0.0035), respectively. The percentage of infants fully breastfed at 1, 3, and 6 months significantly decreased at all time points. Examining hospital practices, there were no differences between the before and during COVID-19 groups.

Conclusions:

The prevalence of any breastfeeding at 3 and 6 months and fully breastfeeding at 1, 3, and 6 months was significantly lower among mothers who gave birth during the pandemic compared with mothers who gave birth before the pandemic. The shift to remote services delivery and the corresponding reduction in live support of WIC services owing to the pandemic may explain the decline in the breastfeeding rate. As the nation and the WIC program prepare for the postpandemic life, it is critical to ensure that breastfeeding support is met in a hybrid of remote and face-to-face settings.

Introduction

The Novel Coronavirus Disease 2019 (COVID-19) pandemic has resulted in many public health nutrition crises, including decreased access to nutritious food and increased food insecurity.¹ With low-income populations already disproportionately affected by such problems, COVID-19 has further exacerbated these disparities.² In response, federal nutrition programs have introduced waivers, extending flexibility to support the nutritional health status of low-income participants during the COVID-19 pandemic.^3,4

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal supplemental nutrition assistance program that serves pregnant, postpartum, and breastfeeding women and infants and children up to the age of 5 years who live in households at or <185% of the federal poverty level and are at nutritional risk.⁵ Participants of the program receive nutrient-dense supplemental food, nutrition and breastfeeding education, and social/medical services referrals.⁵

Breastfeeding education is one of the pillars of the WIC program. In addition to providing staff with the proper lactation training, the WIC program promotes and supports breastfeeding by supplying breast pumps to participants, providing less or no formula to breastfeeding mothers especially during the first month of life, providing a larger WIC food package to breastfeeding mothers, and providing access to lactation support staff and peer counselors.⁶ Peer lactation counseling has been associated with increased rates of breastfeeding initiation, duration, and exclusivity.⁷

With unwavering dedication and commitment, the WIC program has made great strides in breastfeeding promotion and support over the years, leading to a steady increase in breastfeeding rates among its participants.^8,9 As the COVID-19 pandemic unraveled, WIC services began to operate remotely to safeguard the health of its staff and participants. How the COVID-19 pandemic and the resulting remote services impact breastfeeding outcomes among WIC participants is not well understood. On the one hand, given that participants were spending more time at home and the nation was experiencing a widespread formula shortage,¹⁰ partly owing to panic buying, an increase in breastfeeding could be expected. On the other hand, isolation, lack of hands-on support and clear guidance, and mixed messages from media outlets about breastfeeding safety during COVID-19^11,12 could be associated with a decline in breastfeeding.

This study examines the impact of COVID-19 on breastfeeding outcomes among WIC participants in Southern California, utilizing data from the 2020 Los Angeles County (LAC) WIC survey. A greater understanding of these impacts will guide practice and policy on how to best support WIC mothers in times of crisis.

Materials and Methods

Data sources and study sample

Data for this study were from the 2020 LAC triennial WIC Survey. The LAC triennial WIC survey is a cross-sectional computer-assisted telephone interview survey that asks WIC families about their WIC services, health care, and public service experiences in addition to their home and community environments. The survey was conducted among a randomly selected sample of pregnant and breastfeeding mothers and mothers of children up to their fifth birthday who were enrolled in WIC at the time of the survey between July and December 2020. To be eligible to participate, the respondent also had to be an LA County resident, at least 17 years of age, and be able to complete the survey in English or Spanish.

To ensure that certain races and ethnicities were not underrepresented in the sample, this random countywide sample was augmented with additional random samples of Asian WIC families, Black WIC families, and WIC families residing in target communities within the county. A total of 6,753 surveys were completed, with a response rate of 53%. Up to 16 calls were made to reach and interview eligible subjects from each usable telephone listing dialed. Primary reasons for nonresponse included repeated failure to respond to calls, invalid phone numbers, ineligible respondents, and refusals. For this study, we restricted the sample to infants born in LAC hospitals, younger than 2 years of age at the time of the survey, and whose biological mothers were interviewed, resulting in a final sample size of 2,426.

The survey was reviewed and approved by the Committee for the Protection of Human Subjects for the California Health and Human Services Agency.

Study variables

Mothers were asked to report if their babies were breastfed. Any breastfeeding was defined as whether the child was ever breastfed. Any breastfeeding duration (at 1, 3, and 6 months) was computed using the child's age in months at which the mother stopped breastfeeding her child. A child was considered fully breastfed if they were fed only breast milk at the hospital and afterward without any supplemental food or drink. Fully breastfeeding duration (at 1, 3, and 6) was calculated by the age at which the child was given anything besides human milk.

Breastfeeding outcomes were examined dependent on whether their baby was born before or during the pandemic using the cut-off date of March 2020. Stay-at-home ordinances owing to the COVID-19 pandemic were issued for both the City of LA and the State of California on March 19, 2020. For parents of infants born since March 2020, participants were asked whether the COVID-19 pandemic made them more likely to breastfeed, less likely to breastfeed, or had no influence on their decisions around breastfeeding.

Sixty birthing hospitals were identified at the time of the survey, and 21 had a baby-friendly designation. LAC hospitals' baby-friendly designation status, where WIC infants were born, were obtained from Baby-friendly USA.¹³ Mothers were asked about 3 baby-friendly hospital practices related to the 10 steps to successful breastfeeding—whether the child was “breastfed in the first hour after birth” (Step 4), “The hospital gave the respondent formula to take home” (Step 6), and “the hospital gave a telephone number to call for help with breastfeeding” (Step 10).

According to the Baby-Friendly Hospital Initiative (BFHI) Ten Steps to Successful Breastfeeding,¹⁴ mothers should be supported to initiate breastfeeding as soon as possible after birth; hospitals should not provide mothers formula to take home, and hospitals should coordinate discharge so that mothers have timely access to breastfeeding support and care. Mothers' binary responses to these questions were used to examine changes in baby-friendly hospital practices during the COVID-19 pandemic.

Sociodemographic characteristics used to describe the sample included the child's gender and age, mother's age, education, and ethnicity.

Data analysis

Data were weighted to align the distributions of the WIC recipients interviewed to demographic and geographic characteristics of the overall WIC recipient population's demographic and geographic characteristics. Data were analyzed using SAS 9.4. Descriptive statistics explored demographics and breastfeeding outcomes before and during the COVID-19 pandemic. Chi-square tests explored the association between COVID-19 and breastfeeding outcomes, and between COVID-19 and hospital-friendly practices.

Results

At the time of the 2020 survey, children's mean (standard deviation) age was 12.12 (6.44) months, and 48.51% were women. About 72.43% of children had mothers who were Hispanic, and 77.2% had mothers with at least a high school education. The mothers' mean (standard deviation) age was 30 (6.35) years. In addition, 52.56% of WIC children were born in a baby-friendly hospital. Mothers of infants born since March 2020 were asked whether the COVID-19 pandemic made them more likely to breastfeed, less likely to breastfeed, or had no influence on their decisions around breastfeeding, and the majority of respondents (75%) said that COVID-19 did not influence their decisions around breastfeeding (Table 1).

Table 1.

Did the Coronavirus Disease Pandemic Make you More Likely to Breastfeed, Less Likely to Breastfeed, or did it Have no Influence on Your Decisions Around Breastfeeding?

	% (n)
More	16.53% (119)
Less	6.97% (50)
No influence	74.59% (536)
Missing	1.92% (14)

Table 2 shows that, compared with infants born before March 2020, the percentage of infants who received any breastfeeding at 1 month decreased from 79.66% to 76.96%. Although this decrease at 1 month was not statistically significant (p = 0.139), the percentage of infants who received any breastfeeding at 3 and 6 months significantly decreased from 64.57% to 56.79% (p = 0.001) and from 48.69% to 38.62% (p = 0.0035), respectively. The percentage of infants fully breastfed at 1, 3, and 6 months significantly decreased at all time points. Comparing fully breastfeeding rates pre-COVID-19 to during COVID-19, rates of fully breastfeeding dropped from 41.79% to 28.09% (p < 0.0.0001) at 1 month, 28.51% to 18.06% (p < 0.0001) at 3 months, and 15.66% to 10.38% (p = 0.0318) at 6 months.

Table 2.

Breastfeeding Outcomes Among Special Supplemental Nutrition Program for Women, Infants, and Children Participating Born Before and After March 2020

	Total (N = 2,426)	Children born before March 2020 (n = 1,740)	Children born after March 2020 (n = 686)
Any breastfeeding at 1 month	78.89% (1925)	79.66% (1390)	76.96% (534), p = 0.1396
Any breastfeeding at 3 months	62.72% (1430)	64.57% (1127)	56.70% (303), p = 0.001
Any breastfeeding at 6 months	47.47% (942)	48.69% (850)	38.62% (92), p = 0.0035
Fully breastfeeding at 1 months	37.89% (924)	41.79% (729)	28.09% (195), p < 0.0001
Fully breastfeeding at 3 months	26.06% (594)	28.51% (498)	18.06% (97), p < 0.0001
Fully breastfeeding at 6 months	15.02% (298)	15.66% (273)	10.38% (25), (p = 0.0318)

Examining hospital practices, there were no differences between the two groups. The percentage of infants breastfed in the first hour was not statistically different between children born before the pandemic and those born during the pandemic. Similarly, the percentage of mothers reporting not receiving a formula pack to take home was not statistically different between mothers giving birth before the pandemic and those giving birth during the pandemic. In addition, the percentage of mothers reporting receiving a phone number to the breastfeeding helpline was not statistically different between mothers giving birth before the pandemic and those giving birth during the pandemic (Table 3).

Table 3.

Baby-Friendly Hospital Practices Reported by Mothers of Special Supplemental Nutrition Program for Women, Infants, and Children Participating Born Before and After March 2020

	Total	Children born before March 2020 (n = 1,740)	Children born after March 2020 (n = 686)
Child breastfed in the first hour	74.73% (n = 1842)	75.16% (n = 1312)	73.69% (n = 530)
Not given formula pack to take home	50.91% (n = 1255)	47.18% (n = 823)	49.68% (n = 357)
Given phone number to breastfeeding helpline	84.06% (n = 2072)	84.32% (n = 1472)	83.42% (n = 600)

Chi-square tests were not significant.

Discussion

This study explored breastfeeding outcomes comparing mothers who gave birth before the pandemic (March 2020) with those who gave birth during the pandemic (after March 2020). Although the majority (74.6%) of WIC mothers expressed that the COVID-19 pandemic did not have an influence on their decisions around breastfeeding, the prevalence of any breastfeeding at 3 and 6 months and fully breastfeeding at 1, 3, and 6 months was significantly lower among mothers who gave birth during the pandemic compared with mothers who gave birth before the pandemic. This decline was not unique to WIC mothers, as similar results were reported in other studies.^12,15 For example, Brown and Shenker found that mothers with lower education, more challenging living circumstances, and Black and minority ethnic groups were more likely to find the impact of lockdown challenging and stop breastfeeding.¹⁵

In addition, studies have shown that disruption of the baby-friendly hospital practices in some institutions at the beginning of the pandemic adversely affected breastfeeding.¹⁶ However, this was not the case in our study. The percentage of mothers reporting baby-friendly practices at the hospital where they gave birth was not statistically different between mothers who gave birth before the pandemic and those who gave birth during the pandemic.

Although in-depth qualitative research is needed to understand the reasons for the decline in breastfeeding outcomes among WIC mothers, the following are possible explanations. It is well understood that breastfeeding is best supported by high-quality professional and peer support.^17–19 A study conducted in the United Kingdom to understand the impact of the pandemic upon breastfeeding outcomes found that the most common reason for breastfeeding cessation was insufficient professional support.¹⁵ Women were affected by not seeing their health professionals face to face, especially during the early weeks of breastfeeding when care needs are the highest.¹⁵

Breastfeeding support is a priority in the WIC program. However, the shift to remote services delivery and the corresponding reduction in live support of WIC services owing to the pandemic may explain the decline in breastfeeding rates and the increase in early weaning in 2020.

Another possible explanation is the mixed messages that new parents received regarding the safety of COVID-19 and breastfeeding. Early on, the American Academy of Pediatrics recommended separating mother and baby with suspected infection.¹⁶ That guidance was changed as evidence emerged that mother-to-infant transmission of COVID-19 during pregnancy and after birth is unlikely and that the rates of infection and risk of severe disease in infants are very low.²⁰ In fact, given the antimicrobial and anti-inflammatory properties of breast milk,²¹ the World Health Organization (WHO) recommends that women with COVID-19 breastfeed their babies and that direct breastfeeding (i.e., feeding directly from the breast) is the preferred infant feeding option during the pandemic.²²

Although the message is clear now, those early mixed messages likely led to fears around safety and resulted in breastfeeding cessation.¹⁵ A survey conducted in Mexico found that, despite positive messaging promoted by the government about breastfeeding during the pandemic, most respondents expressed that an infant should not be breastfed if the mother is infected with COVID-19.¹² Such beliefs were especially common among lower socioeconomic groups.¹² Another explanation could be the increased rate of perinatal depression that emerged during COVID-19 because of social isolation, financial difficulties, and health worries.²³ Studies have shown that mothers who experience postpartum depression are at increased risk of breastfeeding cessation.²⁴ However, research has not yet examined the rates of perinatal depression among WIC participants during the pandemic.

The question arises as to how to move forward. Before the pandemic, there had been a steady increase in breastfeeding rates among WIC participants.²⁵ Comparing the postpandemic breastfeeding rates to our previous work in 2019,²⁶ prepandemic breastfeeding rates (children born before March 2020) were generally higher than breastfeeding rates at 3 and 6 months in 2017 (data not shown), suggesting that pandemic may have disrupted an improving trend in the duration of any and fully breastfeeding. Owing to the COVID-19 pandemic, these improvements may slow down if actions to promote and protect breastfeeding are not taken.

Although the intersection of the challenges created by the COVID-19 pandemic and new remote technologies has led the WIC program to a place with unexpected service delivery opportunities, in-person care is still invaluable when it comes to breastfeeding. Although some studies have shown that telemedicine support can improve breastfeeding outcomes,^27,28 it is well known that what women value most is the emotional care and warmth of professionals and peers, and that is more likely to occur during face-to-face interactions.^29,30 Through in-person care, counselors can provide more than just practical breastfeeding support. Counselors can clear up any mixed messages regarding COVID-19 and breastfeeding and screen WIC mothers for signs of depression.

It is recognized that remote access has been essential for keeping the WIC program accessible to the thousands of families in need of nutrition support during the pandemic.⁴ In fact, with the onset of the COVID-19 pandemic, the USDA granted states waivers to deliver WIC operations remotely through telephone, video-conferencing, and online education options.³ As a result, participation in the program increased in many regions. For example, data from the Public Health Foundation Enterprises WIC (PHFE WIC) program in Southern California showed a 24% increase in participation between February and June 2020.⁴

However, as the nation and the WIC program prepare for the postpandemic life, it is critical to ensure that breastfeeding support is met in a hybrid of remote and face-to-face settings. In addition, as it becomes safe to return to live WIC support, our findings suggest that the live support of breastfeeding dyads is a priority. It is also critical to follow-up with mothers who could not meet their breastfeeding goals owing to the COVID-19 pandemic, as studies have shown that mothers can experience complications and an increased risk of depression, grief, and trauma if they cannot meet their breastfeeding goals.¹⁵

Our study shows an association between the pandemic and breastfeeding outcomes among WIC participants but cannot support causality or address the participants' breastfeeding experiences. Another limitation is our examination of only 3 baby-friendly hospital practices versus the 10 steps. Finally, all data were self-reported; thus, there is a possibility that maternal self-report for the period before the pandemic began was different than for the period since the pandemic started. However, to minimize poor recall and recall bias, we restricted our sample to mothers of children younger than 2 years.

More research, particularly qualitative research, is needed to understand the breastfeeding experiences of WIC participants. The WIC program and health care professionals can use such insights to ensure that breastfeeding women are better supported should future events arise that limit face-to-face contact with pregnant and postpartum women.

Footnotes

Authors' Contributions

M.K. conducted the analyses, interpreted the results, and wrote the article. S.E.W. conceptualized the study, worked closely with M.K. on the analysis plan, and reviewed and revised all aspects of the article. C.C. provided her expertise on breastfeeding services and reviewed and revised all aspects of the article.

Disclosure Statement

The authors declare that they have no competing interests.

Funding Information

Funding for this work was provided by a grant from First 5 LA to PHFE WIC.

References

Feeding America. The impact of the coronavirus on food insecurity in 2020 & 2021. Available at https://www.feedingamerica.org/sites/default/files/2021-03/National%20Projections%20Brief_3.9.2021_0.pdf (accessed August 9, 2021).

de la Haye

, Miller

, Weber

, et al. The impact of COVID-19 on food insecurity in Los Angeles County: April to May 2020. Available at https://publicexchange.usc.edu/wp-content/uploads/2020/07/USCLAC-Food-Insecurity-Report-April-%E2%80%93-May-2020.pdf (accessed August 9, 2021).

US Department of Agriculture Food and Nutrition Service. WIC COVID-19 waivers. Available at https://www.fns.usda.gov/programs/fns-disaster-assistance/fns-responds-covid-19/wic-covid-19-waivers (accessed August 9, 2021).

Whaley

, Anderson

. The importance of federal waivers and technology in ensuring access to WIC during COVID-19. Am J Public Health, 2021; 111:1009–1012.

Koleilat

, Whaley

, Esguerra

, et al. The role of WIC in obesity prevention. Curr Pediatr Rep, 2017; 5:132–141.

United States Department of Agriculture. WIC. Breastfeeding policy and guidance. Available at https://wicworks.fns.usda.gov/sites/default/files/media/document/WIC-Breastfeeding-Policy-and-Guidance_1.pdf (accessed August 9, 2021).

Martinez

, Strohbach

, Hu

, et al. “Real-world” effect of a peer counselor on breastfeeding outcomes in an urban prenatal clinic in the United States. BMC Pregnancy Childbirth, 2020; 20:671.

Bartholomew

, Adedze

, Soto

, et al. Historical perspective of the WIC program and its breastfeeding promotion and support efforts. J Nutr Educ Behav 2017;49(7 Suppl 2):S139.e1–S143.e1.

Metallinos-Katsaras

, Brown

, Colchamiro

. Maternal WIC participation improves breastfeeding rates: A statewide analysis of WIC participants. Matern Child Health J, 2015; 19:136–143.

10.

The New York Times. Families scramble to find baby formula, diapers, and wipes. Available at https://www.nytimes.com/2020/03/30/parenting/coronavirus-baby-formula-shortages-wipes-diapers.html (accessed August 9, 2021).

11.

Eidelman

. Breastfeeding and coronavirus disease 2019: A study in evolving public health recommendations. Breastfeed Med, 2021; 16:351–352.

12.

Vilar-Compte

, Gaitán-Rossi

, Rhodes

, et al. Breastfeeding media coverage and beliefs during the COVID-19 pandemic in Mexico: Implications for breastfeeding equity. Res Sq 2021;19:rs.3.rs-528093.

13.

Baby Friendly

USA

. Find a baby-friendly hospital or birthing center. Available at https://www.babyfriendlyusa.org/about (accessed August 9, 2021).

14.

Vallenas

, Savage

. Evidence for the ten steps to successful breastfeeding. Available at https://www.who.int/nutrition/publications/evidence_ten_step_eng.pdf (accessed August 9, 2021).

15.

Brown

, Shenker

. Experiences of breastfeeding during COVID-19: Lessons for future practical and emotional support. Matern Child Nutr, 2021; 17:e13088.

16.

Bartick

, Valdés

, Giusti

, et al. Maternal and infant outcomes associated with maternity practices related to COVID-19: The COVID mothers study. Breastfeed Med, 2021; 16:189–199.

17.

Ingram

, Thomson

, Johnson

, et al.; ABA Study Team. Women's and peer supporters' experiences of an assets-based peer support intervention for increasing breastfeeding initiation and continuation: A qualitative study. Health Expect, 2020; 23:622–631.

18.

McFadden

, Gavine

, Renfrew

, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev, 2017; 2:CD001141.

19.

Trickey

, Thomson

, Grant

, et al. A realist review of one-to-one breastfeeding peer support experiments conducted in developed country settings. Matern Child Nutr, 2018; 14:e12559.

20.

American Academy of Pediatrics (AAP). AAP updates guidance on newborns whose mothers have suspected or confirmed COVID-19. Available at https://www.aappublications.org/news/2020/05/21/covid19newborn052120 (accessed August 9, 2021).

21.

Cheema

, Partridge

, Kair

, et al. Protecting breastfeeding during the COVID-19 pandemic. Am J Perinatol 2020 [Epub ahead of print]; DOI: 10.1055/s-0040-1714277.

22.

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; 223:234–236.

23.

Davenport

, Meyer

, Meah

, et al. Moms are not OK: COVID-19 and maternal mental health. Front Glob Womens Health, 2020; 1:1.

24.

Dennis

, McQueen

. Does maternal postpartum depressive symptomatology influence infant feeding outcomes?. Acta Paediatr, 2007; 96:590–594.

25.

Lee

, Edmunds

, Cong

, et al. Trends in breastfeeding among infants enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children—New York, 2002–2015. MMWR Morb Mortal Wkly Rep, 2017; 66:610–614.

26.

Jung

, Nobari

, Whaley

. Breastfeeding outcomes among WIC-participating infants and their relationships to Baby-Friendly hospital practices. Breastfeed Med, 2019; 14:424–431.

27.

Ferraz Dos Santos

, Borges

, de Azambuja

. Telehealth and breastfeeding: An integrative review. Telemed J E Health, 2020; 26:837–846.

28.

Kapinos

, Kotzias

, Bogen

, et al. The use of and experiences with telelactation among rural breastfeeding mothers: Secondary analysis of a randomized controlled trial. J Med Internet Res, 2019; 21:e13967.

29.

Schmied

, Beake

, Sheehan

, et al. Women's perceptions and experiences of breastfeeding support: A metasynthesis. Birth, 2011; 38:49–60.

30.

Demirci

, Kotzias

, Bogen

, et al. Telelactation via mobile app: Perspectives of rural mothers, their care providers, and lactation consultants. Telemed J E Health, 2019; 25:853–858.