Our study emphasizes the critical role of healthcare professionals, specifically nurses, midwives, and doulas, in delivering essential breastfeeding care and education and in impacting breastfeeding rates before and during the pandemic. Participants who received breastfeeding education from nurses, midwives, or doulas were twice as likely to have ever breastfed or pumped milk than participants who did not receive such education. Our findings emphasize the critical role that nurses, midwives, and doulas play in encouraging mothers to breastfeed/pump milk as well as providing education on important breastfeeding practices. Furthermore, this study provides evidence for enacting policies and funding training programs that ensure that nurses, midwives, and doulas are equipped with the necessary knowledge and skills to support breastfeeding, inclusive of staying updated on the latest breastfeeding guidelines and techniques. Additionally, we found that participants who gave birth during the COVID-19 pandemic were significantly less likely to receive breastfeeding education from a nurse, midwife, or doula than participants who gave birth before the pandemic. Our findings highlight the pandemic's significant impact on access to breastfeeding education, underscore the need for public health preparedness, and suggest the potential value of telehealth/virtual health support platforms to connect patients and providers during crises such as the pandemic to offer breastfeeding care.
Approximately three-quarters of the participants were educated about breastfeeding by a nurse, midwife, or doula both before and during the pandemic. Breastfeeding rates were approximately 90% across both periods. Participants who received breastfeeding guidance from nurses, midwives, or doulas were twice as likely to have ever breastfed or pumped milk to their infant than participants who did not receive education. The literature consistently recognizes nurses, midwives, and doulas as vital sources of breastfeeding information and support (9–11). One study reported nurses, midwives, and doulas to be the second most prevalent source of breastfeeding information after a doctor (18). Our findings add to the existing evidence supporting the importance of nurses, midwives, and doulas in providing breastfeeding education and rates and provide evidence to lawmakers and hospital systems to recognize the significance of such healthcare professionals in promoting breastfeeding and considering strategies to enhance their involvement and training.
Moreover, our study revealed that participants who delivered their babies amidst the COVID-19 pandemic exhibited a notable decrease in the likelihood of receiving breastfeeding guidance from healthcare professionals, such as nurses, midwives, or doulas, in contrast to those who gave birth prior to the pandemic. Possible explanations for decreased breastfeeding education during the pandemic explored in previous literature included large-scale shifts in maternity care, fear of COVID-19 transmission/illness, lack of care coordination, and consistency in support (3, 26, 27). Specifically, the healthcare practices during childbirth and during the postpartum period that significantly changed during the pandemic included the employment of visitor restrictions, not permitting birthing support (doulas, birth companions) during delivery/postpartum, and separating the newborn from the parent without breastfeeding support (3). Another change in healthcare during the pandemic was the shift to telehealth and virtual care for provider-patient perinatal meetings/appointments (28, 29). In one study, doulas reported a loss of connection in their role as advocates when moving care virtually, difficulties in helping patients switch to virtual care (30), and worsening breastfeeding disparities for patients without access to lactation support and care (31). Although there were several barriers to providing care for birthing and nursing mothers during the COVID-19 pandemic, published reports doulas and other maternity care workers “were willing to go the extra mile” to aid their patients (31).
We found that participants were more likely to report having breastfed or pumped during the pandemic than before the pandemic contrary to our hypothesis. Our finding does not align with studies reporting a decrease in breastfeeding rates and support during the pandemic (6, 8). However, these findings align with the literature reporting that COVID-19 stay-at-home orders delay breastfeeding cessation plans (32). Recent literature separating the pandemic into early and late periods concluded that mothers during the early pandemic period received less support and education due to the novelty and confusion caused by the coronavirus and its significant impact on hospital systems compared to mothers during the pre- and late pandemic periods (7). Once telehealth was initiated, breastfeeding resources became more accessible for participants. Overall, the study concluded that, compared to prepandemic parents, both early- and late-pandemic parents had lower odds of meeting their breastfeeding goals (7). Furthermore, many mothers reported that a lack of or decreased social and professional breastfeeding support significantly impacted their breastfeeding experience(s) during the pandemic (33).
Although non-Hispanic Asians made up less than four percent of our total prepandemic and pandemic samples, the group reported the highest breastfeeding rates compared to all other racial/ethnic group rates. Our findings are consistent with the literature reporting that Asian mothers have longer overall breastfeeding durations and initiation rates than mothers of other racial/ethnic groups (16, 34). In a recent study, Asian (93%) and Native Hawaiian (99%) women were more likely to report breastfeeding or breastfeeding longer than 10 weeks (18). However, in the previously mentioned study and on our own, disaggregation of the heterogeneous Asian population was not possible. A study before the pandemic that looked at distinct Asian populations revealed breastfeeding disparities within the groups (35). Due to the various, distinct cultures around breastfeeding in this group (and others), it is likely that the results do not reflect all populations classified as “Asian” in this study. Furthermore, non-Hispanic Asian participants were also more likely to receive breastfeeding education from maternity care providers (association increased in significance before the pandemic) and to report ever breastfeeding/pumping than their non-Hispanic White counterparts were. Our study also supports the findings of previous reports in the literature showing that providing breastfeeding information via nurses, midwives, and doulas to populations, including Asian women, is extremely beneficial (18).
Non-Hispanic Black participants made up approximately sixteen percent of both the prepandemic and pandemic samples, with slightly more than three-quarters of the population reporting breastfeeding in both samples. Compared to non-Hispanic White participants, non-Hispanic Black participants were significantly less likely to report breastfeeding. In fact, all the other racial groups except Non-Hispanic Black participants reported higher odds of ever having breastfed/pumped than did the non-Hispanic White participants. Our results are consistent with other published studies on the racial/ethnic disparities in breastfeeding among black-born people (16, 18). Additionally, approximately twenty percent of the Hispanic participants were from the two cohorts, and approximately ninety percent of the population reported breastfeeding. Hispanic participants were more than two times more likely to report breastfeeding than their White counterparts were. Our study results are consistent with the literature. Previous studies have reported that Hispanic mothers have higher levels of breastfeeding initiation and continuation than do all demographic populations; additionally, Hispanic mothers are more likely to intend to breastfeed than black mothers are, and Mexican American mothers are more likely to breastfeed than non-Hispanic white mothers are (15, 34, 36). Interestingly, we found that both non-Hispanic Black and Hispanic participants were more likely to receive breastfeeding information from a nurse, midwife, or doula during the pandemic, although these associations did not meet our significance threshold. Our findings support the findings of previous studies showing the importance of racial/ethnic minorities, black women in particular, receiving breastfeeding education from nurses, midwives, and doulas in increasing breastfeeding rates (18, 37–39).
For both the pre- and pandemic periods, approximately half of our individuals were privately insured, with approximately thirty-five percent insured with Medicaid and the rest uninsured. Among these populations, the highest breastfeeding rate was among privately insured participants, and the lowest rate was among Medicaid-insured participants during both the prepandemic and pandemic periods. Our findings are consistent with the literature (40). Compared to participants with private insurance during the prepandemic period, those with Medicaid or no insurance were significantly less likely to receive breastfeeding education from a nurse, midwife, or doula. We did not observe this association during the pandemic, although we did observe a significant interaction between having no insurance and the pandemic period, which lowered the odds of breastfeeding.
Approximately forty percent of our prepandemic and pandemic samples completed college, and slightly more than a tenth did not complete high school. Among the education levels, the highest percentage of breastfeeding (more than ninety-five percent) was reported by participants with college degrees, and the lowest was reported by participants who did not graduate high school both before and during the pandemic. Participants who completed college were significantly more likely to receive breastfeeding education from a nurse, midwife, or doula than participants with less than a high school education before the pandemic. Interestingly, we did not observe this association during the pandemic. Individuals with a high education level were significantly more likely to report ever breastfeeding than participants without a high school diploma were college-educated participants were almost four times more likely to breastfeed than participants without a high school diploma were.
Slightly less than half of our sample both during the pandemic and before the pandemic reported their pregnancy as intended, approximately forty percent unintended, and fifteen percent unsure. Among these populations and for both pandemic periods, the highest breastfeeding rate was among participants with intended pregnancies, and the lowest rate was among participants with unsure intent. Both before and during the pandemic, participants with intended pregnancies were more likely to receive breastfeeding education from maternity care providers, with the more significant association occurring during the pandemic.
Limitations
When interpreting our findings, it is important to consider limitations and strengths. PRAMS data are self-reported may be prone to recall biases because participants were surveyed about their prenatal, perinatal, and postpartum experiences 2–6 months after childbirth. Furthermore, PRAMS exclusively includes only participants with live births in their dataset, limiting the generalizability of our findings to those who experienced fetal loss, terminated pregnancy, or did not have a live birth. Furthermore, PRAMS data are exclusively reported annually; thus, “2020” was classified in our study as occurring during the pandemic, although the pandemic was not declared a national emergency in the U.S. until March 13, 2020.
Strengths
Despite our limitations, our study also includes several strengths. One is our utilization of the extensive and representative national PRAMS dataset encompassing a diverse sample of postpartum individuals across the U.S. ensuring the reliability and comparability of the data across all participants. Furthermore, our large sample size enhances the generalizability and statistical power of our findings, allowing us to draw meaningful conclusions about the impact of the COVID-19 pandemic on breastfeeding information. In addition, in addition to sensitivity analyses imputing for missing data, our statistical analysis employed methods to control potential confounders, enhancing the reliability and overall robustness of our results. This study underscores the vital role of nurses, midwives, and doula healthcare professionals in promoting breastfeeding and highlights the disparities in breastfeeding rates among different racial and ethnic groups. Our findings emphasize the importance of ongoing initiatives to support breastfeeding and address disparities in maternal and child health.