Abstract
Background:
We surveyed parents who gave birth from 2019 to 2021 to examine changes in breastfeeding experiences and professional and lay breastfeeding support services due to the coronavirus disease 2019 (COVID-19) pandemic. We also examined racial and ethnic disparities in breastfeeding support.
Materials and Methods:
A cross-sectional opt-in survey of 1,617 parents was administered on Ovia's parenting app in January 2022. Respondents were 18–45 years of age and delivered in one of three birth cohorts: August–December 2019, March–May 2020, or June–August 2021. We fit linear and logistic regression models wherein the outcomes were six breastfeeding support and experience measures, adjusting for birth cohort and respondent demographics.
Results:
Parents who gave birth in the early pandemic versus those in the prepandemic had reduced odds of interacting with lactation consultants (odds ratio [OR]: 0.63; 95% confidence interval [CI]: 0.44–0.90), attending breastfeeding classes (OR: 0.71; 95% CI: 0.54–0.94), meeting breastfeeding goals (OR: 0.65; 95% CI: 0.46–0.92), and reporting it was easy to get breastfeeding help (estimate: −0.36; 95% CI: −0.55 to −0.17). Birth cohort was not associated with use of donor milk or receipt of in-hospital help. The later pandemic cohort differed from the prepandemic cohort for one outcome: they were less likely to meet their breastfeeding goals (OR: 0.67; 95% CI: 0.48–0.95). There were racial and ethnic disparities in the use of multiple types of breastfeeding support. Although one-third of respondents felt that the pandemic facilitated breastfeeding because of more time at home, 18% felt the pandemic posed additional challenges including disruptions to lactation support.
Conclusions:
Parents who gave birth in the later pandemic did not report significant disruptions to professional breastfeeding support, likely as a result of the growth of virtual services. However, disparities in receipt of support require policy attention and action.
Keywords: breastfeeding support, lactation support, COVID-19, survey
Introduction
Breastfeeding is the optimal source of nutrition for infants. The World Health Organization (WHO), United Nations Children's fund (UNICEF), and the American Academy of Pediatrics all recommend initiation of breastfeeding within the first hour after birth and exclusive breastfeeding for the first 6 months.1–3 Breastfeeding provides both short-term and long-term health and psychosocial benefits to infants as well as their parents.4 Infants who are breastfed experience lower risk of asthma, obesity, diabetes, sudden infant death syndrome, and infectious diseases.5–12 Parents who breastfeed their infants have lower risk of ovarian and breast cancer, diabetes, and hypertension.13–18
Despite evidence of breastfeeding's benefits, the United States continues to have lower rates of exclusive breastfeeding through 6 months than is recommended by clinical guidelines and Healthy People 2030 targets.19 Furthermore, many parents do not meet their personal breastfeeding goals.20–23 In recent years, public health programs and policies have resulted in significant improvements in breastfeeding initiation and duration, yet new barriers to breastfeeding presented by the coronavirus disease 2019 (COVID-19) pandemic may undermine prior gains.24,25 Furthermore, the pandemic, which disproportionately affected racial and ethnic minorities both directly and indirectly as a result of disruption to the health care system and physical distancing measures, may have exacerbated existing disparities in breastfeeding rates.26–29
The physical distancing measures and longer term behavior changes implemented to reduce COVID-19 transmission have led to changes in the delivery of formal health care services as well as informal support.30 Early in the pandemic, health care providers limited in-person visits, which is the setting wherein breastfeeding support is traditionally provided.31 In addition, isolation from family, friends, and other peer-support networks further reduced the availability of emotional and practical support for breastfeeding.32
Although the full impact of the pandemic on lactation support and breastfeeding rates is unknown, 18% of hospitals reduced in-person lactation support and the majority accelerated discharges after birth in the summer of 2020, further reducing opportunities for early lactation support services.31 Interestingly, not all impacts of the pandemic on breastfeeding are likely to be negative. Greater flexibility to work from home for some parents may have facilitated longer breastfeeding duration.31
Understanding how breastfeeding experiences and supports have changed over the course of the pandemic is critical to informing policies and programs to promote breastfeeding moving forward and during future emergencies. Several qualitative studies and a handful of cross-sectional surveys have detailed positive as well as negative changes in breastfeeding experiences as a result of the pandemic.33–36 For example, in one study, parents reported isolation but also increased bonding opportunities with their infant.37
A 2022 systematic review on the impact of COVID-19 on breastfeeding identified four studies that showed reductions in professional breastfeeding support and dissatisfaction with the care received.38 To our knowledge, only two studies have directly compared cohorts of parents who gave birth before and during the pandemic, and no studies have compared cohorts who gave birth at different stages of the pandemic in the United States. For the studies that did compare prepandemic with pandemic cohorts, one study surveyed women, infants, and children (WIC) participants in Los Angeles County,39 and the other study surveyed parents who received lactation support services at a specific clinic Houston, Texas.40
Given that these studies were focused on one particular community, generalizability is limited. To address gaps in the evidence, we surveyed parents from across the United States who gave birth from 2019 to 2021 to examine changes to breastfeeding experiences and professional and lay breastfeeding support services. We also examined racial and ethnic disparities in breastfeeding support experienced by parents.
Materials and Methods
Sample
A cross-sectional survey of birthing parents was administered on Ovia's parenting app. Ovia's suite of apps are among the most popular pregnancy and parenting apps available in the United States for free download on iOS and Android devices. The parenting app provides information about parenting and includes a child milestone tracker and development guide. At any given time, the app has ∼120,000 active users who engage with it at least three times per week. Ovia apps are frequently used to recruit pregnant and postpartum parents for research studies given their large user base. Multiple studies, including several on the impact of COVID-19 on obstetric care, have shown that Ovia's user population is nationally representative with respect to demographic characteristics.41–45
The survey opportunity was advertised within the app, on the individualized feeds of active users, and through email from October 10, 2021, to January 7, 2022. Three screener questions were used to determine eligibility. To be included, participants needed to be 18–45 years of age and the birthing parent. Participants also needed to have given birth to a child in one of three different time frames or “birth cohorts”: (1) prepandemic (August–December 2019), (2) early pandemic (March–May 2020), or (3) later pandemic (June–August 2021). Parents of multiple children were instructed to answer the survey based on the first-born child in a given cohort.
Recruitment occurred until we obtained 1500 participants (∼500 in each of three birth cohorts). This sample size was determined a priori, as it provides sufficient power to detect differences in lactation consultant interaction and other outcomes measuring breastfeeding experiences and support services across birth cohorts.
Over 200,000 unique users were shown an advertisement within the app and/or received an email advertisement that explained the survey opportunity, and 6,184 Ovia users clicked on an advertisement. Of these 6,184 users, 4,567 (74%) were found ineligible. Most (n = 4,159) were ineligible due to their responses to the three screening questions and the remaining 408 were excluded because responses were likely duplicative (i.e., respondents attempted to take the survey more than once). The most common reason (96%) that participants were excluded based on the screening questions was because they did not give birth in one of the three time periods of interest. The final sample included 1,617 participants, 1,530 (95%) who completed the entire survey and 87 (5%) who gave partial responses.
Survey responses were anonymous. Participants were informed that their participation in the survey was voluntary, and they could end their participation at any time. Participants received a $10 Amazon e-gift card for completing the survey. RAND's institutional review board approved the study.
Survey instrument
The survey consisted of 40 questions on professional and lay breastfeeding support received, COVID-19 vaccine receipt and attitudes, breastfeeding experiences and duration, and demographic characteristics (see Supplementary Appendix for survey instrument). Because there was no validated survey instrument that captured all the domains we aimed to address, we modified existing (validated) questions where possible and developed others. We reviewed and adapted questions from the CDC's Infant Feeding Practices Survey,46 the Kaiser Family Foundation Vaccine Monitor project,47 PRAMS COVID-19 Vaccine Supplement,48 NIS COVID Supplement,49 and from recent systematic reviews of survey instruments on COVID-19 vaccines.50
We conducted cognitive testing on the draft survey instrument with six Ovia app users who gave birth in the spring of 2021. Interviewees were asked to explain how they interpreted each question using the think aloud procedure. They also identified any questions or terms that were confusing, unclear, or cognitively burdensome and commented on whether response options were comprehensive. Findings from cognitive testing informed revisions to the survey instrument to improve clarity and flow.
Outcome measures
We assessed how breastfeeding support and experiences changed across the birth cohorts. The professional support measures included (1) any interaction with a lactation consultant, either during the postpartum hospitalization and/or in the 3 months after giving birth (lactation consultant interaction), (2) receipt of breastfeeding help from any health care professional during the postpartum hospitalization (in-hospital breastfeeding help), (3) participation in any classes or support groups that discussed breastfeeding (class participation), and (4) ease of getting help with breastfeeding from health care professionals in the first 3 months after giving birth (ease of getting breastfeeding help).
We also examined changes in the use of donor or shared milk (whether the infant had ever been fed another person's breast milk) and changes in breastfeeding goal attainment (whether the parent felt they met or were on track to meet their breastfeeding goals). Finally, we included an open-ended question on how the pandemic impacted breastfeeding decisions and experiences. Exact wording of the survey questions is included in Table 1.
Table 1.
Survey Questions for Key Outcomes
| Outcome | Survey question |
|---|---|
| Lactation consultant interaction (binary) | Combination of two questions on which types of health care professionals provided support (1) in the hospital and (2) in the first 3 months after birth (after discharge) |
| In-hospital breastfeeding help (binary) | When you were in the hospital or birth center, did anyone help you with breastfeeding (e.g., show you how to position your child to breastfeed or how to use a breast pump)? |
| Class participation (binary) | Did you attend any classes or support groups that discussed breastfeeding? Check all that apply. |
| Ease of getting breastfeeding help (Likert scale) | How easy was it for you to get breastfeeding help from health care providers in the first 3 months after your child was born? |
| Use of donor milk (binary) | Has your child ever been fed another person's breast milk (e.g., donor milk or shared milk)? |
| Goals Met (Binary) | Do you feel that you met or are on track to meet your breastfeeding goals with your child? |
| Impact of pandemic on breastfeeding experiences and decisions (open ended) | How did the COVID-19 pandemic affect your breastfeeding experience (if at all). For example, did it affect your decision about when you would stop breastfeeding or affect the information you received about breastfeeding? Please explain. |
Statistical methods
We hypothesized that parents who gave birth during the pandemic would report less access to professional breastfeeding support and have more negative breastfeeding experiences relative to those who gave birth before the pandemic. To test these hypotheses, we fit linear and logistic regression models wherein the outcomes were professional breastfeeding support and experience measures (already described) as a function of birth cohort and other control variables. The following demographic variables were included in all regression models: race/ethnicity, age, education, marital status, primary payer, income, and residential location (rurality).
For some outcomes, we also controlled for an indicator of neonatal intensive care unit stay and gestational age at birth. Because the public health response (e.g., social distancing measures) varied by location, we also did a sensitivity check, including state fixed effects in the regression models; however, because we found similar results to those reported here, and no state prohibited in-person professional breastfeeding support during the pandemic, we elected to show results without adjusting for state.
To facilitate comparison of the changes in breastfeeding support and experiences across the birth cohorts, we generated adjusted rates (for binary outcomes) and means (for continuous outcomes) such that all birth cohorts look like the prepandemic cohort in terms of control variables. To generate adjusted rates and means, we used a marginal standardization or recycled prediction approach based on averaging predicted probabilities for each cohort, with all covariates except cohort fixed at the values observed in the prepandemic cohort.51–53 We used the bootstrap method to generate confidence intervals (CIs).
To assess whether there were racial and ethnic and/or socioeconomic disparities in professional breastfeeding support and experiences, we conducted joint tests of significance for race and ethnicity based on the regression model results. We also conducted a linear trend test for income, where we fit the same regression models and coded income as continuous rather than categorical. We interpreted the effects of race, ethnicity, and income when these results were statistically significant.
Although the rate of missingness on all variables was relatively low (95% of respondents completed the entire survey), we conducted multiple imputation sensitivity analyses that used multiple imputation by chained equations54 to generate five completed data sets and pool regression results from each completed data set using Rubin's rules.55
Using an inductive approach, we manually coded responses to the open-ended question on the impact of the pandemic on breastfeeding decisions and experiences into eight thematic categories. We excluded 416 (26%) responses that were not applicable (e.g., because the parent had stopped breastfeeding before the pandemic or had never initiated breastfeeding). We generated descriptive statistics to describe the proportion of responses in each category. All analyses were conducted in R.
Results
Among the 1,617 respondents, 519 (32%) gave birth in the prepandemic period, 522 (32%) in the early pandemic period, and 576 (36%) in the later pandemic period (Table 2). Given that certain demographic differences across cohorts were statistically significant (e.g., the early pandemic cohort had fewer births covered by Medicaid than the prepandemic cohort [20% vs. 26%, p = 0.02]), we adjusted for demographic variables in subsequent analyses to facilitate comparisons across cohorts.
Table 2.
Respondent Characteristics by Birth Cohort
| Prepandemic cohort (N = 519), n (%) | Early pandemic cohort (N = 522), n (%) | p-value: prepandemic versus early pandemic | Later pandemic cohort (N = 576), n (%) | p-value: prepandemic versus later pandemic | |
|---|---|---|---|---|---|
| Age, years | |||||
| 18–24 | 61 (12) | 56 (11) | 74 (13) | ||
| 25–29 | 139 (27) | 165 (32) | 122 (21) | ||
| 30–34 | 174 (34) | 160 (31) | 214 (37) | ||
| 35–39 | 111 (21) | 108 (21) | 143 (25) | ||
| 40–44 | 34 (7) | 33 (6) | 0.55 | 23 (4) | 0.05 |
| Education | p < 0.01 | ||||
| No bachelor's degree | 229 (46) | 241 (48) | 182 (34) | ||
| College graduate (bachelor's degree) | 272 (54) | 263 (52) | 0.50 | 356 (66) | <0.01 |
| Household income | |||||
| <$25,000 | 55 (12) | 41 (9) | 59 (12) | ||
| $25,000–$40,000 | 84 (18) | 107 (23) | 46 (9) | ||
| $40,000–$55,000 | 77 (16) | 75 (16) | 39 (8) | ||
| $55,000–$80,000 | 65 (14) | 73 (16) | 70 (14) | ||
| $80,000 or more | 194 (41) | 173 (37) | 0.17 | 278 (57) | <0.01 |
| Race/ethnicity | |||||
| Hispanic | 118 (24) | 133 (26) | 120 (22) | ||
| Non-Hispanic Black | 34 (7) | 43 (9) | 45 (8) | ||
| Non-Hispanic Asian or Pacific Islander | 16 (3) | 21 (4) | 13 (2) | ||
| Non-Hispanic othera | 45 (9) | 36 (7) | 22 (4) | ||
| Non-Hispanic White | 288 (57) | 271 (54) | 0.39 | 338 (63) | 0.01 |
| Payer | |||||
| Private | 348 (70) | 364 (72) | 403 (75) | ||
| Medicaid | 129 (26) | 102 (20) | 106 (20) | ||
| Other | 17 (3) | 27 (5) | 21 (4) | ||
| Uninsured | 3 (1) | 10 (2) | 0.02 | 5 (1) | 0.12 |
| Marital status | |||||
| Single | 128 (25) | 112 (21) | 116 (20) | ||
| Married | 391 (75) | 410 (79) | 0.22 | 460 (80) | 0.07 |
| Residential location | |||||
| Large city | 129 (26) | 148 (29) | 132 (25) | ||
| Suburb near large city | 186 (37) | 186 (37) | 217 (40) | ||
| Small city or town | 139 (28) | 143 (28) | 136 (25) | ||
| Rural area | 47 (9) | 27 (5) | 0.08 | 53 (10) | 0.68 |
| Initiated breastfeeding (yes) | 488 (94) | 476 (92) | 0.08 | 529 (94) | 0.16 |
Percentages in each category are calculated excluding missing values. Percentages may not add up to 100% for each variable due to rounding. p-values are from t-test and chi-squared tests comparing each pandemic cohort with the prepandemic cohort for differences in means and proportions, respectively.
Other includes American Indian or Alaskan Native, some other race, and more than one race.
Tables 3 and 4 contain adjusted odds ratios (ORs; and regression coefficient for ease of getting breastfeeding help) and CIs for the professional breastfeeding support, practices, and experience outcomes of interest. In adjusted analyses, we found that for four outcomes, the early pandemic cohort of parents reported significantly less support than the prepandemic cohort. Parents who gave birth in the early pandemic had reduced odds of having an interaction with a lactation consultant (OR: 0.63; 95% CI: 0.44–0.90), attending classes or groups that discussed breastfeeding (OR: 0.71; 95% CI: 0.54–0.94), and meeting their breastfeeding goals (OR: 0.65; 95% CI: 0.46–0.92).
Table 3.
Associations Between Birth Cohort and Demographic Characteristics and Breastfeeding Support
| Lactation consultant interaction |
In-hospital breastfeeding help |
Breastfeeding classes |
Ease of getting help |
|||||
|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | p | OR (95% CI) | p | OR (95% CI) | p | Coefficient (95%CI) | p | |
| Intercept | 8.07 (3.55 to 18.35) | <0.01 | 15.29 (4.58 to 50.98) | <0.01 | 1.13 (0.6 to 2.14) | 0.71 | 4.43 (3.99 to 4.88) | <0.01 |
| Cohort | ||||||||
| Prepandemic (Ref) | ||||||||
| Early pandemic | 0.63 (0.44 to 0.9) | 0.01 | 0.76 (0.44 to 1.31) | 0.32 | 0.71 (0.54 to 0.94) | 0.02 | −0.36 (−0.55 to −0.17) | <0.01 |
| Later pandemic | 0.83 (0.56 to 1.21) | 0.33 | 0.7 (0.41 to 1.19) | 0.19 | 1.2 (0.92 to 1.57) | 0.18 | 0.13 (−0.05 to 0.31) | 0.16 |
| Race and ethnicity | ||||||||
| White (Ref) | ||||||||
| Hispanic | 1.09 (0.75 to 1.6) | 0.64 | 1.36 (0.75 to 2.44) | 0.31 | 0.76 (0.57 to 1) | 0.05 | −0.36 (−0.55 to −0.17) | <0.01 |
| Black | 0.48 (0.29 to 0.8) | <0.01 | 0.38 (0.2 to 0.71) | <0.01 | 0.86 (0.55 to 1.34) | 0.5 | 0.02 (−0.27 to 0.32) | 0.87 |
| Asian or API | 1.04 (0.38 to 2.79) | 0.95 | 2.2 (0.29 to 16.71) | 0.45 | 1.1 (0.58 to 2.11) | 0.77 | −0.23 (−0.64 to 0.19) | 0.28 |
| Other | 0.74 (0.42 to 1.31) | 0.3 | 0.8 (0.34 to 1.9) | 0.62 | 0.69 (0.43 to 1.1) | 0.12 | −0.12 (−0.49 to 0.25) | 0.52 |
| Education | ||||||||
| No college (Ref) | ||||||||
| College or more | 1.31 (0.89 to 1.93) | 0.17 | 2.73(1.55 to 4.8) | <0.01 | 1.85 (1.36 to 2.51) | <0.01 | −0.21 (−0.41 to 0) | 0.05 |
| Age, years | ||||||||
| 18–24 (Ref) | ||||||||
| 25–29 | 0.83 (0.51 to 1.35) | 0.45 | 0.77 (0.37 to 1.6) | 0.48 | 0.41 (0.27 to 0.63) | <0.01 | −0.24 (−0.54 to 0.07) | 0.13 |
| 30–34 | 0.95 (0.54 to 1.65) | 0.85 | 0.76 (0.34 to 1.72) | 0.52 | 0.46 (0.29 to 0.72) | <0.01 | −0.22 (−0.55 to 0.11) | 0.2 |
| 35–39 | 0.9 (0.48 to 1.67) | 0.73 | 0.5 (0.21 to 1.19) | 0.12 | 0.41 (0.25 to 0.67) | <0.01 | −0.23 (−0.58 to 0.12) | 0.19 |
| 40–44 | 1.12 (0.45 to 2.79) | 0.81 | 1.47 (0.29 to 7.36) | 0.64 | 0.68 (0.36 to 1.3) | 0.24 | −0.26 (−0.7 to 0.19) | 0.26 |
| Marital status | ||||||||
| Single (Ref) | ||||||||
| Married | 1.14 (0.76 to 1.7) | 0.53 | 1.12 (0.63 to 2.01) | 0.7 | 1.32 (0.93 to 1.87) | 0.12 | −0.02 (−0.27 to 0.22) | 0.86 |
| Payer | ||||||||
| Private (ref) | ||||||||
| Medicaid | 0.83 (0.55 to 1.26) | 0.38 | 0.61 (0.34 to 1.12) | 0.11 | 1.29 (0.9 to 1.83) | 0.16 | −0.25 (−0.5 to 0) | 0.05 |
| Other | 1.03 (0.49 to 2.16) | 0.94 | 2.12 (0.49 to 9.24) | 0.32 | 1.59 (0.91 to 2.79) | 0.11 | −0.07 (−0.44 to 0.3) | 0.71 |
| Uninsured | 0.88 (0.24 to 3.29) | 0.85 | 0.8 (0.1 to 6.55) | 0.83 | 0.46 (0.13 to 1.67) | 0.24 | −0.59 (−1.4 to 0.23) | 0.16 |
| Income | ||||||||
| <25,000 | 0.43 (0.23 to 0.8) | 0.01 | 1.27 (0.51 to3.14) | 0.61 | 0.85 (0.51 to 1.42) | 0.54 | 0.05 (−0.29 to 0.39) | 0.79 |
| 25,000–40,000 | 0.67 (0.38 to 1.17) | 0.16 | 1.54 (0.66 to 3.62) | 0.32 | 0.63 (0.4 to 0.99) | 0.05 | −0.1 (−0.42 to 0.22) | 0.56 |
| 40,000–55,000 | 0.51 (0.3 to 0.86) | 0.01 | 1 (0.46 to 2.19) | 0.99 | 0.88 (0.59 to 1.31) | 0.53 | −0.1 (−0.37 to 0.17) | 0.47 |
| 55,000–80,000 | 0.57 (0.36 to 0.92) | 0.02 | 0.87 (0.45 to 1.7) | 0.68 | 0.51 (0.36 to 0.73) | <0.01 | −0.09 (−0.33 to 0.14) | 0.43 |
| 80,000 plus (Ref) | ||||||||
| Location | ||||||||
| Large city (Ref) | ||||||||
| Rural | 0.48 (0.28 to 0.81) | 0.01 | 0.7 (0.31 to 1.58) | 0.39 | 0.83 (0.52 to 1.32) | 0.44 | −0.1 (−0.4 to 0.2) | 0.52 |
Quantities shown represent regression coefficients and confidence intervals (on the odds ratio scale for binary outcomes) and p-values. Models adjusted for race/ethnicity, age, education, marital status, primary payer, income, and residential location (rurality).
CI, confidence intervals.
Table 4.
Associations Between Birth Cohort and Demographic Characteristics and Feeding Practices and Experiences
| Donor milk |
Met breastfeeding goals |
|||||
|---|---|---|---|---|---|---|
| Estimate | 95% CI | p | Estimate | 95% CI | p | |
| Intercept | 0.17 | (0.06–0.5) | <0.01 | 8.08 | (3.49–18.71) | <0.01 |
| Cohort | ||||||
| Prepandemic (Ref) | ||||||
| Early pandemic | 1.07 | (0.66–1.74) | 0.79 | 0.65 | (0.46–0.92) | 0.01 |
| Later pandemic | 1.38 | (0.88–2.18) | 0.16 | 0.67 | (0.48–0.95) | 0.03 |
| Race and ethnicity | ||||||
| White (Ref) | ||||||
| Hispanic | 0.58 | (0.35–0.95) | 0.03 | 0.78 | (0.56–1.1) | 0.16 |
| Black | 0.74 | (0.36–1.53) | 0.42 | 1.09 | (0.64–1.86) | 0.75 |
| Asian or API | 0.97 | (0.36–2.67) | 0.96 | 0.56 | (0.26–1.19) | 0.13 |
| Other | 0.32 | (0.11–0.93) | 0.04 | 0.79 | (0.45–1.37) | 0.4 |
| Education | ||||||
| No college (Ref) | ||||||
| College | 0.91 | (0.55–1.5) | 0.71 | 1.43 | (0.98–2.09) | 0.06 |
| Age, years | ||||||
| 18–24 (Ref) | ||||||
| 25–29 | 0.63 | (0.33–1.21) | 0.16 | 0.49 | (0.28–0.85) | 0.01 |
| 30–34 | 0.3 | (0.14–0.64) | <0.01 | 0.47 | (0.26–0.86) | 0.01 |
| 35–39 | 0.5 | (0.23–1.07) | 0.07 | 0.43 | (0.23–0.81) | 0.01 |
| 40–44 | 0.55 | (0.2–1.55) | 0.26 | 0.23 | (0.1–0.5) | <0.01 |
| Marital status | ||||||
| Single (Ref) | ||||||
| Married | 1.33 | (0.75–2.37) | 0.33 | 1.22 | (0.81–1.84) | 0.35 |
| Payer | ||||||
| Private (ref) | ||||||
| Medicaid | 1.03 | (0.58–1.84) | 0.92 | 0.91 | (0.6–1.4) | 0.68 |
| Other | 1.11 | (0.44–2.77) | 0.83 | 0.91 | (0.46–1.81) | 0.79 |
| Uninsured | 0.77 | (0.1–6.3) | 0.81 | 1.28 | (0.32–5.17) | 0.73 |
| Income | ||||||
| Less than 25,000 | 0.78 | (0.34–1.82) | 0.57 | 1 | (0.53–1.89) | 0.99 |
| 25,000–40,000 | 0.62 | (0.29–1.34) | 0.23 | 0.69 | (0.4–1.19) | 0.18 |
| 40,000–55,000 | 0.51 | (0.23–1.12) | 0.1 | 0.87 | (0.52–1.45) | 0.6 |
| 55,000–80,000 | 1.57 | (0.93–2.66) | 0.09 | 0.94 | (0.61–1.45) | 0.78 |
| 80,000 plus (Ref) | ||||||
| Location | ||||||
| Large city (Ref | ||||||
| Rural | 0.59 | (0.28–1.26) | 0.17 | 1.61 | (0.86–2.99) | 0.14 |
Quantities shown represent regression coefficients and confidence intervals (on the odds ratio scale for binary outcomes) and p-values. Models adjusted for race/ethnicity, age, education, marital status, primary payer, income, and residential location (rurality).
Furthermore, the early pandemic cohort was less likely to report that it was easy to get breastfeeding help in the first 3 months after giving birth (estimate: −0.36; 95% CI: −0.55 to −0.17). The later pandemic cohort, in contrast, did not differ significantly from the prepandemic cohort regarding receipt of professional breastfeeding support and experiences with one exception: they, like parents in early pandemic cohort, continued to be less likely to meet their breastfeeding goals as compared with the prepandemic cohort (OR: 0.67; 95% CI: 0.48–0.95). Birth cohort was not associated with use of donor milk or receipt of in-hospital breastfeeding help.
To facilitate interpretation of breastfeeding experiences across birth cohorts, Table 5 displays adjusted rates or means for each outcome variable, assuming all cohorts are the same as the prepandemic cohort in terms of demographics. Related to the mentioned points, 78.1% of parents who gave birth in the early pandemic reported having interactions with lactation consultants versus 84.5% who gave birth in the prepandemic period (p = 0.01). A total of 71.3% and 71.9% of parents who gave birth in the early pandemic and later pandemic, respectively, reported meeting or being on track to meet their breastfeeding goals versus 78.9% who gave birth in the prepandemic period (p = 0.01 and 0.03)
Table 5.
Adjusted Rates and Means for Breastfeeding Support and Experience Outcomes by Birth Cohort
| Measure | Overall rate (sample size) | Pre-pandemic cohort rate (CI) | Early pandemic cohort rate (CI) | Later pandemic cohort rate (CI) |
|---|---|---|---|---|
| Donor Milk | 9.6% (1,586) | 7.9% (CI: 5.6%–10.4%) | 8.3% (CI: 5.8%–11.0%) | 10.5% (CI: 7.7%–13.5%) |
| Lactation consultant interactiona | 82.2% (1,478) | 84.5% (CI: 81.3%–87.7%) | 78.1% (CI: 73.6%–82.2%) | 82.1% (CI: 78.3%–85.7%) |
| In-hospital breastfeeding helpb | 92.3% (1,459) | 93.6% (CI: 91.2%–95.8%) | 91.9% (CI: 89.0%–94.7%) | 91.3% (CI: 87.9%–94.0%) |
| Breastfeeding classes | 41.0% (1,564) | 41.8% (CI: 40.6%–43.0%) | 34.3% (CI: 33.1%–35.3%) | 46.0% (CI: 44.8%–47.2%) |
| Ease of getting helpc | 3.7 (999) | 3.7 (CI: 3.6–3.9) | 3.4 (CI: 3.2–3.5) | 3.9 (CI: 3.7–4.0) |
| Meeting goals | 74.4% (1,298) | 78.9% (CI: 74.5%–82.8%) | 71.3% (CI: 66.3%–75.8%) | 71.9% (CI: 67.1%–76.5%) |
Sample size refers to the number of observations without missing or inapplicable values. Cohort rates and means are adjusted to look like the prepandemic cohort on covariates indicated in Table 2.
Main analysis includes those who initiated breastfeeding and a sensitivity analysis excludes them.
Main analysis includes those who initiated breastfeeding and a sensitivity analysis excludes them. Excludes people who did not give birth in a hospital or birth center.
Excludes those who said they did not try to get help.
Adjusting for multiple demographic characteristics and birth cohort, we observed evidence of racial and ethnic as well as socioeconomic disparities in the receipt of professional breastfeeding support. First, the probability of lactation consultant interaction at any point in the postpartum period increased with income (p = 0.02 in linear trend test). Second, Black respondents were significantly less likely than White respondents to report lactation consultant interaction postpartum (OR: 0.48; 95% CI: 0.29–0.8 in joint test for race/ethnicity) and in-hospital breastfeeding help (OR: 0.38; 95% CI:0.2–0.71).
Furthermore, Hispanic respondents were significantly less likely to report attending classes or groups that discussed breastfeeding (OR: 0.76; 95% CI:0.57–1) and that it was easy to get breastfeeding help in the first 3 months after birth (estimate: −0.36; 95% CI: −0.55 to −0.17) compared with White respondents.
Although our main analysis for the outcomes of lactation consultant interaction and in-hospital breastfeeding help only included participants who reported initiating breastfeeding, we conducted sensitivity analyses including those who did not initiate breastfeeding. These analyses found consistent results for the effect of birth cohort. Multiple imputation sensitivity analyses to address missing data found that birth cohort was associated with multiple outcomes, with similar effects for all the outcomes indicated in the complete case analysis. However, birth cohort was also associated with receipt of in-hospital breastfeeding help (p = 0.02), with the early and later pandemic cohorts much less likely to receive in-hospital help than the prepandemic cohort (OR: 0.72 for early pandemic and OR: 0.54 for later pandemic).
In total, 916 parents described how the pandemic impacted their breastfeeding decisions and experiences in their own words. Themes are listed hereunder, and illustrative quotes are given in Table 6. Just over half of respondents (n = 464; 51%) indicated the pandemic had no impact on their breastfeeding decisions or experiences. However, many still noted that they appreciated that they could pass antibodies to their infants through breastfeeding and that this was considered to provide additional immunity/protection for the infant.
Table 6.
Summary of Open-Ended Responses on the Impact of the Pandemic on Breastfeeding
| Impact on breastfeeding | Theme | Illustrative quotes |
|---|---|---|
| No impact | No impact of the pandemic on my breastfeeding decisions | “It didn't affect it at all other than being grateful that I was breastfeeding my child and giving him extra protection through the pandemic.” – Parent who gave birth in December, 2019 |
| Positive impact | I breastfed longer to give my baby antibodies | “It [the COVID-19 pandemic] made me decide to push through to at least 6 months rather than the 4 months I had originally planned. I want her immune system as strong as possible. I also had COVID while breastfeeding and I think the breast milk helped my baby not really get sick at all.” – Parent who gave birth in June, 2021 |
| I breastfed longer because I was at home more | “Honestly, the COVID pandemic probably helped extend my breastfeeding experience because it allowed me to work from home and still nurse her while I worked.” – Parent who gave birth in April, 2020 |
|
| I breastfed longer for other varied reasons | “I was definitely worried about being able to get formula, so I was determined to breastfeed” – Parent who gave birth in March, 2020 |
|
| Negative impact | I could not get professional or organized support | “My support system fell apart when the pandemic began. I was attending a weekly in person breastfeeding group led by an amazing lactation consultant. When the pandemic began the group was cancelled and my support system disappeared. I knew I could always call, but it wasn't the same.” – Parent who gave birth in September, 2019 |
| I had less social support from friends and/or family | “When first beginning breastfeeding, the pandemic limited seeing my mother at all who had breast fed 4 babies and could have been helpful or supportive.” – Parent who gave birth in March, 2020 |
|
| I breastfed for less time due to pandemic-related stress | “My supply dropped during the initial wave due to stress over health, finances, the unknown. It was also even more exhausting to try to work remote and breastfeed and pump and take care of everything else.” – Parent who gave birth in November, 2019 |
|
| I breastfed for less time for other varied reasons | “I'm a nurse and so it made work too busy for me to get to pump as often as I wanted. My milk dried up faster and I had to stop early.” – Parent who gave birth in May, 2020 |
In total, 287 (27%) respondents indicated that the pandemic caused them to breastfeed for a longer period of time than they might have otherwise. A substantial subset of parents (n = 166; 18%) stated that passing antibodies (from COVID-19 vaccination and/or after COVID-19 infection) to their infant specifically motivated them to breastfeed for longer. In addition, a group of parents (n = 84; 9%) responded that new remote work options and stay-at-home orders gave them more time at home that facilitated breastfeeding. Less than 40 respondents noted that fears of formula shortages or that having partner support in the home contributed to longer breastfeeding duration.
Eighteen percent of respondents (n = 165) indicated that the pandemic created challenges that made them stop breastfeeding earlier than they would have otherwise. Leading challenges included lack of professional or organized support (n = 123; 13%), insufficient support from friends and family (n = 8; 1%), stress resulting from the pandemic (n = 13; 1%), or other miscellaneous factors (e.g., additional work demands due to staff shortages; n = 21; 2%). Parents pointed out that in-person lactation consultants and in-person classes and support groups were the most difficult services to access.
Discussion
In this study, we found that parents who gave birth in the early pandemic received less professional breastfeeding support overall compared with parents who gave birth before the pandemic or later in the pandemic, and parents who gave birth in both pandemic periods were less likely to meet their breastfeeding goals. We did not find evidence that use of donor milk or in-hospital support changed over time. There appeared to be racial and ethnic disparities in the use of multiple types of professional breastfeeding support.
Open-ended responses on the impact of the pandemic on breastfeeding experiences indicated that although one-third of respondents felt that the pandemic facilitated breastfeeding, a sizable fraction (18%) felt the pandemic posed additional challenges that caused them to stop breastfeeding earlier than they would have otherwise because of the lack of professional and social support.
To date, there is limited literature on the impact of the pandemic on professional breastfeeding support services and on breastfeeding rates. A 2021 qualitative study reported reduced access to breastfeeding support among postpartum parents. Nonetheless, multiple parents reported that the pandemic facilitated breastfeeding owing to extended maternity leave and concerns about formula shortages.32 Our study provides quantitative evidence of the negative as well as positive impacts of the pandemic on breastfeeding.
Furthermore, our study shows that the largest disruptions to breastfeeding support were in the early months of the pandemic, with less disruption among parents who gave birth in summer 2021. Although more research is needed to explore this finding as well as how support is changing for additional birth cohorts as the pandemic evolves, it is possible that the widespread use of virtual support may have helped to ensure access to lactation support after the initial disruption.
An evaluation of breastfeeding consultations on a mobile application tracked utilization data from before and during the pandemic and found that queries per month increased by >10,000.56 Lactation professionals also shifted toward providing virtual support; a survey of lactation professionals in Connecticut found that ∼70% were using telehealth to provide lactation support in 2020.57
One of the two studies that we identified that compared birth cohorts from before and during the pandemic surveyed parents at a clinic where lactation support services were offered. The survey results found reduced breastfeeding satisfaction among parents who delivered during the pandemic,40 which may reflect the changing nature of interactions with support staff and transitions to virtual platforms. However, despite the decreased satisfaction, the authors found no differences in exclusive breastfeeding at 6 months between the two cohorts. The second study that compared birth cohorts, in contrast, did find a significant difference in breastfeeding rates at 6 months, with parents who gave birth during the pandemic experiencing lower levels of exclusive breastfeeding.39
Our findings that Black parents reported fewer interactions with lactation consultants and in-hospital breastfeeding help are consistent with the literature that has attributed lower breastfeeding rates among minority parents in part to lack of access to breastfeeding support and education.26,58 A 2012 study reported that Black parents were less likely to receive in-hospital support or telephone contacts for postdischarge support.59 Furthermore, a study of the Women Infants and Children (WIC) program showed that WIC sites with higher proportions of Black clients were less likely to offer clinic-based breastfeeding support services.60
Initial data on the impact of the COVID-19 pandemic have shown that racial and ethnic minorities have been disproportionately affected. It follows that the pandemic may be exacerbating longstanding inequities in access to breastfeeding support, and additional research is needed to describe disparities as well as identify and test strategies to mitigate them.
The study has several limitations. First our survey sample was not probability based and should be regarded as a large convenience sample. To address this, we presented adjusted rates so that demographic differences across birth cohorts were minimized, allowing us to better attribute changes in self-reported breastfeeding supports and experiences to the timing of giving birth. Second, recall bias may be an issue among the parents who gave birth in 2019. Third, the respondents were somewhat older, more educated, had higher income, and more likely to be insured than the population of parents who gave birth in the United States in 2019 as reported by the Centers for Disease Control and Prevention.
For example, although 42% of U.S. births were covered by Medicaid in 2019, 22% of respondents in our sample reported having Medicaid insurance.61 Our focus was on identifying changes across birth cohorts rather than on generating nationally representative estimates.
Conclusions
Although it is not yet clear whether the pandemic has impacted breastfeeding initiation or duration in the United States, evidence will be emerging in coming months. Given the importance of early and ongoing professional and lay breastfeeding support, it is key to understand not only how support has been impacted among different populations of parents but also whether the virtual services that replaced in-person services during the pandemic provided comparable quality and facilitated the same type of engagement. Our study showed that by the summer of 2021, parents reported somewhat similar levels of professional support in terms of frequency as before the pandemic; however, we do not know whether that support was of equivalent quality.
Furthermore, one key advantage of the pandemic for breastfeeding was more opportunities for some parents to work from home and/or extend their parental leave. Policies that enable this outside of a public health emergency (e.g., longer parental leave, telework options) could significantly improve breastfeeding rates and experiences.
Supplementary Material
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This project was funded by the National Institute of Nursing Research (R01NR018837).
Supplementary Material
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