International Journal of

Environmental Research
and Public Health

Article
Encouraging and Reinforcing Safe Breastfeeding Practices
during the COVID-19 Pandemic
Flora Ukoli 1, *, Jacinta Leavell 2 , Amasyah Mayo 3 , Jayla Moore 3 , Nia Nchami 3 and Allysceaeioun Britt 4

1 Department of Surgery, Meharry Medical College, Nashville, TN 37208, USA

2 Department of Dental Public Health, School of Dentistry, Meharry Medical College, Nashville, TN 37208, USA
3 Meharry Medical College, Nashville, TN 37208, USA
4 Division of Public Health Practice, School of Graduate Studies and Research, Meharry Medical College,
Nashville, TN 37208, USA
* Correspondence: [email protected]

Abstract: Aim: Promote safe breastfeeding during the pandemic. Methods: All participants were
encouraged to request safe breastfeeding education from their prenatal provider. Pregnant mothers
received appropriate breastfeeding and COVID-19 safe breastfeeding education in line with the CDC’s
COVID-19 breastfeeding guidelines. Data were obtained from 39 mothers attending Nashville General
Hospital pediatric well-baby clinics (Group I: from December 2019 to June 2020) and 97 pregnant
women attending prenatal clinics (Group II: from July 2020 to August 2021). Results: The participants’
ages ranged from 15 to 45 years, with a mean of 27.5 ± 6.2. The women in both groups were similar
in age, education, employment, and breastfeeding experience. They were equally unlikely to use
face masks at home even while receiving guests or holding their babies. Although 121 (89.0%)
women claimed face mask use while shopping, the rate for never doing so was 7 (18.0%) vs. 8
(8.3%) (p < 0.006) for Groups I and II, respectively. Safe practices included limited outing (66 (48.5%)),
sanitized hands (62 (45.6%)), restricted visitors (44 (32.4%)), and limited baby outing (27 (19.9%)), and
Citation: Ukoli, F.; Leavell, J.; Mayo,
8 (8.3%) in Group II received COVID-19 vaccinations. About half described fair and accurate COVID-
A.; Moore, J.; Nchami, N.; Britt, A.
Encouraging and Reinforcing Safe
19 safe breastfeeding knowledge, but 22 (30.1%) of them claimed they received no information.
Breastfeeding Practices during the Breastfeeding contraindication awareness for Groups I and II were as follows: cocaine = 53.8% vs.
COVID-19 Pandemic. Int. J. Environ. 37.1%, p < 0.06; HIV = 35.9% vs. 12.4%, p < 0.002; breast cancer = 17.9% vs. 16.5%; and COVID-19
Res. Public Health 2023, 20, 1756. with symptoms = 28.2% vs. 5.2%, p < 0.001. The information source was similar, with family, friends,
https://doi.org/10.3390/ and media accounting for 77 (56.6%) of women while doctors, nurses, and the CLC was the source for
ijerph20031756 21 (15.4%) women. Exclusive breastfeeding one month postpartum for Groups I and II was 41.9% and
Academic Editors: Elizabeth O. Ofili,
12.8% (p < 0.006), respectively. Conclusion: The mothers were not more knowledgeable regarding
Emma Fernandez-Repollet, Richard breastfeeding safely one year into the COVID-19 pandemic. Conflicting lay information can create
J. Noel, Jr., Daniel F. Sarpong, healthy behavior ambivalence, which can be prevented by health professionals confidently advising
Magda Shaheen, Paul B. Tchounwou mothers to wear face masks when breastfeeding, restricting visitors and outings, and accepting
and Richard Yanagihara COVID-19 vaccination. This pandemic remains an open opportunity to promote and encourage
breastfeeding to every mother as the default newborn feeding method.
Received: 26 October 2022
Revised: 29 December 2022
Accepted: 3 January 2023
Keywords: breastfeeding; COVID-19; African American; breastfeeding guidelines
Published: 18 January 2023

1. Introduction
Copyright: © 2023 by the authors. The COVID-19 virus outbreak first reported in Wuhan, China rapidly developed into
Licensee MDPI, Basel, Switzerland. a pandemic, with limited knowledge of its biology and transmission. The first COVID-19
This article is an open access article
case was reported on 2 January 2020, but the World Health Organization first reported
distributed under the terms and
pneumonia of an unknown origin on 31 December 2019. Pandemic control measures that
conditions of the Creative Commons
included high standards of personal hygiene, proper handwashing with soap or sanitizer,
Attribution (CC BY) license (https://
and very strict public health measures such as lockdowns, flight restrictions, and social
creativecommons.org/licenses/by/
distancing were disseminated around the globe [1–3]. The Centers for Disease Control and
4.0/).

Int. J. Environ. Res. Public Health 2023, 20, 1756. https://doi.org/10.3390/ijerph20031756 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023, 20, 1756 2 of 16

Prevention COVID-19 guidelines implemented by the National and State Department of

Health echoed these same measures, which included lockdowns and stay home directives for
all non-essential workers [4]. The very first control measure worldwide was the stay home
lockdown. Special guidelines were developed to protect healthy pregnant and breastfeeding
mothers, as well as women who were ill or contracted the virus [5]. Worldwide and national
agencies immediately recommended the usual public health guidelines to control the spread
of respiratory infectious disease, such as the use of face masks [6], mass immunization [7,8],
and regular testing [9]. Strategies for successful health prevention and promotion programs
may continue to evolve but cannot shift from the basic ecological model that involves actions
at the individual, interpersonal, organizational, community, and policy levels [10]. While
critics have accused proponents of lifestyle interventions of promoting a victim-blaming
ideology by neglecting the importance of social influences on health and disease, the need
to focus attention on both individual and societal factors cannot be overemphasized [11].
COVID-19 disparities exist, such as how African Americans, who are only 1.1 times at
risk of infection, are 2.4 times more likely to be hospitalized and 1.7 times more likely to
die of COVID-19 compared with white individuals. This risk is exceeded by the American
Indian and Hispanic populations [12]. In addition to ethnicity and race, pregnancy also
posed a higher risk of severe illness when contracting viruses such as COVID-19 [5]. In
utero mother-to-child transmission of this virus is unlikely, but newborns are susceptible
to person-to-person spread. Since the virus has not been detected in amniotic fluid or
breastmilk, and breastmilk protects newborns and infants against many illnesses, it is rec-
ommended that mothers who have COVID-19 continue breastfeeding. Therefore, mothers
with COVID-19 must wear a face mask and wash their hands before breastfeeding. Sick
mothers who express breastmilk to maintain a milk supply should also wash their hands
before touching any pump or bottle parts or consider a person without COVID-19 feeding
expressed breastmilk to the infant [5]. Mothers, particularly working mothers and minority
and low-income mothers who already face challenges with meeting their breastfeeding
goals, will require instructions and additional support from their health care providers to
meet both breastfeeding and COVID-19 protection goals [13].
COVID-19 case rates differ across workplace settings, directing attention to social
inequalities and concern for vulnerable workers. Elevated risk has been reported among
males, who dominate the construction, retail, and wholesale manual workforce in South
Asia [14], Latino and black workers in manual labor and in-service occupations among
Californian workers [15], the least skilled occupations, such as security guards, taxi drivers,
and restaurant chefs [16], and health care workers [17]. Health care workers have recorded
comparable low rates, probably because of rigorous implementation and enforcement of
infection control and occupational safety measures [14,17]. Social and workplace inequity
similarly impact breastfeeding rates as a result of variations in policies across industries,
with women in service-oriented industries such as accommodation, restaurants, and retail
reporting the least breastfeeding support [18], even as women in medicine [19] and public
health [20] continue to experience workplace barriers including time constraints, lack of
proper lounges that provide privacy and refrigeration for storing expressed milk, supervisor
support, and adequate maternity leave. One third of working women, irrespective of
socioeconomic status or race, succeed in combining exclusive breastfeeding (EBF) and
work, highlighting the need for flexible workplace support [13], paid maternity leave [21],
and extended break times, in addition to flexible work schedules [22]. Since the benefits of
breastfeeding and breastmilk include protection from viral and bacterial infections [23,24],
breastfeeding promotion should emphasize the additional benefit of COVID-19 protection
for infants. The immunoglobulin content and anti-inflammatory properties of maternal
antibodies necessary to ward off viral infections are present in breastmilk [25]. As more
mothers become less familiar with breastfeeding, it should be standard prenatal practice
to provide all mothers breastfeeding classes, irrespective of their proposed infant feeding
plan [22]. Mothers at risk of not breastfeeding, such as low-income and African American
mothers, will also require additional postnatal lactation and doula services to achieve
Int. J. Environ. Res. Public Health 2023, 20, 1756 3 of 16

adequate breastfeeding goals [26]. The breastfeeding promotion role of prenatal health
professionals is an important cornerstone for success [27–32].
Breastfeeding is acclaimed as the optimal infant feeding method that provides significant
mother and baby benefits. By the end of the 20th century, formula was entrenched as
equivalent if not superior to breastmilk, especially if returning to work [33,34]. Misconceptions
and negative attitudes [34,35] are counteracted by the Baby-Friendly Hospital Initiative
(BFHI)’s ‘Ten Steps to Successful Breastfeeding’ [36], which is now supported by maternal and
pediatric medical associations [35,37–39], the U.S. Preventive Services Task Force [40], and
the Centers for Disease Control and Prevention [41,42]. Breastmilk plays a vital role in the
development of the neonatal immune system and protection from infection by respiratory
viruses, including the SARS-CoV-2 virus [43]. Promoting breastfeeding during the pandemic
is therefore justified since the virus has not been detected in breastmilk, and there has been no
evidence of vertical transmission [44]. It is consistently agreed that breastfeeding should be
encouraged throughout the COVID-19 pandemic, and mother and infant dyads should be
cared for together, except in instances where the mother is too ill to breastfeed [45].
This COVID-19 breastfeeding guideline adherence intervention focused on the impact
of the individual level of health promotion on both breastfeeding and COVID-19 safety
behaviors while acknowledging the important role of organizational support. The goal of
this study was to increase the number of minority mothers who breastfeed adequately and
safely during the COVID-19 pandemic by including COVID-19 breastfeeding guideline
information in an ongoing breastfeeding promotion program. The PRECEDE-PROCEED
Planning Model provided a conceptual framework where health interventions begin with
socio-ecological assessments of the health issue in the target population [46,47]. Although
the focus is on the individual level of the socio-ecological model, the importance of the other
four interrelated levels of influence on health behaviors, namely interpersonal, community,
organizational, and public policy, are acknowledged [11,48,49]. This intervention will
support pregnant women by providing unbiased breastfeeding and COVID-19 safety
information and give them practical strategies for success.

2. Materials and Methods

The study targeted African American, low-income, and minority mothers and preg-
nant women who received prenatal care at the Nashville General Hospital and Mathew
Walker Comprehensive Health Center in Nashville, Tennessee. The intervention was devel-
oped using Community Engagement Research principles [50] in partnership with a well
constituted community advisory board (CAB), whose sessions were conducted virtually.
Institutional Review Board (IRB) approval was secured before implementing this inter-
vention, which emphasized the breastfeeding guidelines for COVID-19 cases, preexisting
chronic medical conditions, HIV, other infections, mental illness, and alcohol and drug
use disorders. An adequate informed consent process was administered by a lactation
counselor, and each participant signed IRB-approved consent forms before enrolment.
Phase 1: Health Behavior Assessment. This phase was limited to women attending the
well-baby clinic with an infant less than a year old being included in the survey. Mothers
of babies older than one year were excluded from participating. Thirty-nine women with
infants born after 1 January 2020 who signed IRB-approved informed consent were enrolled
at Meharry Medical Practice pediatric clinic to complete a short COVID-19 Breastfeeding
Guideline Assessment Survey. Standard demographics, pre-existing medical conditions,
and family size information were collected by a trained interviewer. COVID-19 stay-at-
home and individual COVID-19 safety behaviors were ascertained by using polar questions
with the yes or no answer format. COVID-19 status at enrollment was either positive,
negative, or unknown for those who had not tested. Participants indicated if they breastfed
at birth, 3 months, 6 months, and 12 months, providing the breastfeeding frequency and
duration, breastmilk expression frequency and duration, and the frequency and volume
of infant feeds with either expressed breastmilk or formula. They completed the survey
within 30–45 min by interview and received a USD 20 gift card in appreciation of their
Int. J. Environ. Res. Public Health 2023, 20, 1756 4 of 16

time. Responses by these mothers (Group I) at this phase indicated gaps in knowledge
and behavior lapses regarding COVID-19 breastfeeding safety that were then emphasized
in the information provided for pregnant women in Phase 3 of this project. The Group I
mothers were either pregnant or just had a baby at the onset of the COVID-19 pandemic.
Phase 2: Intervention Development. Unsupportive hospital practices and policies
translate into barriers for women at high risk of not breastfeeding [40], which can be
overcome by physicians emphasizing breastmilk superiority over formula. Irreversible
actions during the prenatal period, at delivery, and within days of delivery can potentially
compromise exclusive breastfeeding (EBF) and potentially complicate the efforts of pedia-
tricians who support and promote breastfeeding. In light of the urgency of the COVID-19
pandemic, a draft intervention plan was tabled before a well-constituted CAB for discus-
sion and advice, and their input was used to develop this COVID-19 safe breastfeeding
intervention Figure 1. The three components of the intervention were as follows:
(i) Participants received a six-panel breastfeeding brochure with a two-panel COVID-19
safe breastfeeding insert (Supplementary Materials).
(ii) Participants were advised to discuss breastfeeding during the pandemic with their
obstetrician and to request referral to a certified lactation counselor for breastfeeding
evaluation and training.
(iii) Participants were encouraged to call the program educator or PI for breastfeeding
support as needed.
Phase 3: Program Implementation Feasibility and Evaluation. Flyers were displayed in
waiting rooms and handed to pregnant women attending prenatal clinics at the Nashville
General Hospital and the Mathew Walker Comprehensive Health Center in Nashville,
Tennessee. Inclusion criteria included being African American, having a low income, or
being a minority while at least 18 years old and at least 5 months pregnant. Women in
the late second or third trimester who read and signed informed consent were enrolled
in the study (Group II). They understood that they would complete a pre-intervention
survey, attend follow-up visits at 1 month, 3 months, and 6 months postpartum, have the
weight and length information of their babies available at the follow-up, and that they
would receive a USD 20 gift card and other study gifts at each completed study visit. The
voluntary nature of participation was emphasized, and the participants knew they could
withdraw at any time without any penalty, did not have to plan to breastfeed, and that
there was no penalty for not breastfeeding or adhering to COVID-19 safety directives. They
understood that average or approximate estimates of breastfeeding frequency, duration,
and feed volumes were good enough, as accurate recall would be a challenge. Participants
were not required to take the COVID-19 test nor the COVID-19 vaccine to enroll in this
intervention. Group II mothers delivered at least one year into the pandemic.
Questionnaires:
(i) Group I: Mothers recruited from December 2019 to June 2020 (early pandemic period).
COVID-19 Breastfeeding Guideline Assessment Survey: Demography, medical his-
tory, and breastfeeding items from CDC Breastfeeding Survey [39] and BFHI Questionnaire
for Breastfeeding Mothers [51], COVID-19 safety guideline items, COVID-19 status, and
stay home history.
(ii) Group II: Pregnant Women recruited from July 2020 to August 2021 (later pandemic
period).
Pre-intervention survey: Demography, medical history, breastfeeding items from
CDC Breastfeeding Survey [39] and BFHI Questionnaire for Breastfeeding Mothers [49],
breastfeeding related interaction with their physician, CLC encounter, COVID-19 guideline
items, COVID-19 status, and stay home history.
Post-intervention survey: CLC referral and consultation, breastfeeding class atten-
dance, COVID-19 guideline items, breastfeeding items such as breastfeeding initiation at
birth, breastfeeding frequency and duration, breastmilk expression frequency and duration,
and formula or breastmilk feed frequency and volume.
 Int. J.J.Environ.
Int. Environ.Res.
Res.Public
PublicHealth
Health2022, 20,x1756
2023,19, FOR PEER REVIEW 5 5ofof17
16

Healthcare providers should respect maternal autonomy in the medical decision-making process. Breastfeeding
mothers should wear a face mask and practice hand hygiene.

Mother and infant can room in and practice skin-to-skin, especially immediately after birth and during
establishment of breastfeeding, whether they or their infants have suspected or confirmed COVID-19 cases.

Mothers with suspected or confirmed COVID-19 cases should be encouraged to initiate or continue breastfeeding.
They should be advised that the benefits of breastfeeding substantially outweigh the potential risks of
transmission.

People without suspected or confirmed COVID-19 cases and who have not been in close contact with someone
who had COVID-19 or who received the COVID-19 vaccine do not need to take special precautions when
breastfeeding or expressing milk.

A breastfeeding person who is not fully vaccinated against COVID-19 should wear a mask, practice hand hygiene,
and take additional precautions such as social distancing, avoiding crowds, and restricting visitors to their homes
to protect themselves and the child.

Mothers with suspected or confirmed COVID-19 cases should not be considered as posing a potential risk of
transmission to their neonates once they meet the criteria to discontinue isolation:
o At least 10 days since their symptoms first appeared (up to 20 days if they have a more severe-to-critical
illness or are severely immunocompromised).
o At least 24 hours since their last fever without the use of antipyretics and their other symptoms have
improved.

Plastic infant face shields are not recommended, and masks should not be placed on neonates or children younger
than 2 years of age. Neonates can be placed in an incubator when feasible.

Separation of mother and infant may be necessary for the following:

o Mothers who are too ill to care for their infants or who need higher levels of care.
o Neonates at higher risk of severe illness (e.g., preterm infants, infants with underlying medical
conditions, and infants needing higher levels of care).

Separation in order to reduce the risk of transmission from a mother with suspected or confirmed COVID-19
presence to her neonate may not be necessary if the neonate tests positive for COVID-19.

Source:
CDC https://www.cdc.gov/coronavirus/2019-ncov/hcp/care-for-breastfeeding-women.html#BreastfedChild
CDC https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.html
WHO https://www.who.int/news-room/commentaries/detail/breastfeeding-and-covid-19
Figure 1. Summary of CDC and WHO SARS-CoV-2 (COVID-19) breastfeeding
Figure 1. Summary of CDC and WHO SARS-CoV-2 (COVID-19) breastfeeding recommendations.
recommendations.
Int. J. Environ. Res. Public Health 2023, 20, 1756 6 of 16

Data Analysis:
The primary study outcomes were COVID-19 breastfeeding guideline adherence
and EBF rates at 1 month, 3 months, and 6 months. Descriptive demographic statistics
were tabulated by enrollment period, comparing mothers in the early COVID-19 pandemic
period (Group I) to mothers at least one year into the COVID-19 pandemic period (Group II).
Comparative statistical tests between mothers in Groups I and II and across demographic
subgroups were two-sided using a 5% significance level and performed using the two-group
T-test for continuous variables or the Chi-square test or Fisher’s exact test for discrete data
as appropriate. The SPSS software (version 26) was used to conduct all statistical analyses.

3. Results
The age range for 136 enrolled mothers was 15–45 years, with a mean of
27.5 ± 6.2 years, and mean ages of 39 in Group I and 97 in Group II of 29.5 ± 7.1 years versus
26.7 ± 5.7 years, respectively (p < 0.02). Group I mothers were more likely to be married
(13 (33.3%) versus 17 (17.5%), p < 0.04) and unemployed (16 (41.0%) versus 24 (24.7%),
p < 0.04). Among working mothers, 11% planned to return to work by 4 weeks postpartum,
76% planned to return in between 4 and 12 weeks, and 13% planned to return by at least
13 weeks postpartum. About half of the study population had no more than a high school
education, and just over two thirds were on government nutrition assistance, namely the
Supplemental Nutrition Assistance Program (SNAP) or Special Supplemental Nutrition
Program for Women, Infants, and Children (WIC). (Table 1). The mothers worked in offices
or schools, (23.5%), stores, warehouse, or factories, (23.5%), hospital or medical facilities,
(16.3%), at home (15.3%), restaurants or fast food, (12.2%), and emissions. (9.2%). Over-
all, 57 (58.2%) working mothers claimed to have privacy to express breastmilk at work
(10 (41.7%) versus 47 (64.4%), p < 0.05 for Groups I and II, respectively). Living with at
least one preexisting condition such as hypertension, diabetes, or asthma was reported by
30 (22.1%) mothers, and 14 (10.3%) admitted marijuana use.

Table 1. Demographic characteristics of participating mothers during the early and later COVID-19
pandemic periods.

Study Population Total

Characteristics Group I § Group II §§
No. %
Early Pandemic Later Pandemic
Age in years *
<21 4 (10.3) 14 (14.4) 18 13.2
21–34 25 (64.1) 74 (76.3) 99 72.8
>34 10 (25.6) 9 (9.3) 19 14.0
Education
High School 21 (53.9) 52 (53.6) 73 53.7
Some College 5 (12.8) 22 (22.7) 27 19.8
College Degree 13 (33.3) 23 (23.7) 36 26.5
Marital Status *
Single 26 (66.7) 80 (82.5) 106 77.9
Married 13 (33.3) 17 (17.5) 30 22.1
Employment
Unemployed 14 (35.9) 24 (24.7) 38 27.9
Part-Time 5 (12.8) 29 (29.9) 34 25.0
Full-Time 20 (51.3) 44 (45.4) 64 47.1
Income **
<USD 25,000 16 (41.0) 33 (34.0) 49 36.0
USD 25,000–49,999 14 (35.9) 19 (19.6) 33 24.3
>USD 50,000 8 (20.5) 13 (13.4) 21 15.4
Not Stated 1 (2.6) 32 (33.0) 33 24.3
Int. J. Environ. Res. Public Health 2023, 20, 1756 7 of 16

Table 1. Cont.

Study Population Total

Characteristics Group I § Group II §§
No. %
Early Pandemic Later Pandemic
Nutrition assistance *
WIC # and SNAP ## 19 (48.7) 26 (26.8) 45 33.1
WIC or SNAP 12 (30.8) 37 (38.1) 49 36.0
None 8 (20.5) 24 (35.1) 42 30.5
Work Return Plan
<4 Weeks 4 (10.3) 7 (7.2) 11 8.1
4–7 Weeks 8 (20.5) 27 (27.8) 35 25.7
8–12 Weeks 9 (23.1) 32 (33.0) 41 30.1
≥13 Weeks 5 (12.8) 8 (8.2) 13 9.6
Not Working 13 (33.3) 23 (23.7) 36 26.5
Daycare Use Plan ***
Yes 4 (10.3) 29 (29.9) 33 24.3
No 35 (89.7) 44 (45.4) 79 58.1
Undecided 0 (0.00) 24 (24.7) 24 17.6
§ Group I: Meharry Well-Baby Clinic, early pandemic period (from December 2019 to June 2020). §§ Group II:
Meharry Prenatal Clinic, later pandemic period (from July 2020 to August 2021). # WIC: Special Supplemental
Nutrition Program for Women, Infants, and Children. ## SNAP: Supplemental Nutrition Assistance Program.
* p < 0.05. ** p < 0.01. *** p < 0.001.

Regarding reported breastfeeding experience, 49 (36.0%) witnessed their mother, sister,

or aunt breastfeeding, and 48(35.3%) witnessed a friend, while 43 (31.6%) never saw anyone
breastfeeding. Of the 104 mothers with a previous baby, 33 (31.7%) breastfed for less than
a month, 30 (28.8%) for 1–5 months, and 21 (20.2%) for 6 months or longer. Meanwhile,
69 (50.7%) had not decided on a breastfeeding plan, 30 (22.1%) planned to breastfeed for
3–6 months, and 37 (27.2%) planned to do so for 6 months or longer. Formula use at birth
and any time before 6 months was the plan for 106 (78.0%) mothers, 11 (8.1%) planned to
introduce formula at 6 months, and 19 (14.0%) planned to not use any formula. Referral
to the WIC program was reported by 48 (65.8%) mothers, 34 (46.6%) were referred to a
CLC, and 22 (30.1%) received information about breastfeeding safely during the COVID-19
pandemic. In addition, 78 (57.4%) described fair and accurate COVID-19 breastfeeding
safety tips, 21 (15.4%) cited health providers as their information source, and 22 (30.1%)
claimed they did not receive COVID-19 safe breastfeeding information (Table 2).
Overall, 121 (89.0%) mothers reported face mask use while shopping, and the rate for
never doing so for Groups I and II was 7 (18.0%) versus 8 (8.3) (p < 0.006), respectively.
Face mask use at home was reported to be unlikely by 114 (83.8%) mothers, but they
would do so while receiving guests (14 (10.3%)) and while holding their babies (4 (2.9%)).
COVID-19 safety practices included limited mother outing (66 (48.5%)), sanitizing hands
regularly (62 (45.6%)), restricted visitors to the house (44 (32.4%)), and limited baby outings
(27 (19.9%)), and 8 (8.2%) Group II mothers received COVID-19 vaccinations. COVID-19
testing was not performed by 71 (52.2%) mothers, while 56 (41.2%) tested negative and 8
(5.8%) were positive (Table 3).
Awareness of health and drug breastfeeding contraindications among the mothers
in Groups I and II were 24 (61.5%) vs. 33 (34.0%) (p < 0.001) and 28 (71.8%) vs. 53 (54.6%)
(p < 0.01), respectively. Knowledge for the mothers about specific contraindications were
as follows for cocaine (53.8% vs. 37.1%, p < 0.06), HIV (35.9% vs. 12.4%, p < 0.002), breast
cancer (17.9% vs. 16.5%), and COVID-19 with symptoms (28.2% vs. 5.2%, p < 0.001). The
Group I and II mothers who had some or the correct idea about the definition of exclusive
breastfeeding totaled 29 (74.4%) versus 35 (36.1%) (p < 0.001), respectively (Table 4).
Int. J. Environ. Res. Public Health 2023, 20, 1756 8 of 16

Table 2. Preparation for safe breastfeeding among participating mothers during the early and later
COVID-19 pandemic periods.

Study Population Total

Characteristics Group I Group II
No. %
Early Pandemic Later Pandemic
Privacy at work to breastfeed
Among working mothers * 10 (41.7) 47 (64.4) 57 58.2
Breastfeeding experience
Was breastfed 13 (33.3) 28 (28.9) 41 30.1
Witnessed mother 9 (23.1) 17 (17.5) 26 19.1
Witnessed mother or relatives 12 (30.8) 37 (38.1) 49 36.0
Witnessed friend 16 (41.0) 32 (33.0) 48 35.3
Witnessed anybody 24 (61.5) 69 (71.1) 93 68.4
Breastfed previous baby
<1 month 9 (23.1) 24 (24.7) 33 24.3
1–5 months 9 (23.1) 21 (21.6) 30 22.1
≥6 months 9 (23.1) 12 (12.4) 21 15.4
No previous baby 12 (30.8) 40 (41.2) 52 38.2
Referral
WIC 26 (74.3) 22 (57.9) 48 65.8
CLC 19 (54.3) 15 (39.5) 34 46.6
COVID-19 breastfeeding 12 (34.3) 10 (26.3) 22 30.1
Breastfeeding goal
None or undecided 19 (48.7) 50 (51.5) 69 50.7
3–5 months 9 (23.1) 21 (21.7) 30 22.1
≥6 months 11 (28.2) 26 (26.8) 37 27.2
Formula plan
At birth or undecided 19 (48.7) 65 (67.0) 84 61.8
Before 6 months 10 (25.7) 12 (12.3) 22 16.2
≥6 months 5 (12.8) 6 (6.2) 11 8.1
No formula 5 (12.8) 14 (14.4) 19 14.0
# COVID-19 BF knowledge.
Fair or correct 19 (48.7) 59 (60.8) 78 57.4
Incorrect or do not know 20 (51.3) 38 (39.2) 58 42.6
Information source **
Media, self, friend, or family 20 (51.3 57 (58.8) 77 56.6
Doctor, nurse, or CLC 4 (10.3) 17 (17.5) 21 15.4
Not recorded 15 (38.5) 23 (23.7) 38 27.9
# COVID-19 breastfeeding safety guideline knowledge. * p < 0.05. ** p < 0.001.

Table 3. COVID-19 breastfeeding safety guideline adherence pattern among mothers during the early
and later COVID-19 pandemic periods.

Study Population Total

Characteristics Group I Group II
No. %
Early Pandemic Later Pandemic
Facemask at home
Never 29 (74.4) 85 (87.6) 114 83.8
Guests visiting 6 (15.4) 8 (8.2) 14 10.3
Holding baby 3 (7.7) 1 (1.0) 4 2.9
Almost always 1 (2.6) 3 (3.1) 4 2.9
Face mask shopping **
Never or sometimes 7 (18.0) 8 (8.3) 15 11.0
Most always 32 (82.1) 89 (91.7) 121 89.0
Int. J. Environ. Res. Public Health 2023, 20, 1756 9 of 16

Table 3. Cont.

Study Population Total

Characteristics Group I Group II
No. %
Early Pandemic Later Pandemic
COVID-19 safety action
Mother outings limited 17 (43.6) 49 (50.5) 66 48.5
Hands washed or sanitized 17 (43.6) 45 (46.4) 62 45.6
Visitors restricted 11 (28.2) 33 (34.0) 44 32.4
Baby outings avoided 6 (15.4) 21 (21.6) 27 19.9
Vaccinated 0 (0.0) 8 (8.2) 8 5.9
COVID-19 testing
Not testing 14 (35.9) 57 (58.8) 71 52.2
Negative test 21 (53.8) 36 (37.1) 57 41.2
Positive with no symptoms 0 (0.0) 1 (1.0) 1 0.7
Positive with symptoms 4 (13.0) 3 (3.1) 7 5.1
** p < 0.01.

Table 4. Breastfeeding contraindication awareness among participating mothers.

Study Population Total

Breastfeeding
Knowledge Topic Group I Group II
No. %
2019–2020 2020–2021
Health contraindications ***
Yes 24 (61.5) 33 (34.0) 57 41.5
No 15 (38.5) 28 (28.9) 43 31.6
Do not know 0 (0.0) 36 (37.1) 36 26.5
Drug contraindications **
Yes 28 (71.8) 53 (54.6) 81 59.6
No 11 (28.2) 26 (26.8) 37 27.2
Do not know 0 (0.0) 18 (18.6) 18 13.2
Specific health contraindication
HIV ** 14 (35.9) 12 (12.4) 26 19.1
Breast cancer 7 (17.9) 16 (16.5) 23 16.9
COVID-19 with symptoms *** 11 (28.2) 5 (5.2) 16 11.8
COVID-19 with no symptoms ** 6 (15.4) 3 (3.1) 9 6.6
Mental illness (severe) ** 6 (15.4) 2 (2.1) 8 5.9
Specific drug contraindication
Cocaine * 21 (53.8) 36 (37.1) 57 41.9
Heroin 17 (43.6) 33 (34.0) 50 36.8
Marijuana 11 (28.2) 23 (23.7) 34 25.0
Opioid or oxycodone * 13 (33.3) 16 (16.5) 29 21.3
Chemotherapy *** 9 (23.1) 3 (3.1) 12 8.8
Exclusive Breastfeeding ***
Some or correct idea 29 (74.4) 35 (36.1) 64 47.0
Wrong idea or do not know 10 (25.6) 62 (63.9) 72 52.9
* p < 0.05. ** p < 0.01. *** p < 0.001.

Exclusive breastfeeding one month postpartum for Groups I and II was reported by
41.9% and 12.8% (p < 0.006) of mothers, while the results were 33.3% and 4.5% (p < 0.007)
for 3 months and 20.0% and 0% for 6 months, respectively. Providing the baby breastmilk
one month postpartum for Groups I and II was reported by 67.7% and 56.4% (p < 0.03) of
mothers, while the results were 55.6% and 31.8% (p < 0.02) for 3 months and 46.7% and
33.3% for 6 months (Table 5).
Int. J. Environ. Res. Public Health 2023, 20, 1756 10 of 16

Table 5. Comparing breastfeeding rates among mothers in the early (2019–2020) and later (2020–2021)
COVID-19 pandemic periods.

Group I Group II Totals §

Breastfeeding Patterns
Early Pandemic Later Pandemic No. %
1 month postpartum n = 31 n = 39 n = 70
Breastmilk provided * 21 (67.7) 22 (56.4) 43 61.4
Exclusive breastfeeding ** 13 (41.9) 5 (12.8) 18 25.7
Nursing at the breast * 19 (61.3) 15 (38.5) 34 48.6
3 months postpartum n = 27 n = 22 n = 49
Breastmilk provided * 15 (55.6) 7 (31.8) 22 44.9
Exclusive breastfeeding ** 9 (33.3) 1 (4.5) 10 20.4
Nursing at the breast 13 (48.1) 5 (22.7) 18 36.7
6 Months postpartum n = 15 n = 12 n = 27
Breastmilk provided 7 (46.7) 4 (33.3) 11 40.7
Exclusive breastfeeding 3 (20.0) 0 (0.0) 3 11.1
Nursing at the breast 6 (40.0) 4 (33.3) 10 37.0
* p < 0.05. ** p < 0.01. § Totals based on follow-up completed by December 2021.

4. Discussion
Although COVID-19 is an acute infectious disease, and cancer is primarily a chronic
condition, both benefit from multilevel public health strategies directed at the patient,
provider, community, and healthcare policy, thus sharing a common set of barriers to
care impacted by social determinants of health. Lessons learned from decades of cancer
prevention and control, such as the impact of rapid integration of research evidence into
practice, is a proven strategy that can similarly improve COVID-19 response [52]. In the
same way that racial and ethnic disparities in cancer survival are largely attributable to
poverty, delayed screening, differences in provider care recommendations, and lack of
access to the latest treatments [53], emerging evidence indicates the same for COVID-19
deaths due to preventable underlying causes [54]. As effective strategies to treat and
manage COVID-19 accumulate, the potential for disparities will increase, as access to
these healthcare advances are unlikely to be equally distributed [53]. This study indicates
similarly low COVID-19 breastfeeding safety knowledge and practices among mothers
enrolled at the onset of the COVID-19 pandemic and those enrolled one year into the
pandemic. One reason for this may be related to the absence of breastfeeding training
for pregnant mothers. Most mothers in this study reported that they did not receive
breastfeeding training, and only very few were referred to a CLC. It is not unlikely that
mothers who declared a desire to formula feed were not referred for such counseling. Most
women in this study population did not witness their mothers breastfeed, and only 36%
witnessed any family member doing so. The lack of breastfeeding role models within
the family might contribute to low breastfeeding rates in populations at increased risk of
not breastfeeding. To overcome such a societal bias, the WHO and the CDC have since
recommended that all mothers receive breastfeeding education (Step 3 of the ‘Ten Steps
to Successful Breastfeeding’) instead of providing such education only to the few women
who request it. If mothers were not receiving breastfeeding training routinely, it was
unlikely that they would have received COVID-19 safe breastfeeding directives. In this
study, 70% did not receive any COVID-19 safe breastfeeding directives, and most of those
who reported knowledge in this area received that information from the media, friends,
and family members. Only 15% received such directives from a doctor, nurse, or CLC.
There was no difference in the pattern of information sources between mothers seen at
the onset and one year into the pandemic. More worrisome is the overall drop in general
breastfeeding knowledge and practice among Group II mothers compared with Group I,
suggesting a possible oversight in maintaining routine breastfeeding protection, promotion,
and support care during the pandemic.
Int. J. Environ. Res. Public Health 2023, 20, 1756 11 of 16

Mothers and their families need to be well informed about breastfeeding during
COVID-19 [43,44,55]. Breastfeeding should be encouraged for all mothers, and even
mothers who are too ill to breastfeed should be encouraged to express their milk [45]. They
will, however, need to be supported to maintain appropriate respiratory hygiene [56] and
adequate infection control measures [57]. COVID-19 safe breastfeeding knowledge and
behavior in this population was similarly low across education, economic, and marital
sociodemographic groups. That multiparous mothers also recorded low knowledge and
safe breastfeeding practices compared with the mothers having their first babies is an
indication that they did not receive necessary breastfeeding promotion support in their
previous pregnancies. Adequate breastmilk initiation and flow sustenance stand firm
on the concept of constant mammary gland stimulation resulting from ‘rooming in’ and
‘feeding on demand’. Mothers who were probably unaware of such concepts did not
know to capitalize on the COVID-19 lockdown opportunity and maximize the opportunity
to achieve their full lactation potential. Just over half of these mothers were at home,
either because of the COVID-19 directive or because they were initially unemployed. Only
one third of those who had planned to breastfeed claimed they were able to breastfeed
more by being at home, while staying at home did not make any difference to those
who had not planned to breastfeed. They did not seize the opportunity to breastfeed,
probably because they were not aware that staying home was an advantage for their babies.
This finding reflects the results from other studies, where minority and low-education
mothers struggled to receive breastfeeding support while others were able to exploit the
breastfeeding opportunity of the lockdown [58]. Safe breastfeeding action was also very
low both in the early and later pandemic periods, with up to 80% taking their babies
to public places. Most mothers did use a face mask while shopping but did not protect
their babies by restricting visitors to the house nor wear a face mask while holding their
babies. It would appear that they were not aware of the COVID-19 safe breastfeeding
recommendations to protect their babies [59].
A Phase III randomized, multicenter, endpoint-driven, double-blind, placebo-controlled
clinical trial conducted among healthy adults clearly demonstrated the efficacy and safety
of the adsorbed inactivated COVID-19 vaccine [60]. The professional board of obstetrics and
gynecology published a position statement to offer vaccination to pregnant women [61]
and requested that medical professionals not allow breastfeeding mothers to face the
decision to breastfeed or vaccinate alone [62]. Research has also demonstrated the effec-
tiveness and safety of COVID-19 vaccination among breastfeeding mothers, with only
minimal disruption of lactation or adverse effects on the breastfed child [63], providing
anti-SARS-CoV-2-specific IgA and IgM antibodies that pass into the breastmilk and protect
the breastfed baby [64,65]. It is important for anyone handling a baby, including mothers, to
be vaccinated and masked [65]. Although all participants in this study were informed about
the importance of COVID-19 testing and vaccine safety in pregnant and lactating mothers,
and they received individual encouragement by the program educator to get tested and
vaccinated, only 8% of the mothers in the later pandemic period received vaccinations
when they became available, and just about half of the study participants were tested for
COVID-19. Vaccine uptake in this population was much lower than the 44.4% uptake
for pregnant women reported in another study. They observed a lower uptake compared
with those for non-pregnant women (76%) and breastfeeding mothers (55%), which was
attributed to the additional stress of being pregnant and the misplaced fear of the effect of
the vaccine on the fetus [66]. Inadequate professional breastfeeding support in populations
at a high risk of not breastfeeding is expected. Many of the women in the study’s target
population were working mothers on low wages, including essential workers, and they
reported a lack of workplace support such as breastfeeding lounges or extended break
periods. They denied receiving information about how to breastfeed safely during the
pandemic and did not notice provisions or directives to get vaccinated while pregnant or
lactating at their doctor’s offices or their workplaces.
Int. J. Environ. Res. Public Health 2023, 20, 1756 12 of 16

There is a need for adequate coordination across the mother and baby care continuum.
The team of physicians, nurses, and midwives should engage mothers in breastfeeding
conversations early in pregnancy, actively encourage and refer them to CLCs for breastfeed-
ing evaluation and training, and not leave mothers to make decisions about infant feeding
based on the misconception of breastmilk and formula equivalence [67]. Pediatricians will
readily prescribe appropriate formula for rare but real instances as required [68]. Physicians
who provide prenatal care are, however, in the best position to recognize potential breast-
feeding challenges, provide personalized guidance for individual circumstances [69,70],
and address emerging health threats by emphasizing COVID-19-specific breastfeeding
guidelines at this current time [5]. CLCs are trained to provide in-depth breastfeeding
education and training and have the time to meet the added breastfeeding needs of the over
50% of mothers in the United States whose babies are inadvertently offered formula and
pacifiers at birth [71]. Allowing babies to latch onto the bottle at birth is a known reason for
babies experiencing challenges or distress latching to their mother’s nipple, a condition
sometimes referred to as ‘nipple confusion’ [72,73]. Delivery room nurses and physicians
are in the position to ensure breastfeeding initiation at birth (Step 4: ‘Ten Steps to Successful
Breastfeeding’), as the skin-to-skin action by itself is insufficient breastfeeding care for
the newborn. While obtaining an International Board-Certificated Lactation Consultant
(IBCLC) designation is not required to provide basic delivery room breastfeeding care to
mothers, prenatal and neonatal care providers do need the skills to effectively advocate
for patients, especially for uneducated [74] and adolescent mothers [75]. They also need
to monitor and ensure that their patients receive adequate breastfeeding support both at
birth and postpartum [76–78]. In this study, the mothers did not report postpartum breast-
feeding follow-ups. Physicians may be less inclined to conduct postpartum breastfeeding
follow-ups since a majority of mothers elect to bottle feed with formula.

5. Conclusions
The mothers in this study recorded low breastfeeding rates with little adherence
to COVID-19 safe breastfeeding practices one year into the pandemic. The pandemic
remains an open opportunity to intensify breastfeeding programs, encourage every mother
to breastfeed, and for hospitals and maternities to adopt breastfeeding as the default
newborn feeding method. Physicians, nurses, and midwives should refer all pregnant
women to CLCs for breastfeeding evaluation and training and invite the IBCLC when
medically indicated. Conflicting lay information that creates ambivalence can be prevented
by urgently implementing policy revisions within existing breastfeeding guidelines to
address emergent threats such as the COVID-19 pandemic. Health professionals should
confidently advice mothers to frequently sanitize their hands, wear face masks when
breastfeeding, limit outings, restrict visitors, and take COVID-19 tests and vaccines.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/ijerph20031756/s1, Breastfeeding Safely During COVID-19 Pan-
demic; Breastfeeding Tips; Recruitment Flyer—No Cost Safe Breastfeeding Advise; Recruitment Card:
Breastfeed Safely—Inviting Women in the 3rd Trimester.
Author Contributions: Conceptualization, F.U. and J.L.; methodology, F.U.; validation, F.U., J.L. and
A.B.; formal analysis, F.U.; investigation, F.U., N.N., J.M., A.M.; resources, F.U.; data curation, J.M.,
F.U.; writing—original draft preparation, F.U.; writing—review and editing, J.L.; supervision, F.U.;
project administration, F.U.; funding acquisition, F.U., J.L., A.B. All authors have read and agreed to
the published version of the manuscript.
Funding: Funding was provided by RCMI Administrative Supplement Grant #3U54MD007586-34S4.
PI: Adunyah S. and Hildreth J.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki, and approved by the Institutional Review Board of Meharry Medical College. (Protocol
Number 20-09-1033 and 10/13/2020 date of approval).
Int. J. Environ. Res. Public Health 2023, 20, 1756 13 of 16

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author. The data are not publicly available at this time as this is an ongoing project.
Acknowledgments: The authors thank the physicians and staff of Nashville General Hospital Pedi-
atric and Prenatal Clinics and the Mathew Walker Comprehensive Health Center Prenatal Clinic,
especially Elosha Johnson and Junie Saint Clair. Appreciation is extended to all the patients in these
clinics who listened to our breastfeeding promotion messages, with special thanks to the patients who
volunteered as study participants for their commitment as they struggled to cope with motherhood
during the COVID-19 pandemic.
Conflicts of Interest: There are no conflicts of interest to declare for any of the authors.

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