Impact of COVID-19 on maternal and child health

The study by Timothy Roberton and colleagues (July, 2020),¹ which modelled the indirect effects of COVID-19 on maternal and child mortality in low-income and middle-income countries (LMICs), highlights potential consequences of disruptions to routine health care and decreased access to food. While the total projected impact is shocking, the analysis omitted modelling disruptions in breastfeeding practices because the authors “assumed only a marginal reduction in these activities.”¹ The COVID-19 pandemic is already indirectly threatening breastfeeding practices (early initiation and exclusive and continued breastfeeding). Universal breastfeeding could prevent 823 000 child deaths per year,² yet additional examination as part of COVID-19 impact modelling is needed.

During the COVID-19 pandemic, reductions in breastfeeding prevalence will plausibly occur due to limitations in the provision and use of health services and disruptions to the enabling environment. Limitations in the availability of skilled health workers and increased reluctance by women to use the health system could lead to lower coverage of antenatal care, postnatal care, and facility and community-based lactation support and counselling. Anecdotal evidence suggests that some health facilities are inappropriately separating newborn babies from mothers and discouraging breastfeeding because of unfounded fears of transmission of COVID-19 through breastmilk. These situations might result in a decline in early initiation of breastfeeding after birth—missing the child's first natural vaccine (colostrum)—and, in turn, exclusive breastfeeding.

The enabling household environment for breastfeeding can be compromised by the potential increased demand for child caregiving during lockdowns and school closures. The societal enabling environment can be threatened by formula manufacturers that exploit fears of contagion through coercive marketing practices in violation of the International Code of Marketing of Breast-Milk Substitutes.³ Although some determinants of breastfeeding could be positively affected by the pandemic, we hypothesise that there are negative social, economic, corporate, and health-system forces affecting the mother's decision to breastfeed that should be considered.

We estimated, using the Alive & Thrive cost of not breastfeeding tool,⁴ that a hypothetical effect of small (5%), moderate (10%), medium (25%), or severe (50%) relative reductions in the prevalence of breastfeeding due to COVID-19 disruptions would result in 16 469 (small reduction), 32 139 (moderate reduction), 75 455 (medium reduction), and up to 138 398 (severe reduction) child deaths across 129 LMICs over a 1-year period, plus additional morbidity (appendix).

This analysis highlights the need for continued support from governments to promote and protect breastfeeding, in line with the Global Breastfeeding Collective's call to action during COVID-19.⁵ We encourage authors publishing on the estimated indirect impacts of COVID-19 pandemic to consider the substantial morbidity and mortality repercussions from pandemic-related disruptions to breastfeeding.