The study results show that the infection control measures introduced at postnatal facilities are likely to have had a negative effect on first-time mothers’ perception of breastfeeding assistance received during their stay in the postnatal facility. Women who had their partner present were more satisfied with the assistance they received.
Breastfeeding guidance was found to be wanting when compared to expectations of a Mother-Baby Friendly facility. There was greater reliance on breast-milk substitutes, and fewer women were exclusively breastfeeding after two weeks compared to the results of earlier surveys.
The pandemic changed the working day
There were differences between counties with respect to the amount of help the women felt they had received. This may have been because it was left up to the individual care facility to draw up local procedures for how to enforce the recommended measures for infection control (16).
Also, there may well be differences in culture between units. One study found that the mothers’ sense of support increased when the midwife had a positive attitude to breastfeeding (21). The redistribution of resources that took place during the pandemic may have adversely affected the midwives’ attention and attitude to aspects of care such as breastfeeding.
The coronavirus pandemic has changed the working day at postnatal facilities in that staff spend time and resources on infection control measures. An increased workload and associated frustrations can have left less time available for staff to provide breastfeeding assistance, which is often a time-consuming task. Women are likely to have noticed this capacity reduction, as reflected in news stories and feature articles published in the daily press (22, 23).
Women who spent less than 48 hours in the postnatal facility, felt that they received less help.
Among the women who had their partner present, a larger proportion felt supported while in the postnatal facility. This may be because the women included the support received from their partners when answering the question.
If the healthcare personnel had less time available to spend with the women during the coronavirus pandemic, and their partner was not present, this is likely to have affected the women’s experience of support and assistance received.
Women who spent less than 48 hours in the postnatal facility, felt that they received less help. This is unfortunate, because women who go home early need significant guidance to be able to handle the challenges of breastfeeding on their own (9). When their time in the facility is reduced, the breastfeeding assistance provided should be adjusted accordingly.
Insufficient information and guidance
It is surprising that the women received little information and guidance. The guidance points are tools intended to make sure that women receive appropriate information while in a postnatal facility (11).
Most such facilities in Norway are accredited as Mother-Baby Friendly because they have been found to provide information about most of the guidance points to at least 80 per cent of women. We must therefore assume that the figures revealed in this study are significantly lower than normal (11).
The partner’s presence affected only one item of guidance. Length of stay in the facility had a greater impact. For instance, a lower proportion of the women who returned home early received information about milk pains.
Because milk pains normally occur two to four days after delivery (18), it is worrying that so few had received such information when discharged after two days and left to manage on their own.
Nor had sufficient guidance in accordance with the Mother-Baby Friendly standard been provided to women who stayed for longer than recommended in the facility during the coronavirus pandemic, so we can assume that a greater workload and changes to resource allocations will have played a part.
More extensive use of breast-milk substitutes
We found that approximately half the study sample had given their babies a breast-milk substitute while in the postnatal facility. This is a significant increase compared to the infant feeding surveys of 2013 and 2020 (24, 25).
In these surveys, 25 and 29 per cent respectively answered that they had given their baby a breast-milk substitute in the first week of life (24, 25). According to ‘Ten Steps to Successful Breastfeeding’, breast-milk substitutes should never be given unless medically indicated.
In our study, only 53.1 per cent of infants were exclusively breastfed.
In order to be accredited as a Mother-Baby Friendly facility, the hospital must be able to report exclusive breastfeeding while in the facility for at least 80 per cent of full-term babies (12). In our study, only 53.1 per cent of infants were exclusively breastfed, which demonstrates that the Mother-Baby Friendly standard was not achieved for these women during the pandemic.
Our results do not tell us if there was a medical reason for the increased reliance on breast-milk substitutes, but the volume involved suggests that in general, there was no such indication. This is supported by the fact that in our study, the use of breast-milk substitutes was just as high at birth centres as in maternity units and clinics.
Only healthy mothers and infants are routed to birth centres, so no medical indication for a breast-milk substitute would therefore be expected (26). It may be the case that breast-milk substitutes were given because the postnatal facilities were busy during the pandemic. ‘Ten Steps to Successful Breastfeeding’ specifies that a lack of resources is not a sufficiently good reason to give a breast-milk substitute (12).
Breastfeeding status two weeks after delivery
National infant feeding surveys undertaken in 2013 and 2020 show that the proportion of women who exclusively breastfed their babies after two weeks, was 84 and 85 per cent respectively (24, 25). By comparison, the exclusive breastfeeding proportion in our study was considerably lower (71.6 per cent).
Unlike our sample, the women who responded to the infant feeding surveys included both primiparous and multiparous women. This may have been one reason for the difference.
A woman’s partner plays an important part in establishing the breastfeeding (7, 27). Nevertheless, our study found no significant difference between the women whose partners were present and those whose partners were not present with respect to breastfeeding status at two weeks postpartum. Only a small group of women were allowed to have their partner present (19.9 per cent).
We can assume that the partners who were allowed to be present, had their freedom of activity restricted due to infection control measures.
We can assume that the partners who were allowed to be present, had their freedom of activity restricted due to infection control measures. This may have affected their opportunity to provide respite and make things easier, which is an important part of the partners’ support function. This may have affected the impact of their presence (7).
It was a surprising finding that women who spent a short time in the facility were more likely to exclusively breastfeed, despite the fact that they reported having received less guidance than the women who spent longer in the facility. This may be associated with the fact that there was a greater reliance on breast-milk substitutes among those who stayed for longer. This factor is known to influence exclusive breastfeeding (28).
We must take account of the fact that those who stayed for longer, may have had medical issues that gave rise to breastfeeding challenges.
Strengths and weaknesses of the study
The fact that the study used a convenience sample can have affected the transferability of its findings. This data collection method means that we cannot tell how many women could have taken part, and who opted not to respond. The high number of respondents is a strength.
In Norway, approximately 3800 (29) first-time mothers give birth in any two-month period, so our response rate is around 23 per cent. The respondents are similar to the general birthing population in terms of measured background variables.
Among the women in our study, 79.5 per cent were between 25 and 35 years of age. The average age of first-time mothers in Norway in 2019 was 29.7 years (29). The proportion of women who delivered by caesarean section (15.8 per cent), is similar to the caesarean section prevalence in the Norwegian birthing population (15.9 per cent) (29).
Recruitment took place via social media.
Recruitment took place via social media. Despite the fact that the majority of the population makes use of such media, we must assume that we failed to reach parts of the population. Additionally, the various Facebook groups that we chose to use as vehicles of recruitment, may have affected the sample and can potentially have produced a biased sample.
In an effort to counteract any such bias, we asked a number of different groups to share the questionnaire, which they did. Studies show that recruitment via Facebook can provide representative samples that match traditional data collection methods (30).
Any cross-sectional study runs the risk of potential memory bias (19). However, this study was conducted soon after the events we were asking about and the risk that respondents may have failed to remember will therefore be small.
It is a weakness of the study that the questionnaire that we used had not been validated. We therefore spent considerable time on formulating the questionnaire, taking heed of input from the Norwegian National Advisory Unit on Breastfeeding and conducting a pilot test.
We chose descriptive statistics and bivariate analyses, which in our opinion are appropriate choices that suit the objective of the study. Any interpretation of the results must take account of the simple analytic approach.
We have found that the breastfeeding assistance that first-time mothers received during the coronavirus pandemic did not meet the Mother-Baby Friendly standard. Since most hospitals have been accredited to this standard, we can assume that the infection control measures impacted negatively on the assistance they received. Only half the sample felt that they received good breastfeeding support in the postnatal facility.
Breast-milk substitutes were administered more widely and insufficient information and guidance were provided. We know that this affects the number of women who exclusively breastfeed, and the duration of their breastfeeding. The proportion of women who were exclusively breastfeeding two weeks after delivery, was lower in our study than in other studies.
Because our sample included only first-time mothers, we cannot conclude that the infection control measures are the definitive cause of this low proportion.
This study looked at breastfeeding in the two-week period after birth. In order to understand the full consequences of the infection control measures, it will be necessary to study breastfeeding progression in the longer term.
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