The protection, promotion, and support of breastfeeding is a priority for public health, since breastfeeding offers mothers and children a constellation of short- and long-term health benefits (1, 2). Evidence has consistently shown that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not likely to be transmitted via breastmilk (i.e. vertical transmission) (3–7). In addition, COVID-19 appears to be less prevalent and, generally, less severe in infants (8, 9), and there is evidence that breastmilk from mothers with a history of COVID-19 infection contains specific IgA with an activity against SARS-CoV-2 (9–13). Furthermore, prospective cohort studies have found that anti-SARS-CoV-2 IgA and IgG generated by anti-COVID-19 mRNA-based vaccines administered to lactating and pregnant mothers are transferred to their babies via breastmilk (14, 15) and umbilical cord blood (16, 17), while COVID-19 mRNA does not (18, 19). Moreover, evidence suggests that vaccine-induced immune responses are even greater than natural infection-induced immunity (17), due to an IgG-dominant response (20). In general terms, breastmilk protects babies through anti-microbial and anti-inflammatory factors that promote the development of the immune system (21, 22). Accounting for this evidence, as well as the susceptibility of newborns to person-to-person spread of COVID-19 through contact with mothers and caregivers (i.e., horizontal transmission) (9), the World Health Organization (WHO) recommends that women with COVID-19 should breastfeed their babies (21, 23) and that direct breastfeeding should be supported as the preferred infant feeding option during the pandemic (i.e. feeding directly from the breast). WHO also recommends that breastfeeding women to be vaccinated against COVID-19.
Protecting, promoting and supporting breastfeeding even among infected mother-infant dyads is important given the numerous health benefits of breastfeeding (24) and COVID-19-affected or -suspected mothers should be informed about the importance of continued direct breastfeeding. During the birth hospitalization period, mother-infant dyads should be cared for together, including skin-to-skin contact and room sharing, which is critical for helping mothers establish and continue breastfeeding (8). Not doing so increases neonatal morbidity and mortality (25).
Despite the WHO’s strong emphasis on promoting breastfeeding and keeping the mother-infant dyad together during the COVID-19 pandemic, some governments, professional organizations, and hospitals have adopted conflicting practices (26). During the early stages of the pandemic, for example, they recommended that infected mothers be separated from their infants after birth to reduce the risk of infant COVID-19 infection. Such recommendations generated uncertainties for new parents (8, 27). Sola et. al. (28) analyzed evidence from 7 countries of the Ibero American Society of Neonatology (Argentina, Colombia, Ecuador, Equatorial Guinea, Honduras, Peru and Dominican Republic) from March to May 2020, to evaluate how has the pandemic impacted pregnant and breastfeeding women and newborns in Latin America. Findings showed that lack of breastfeeding support and mother-infant dyad separation among COVID-19 positive women were common during the pandemic. For example, only 24% of infected mothers were allowed to breastfeed after birth and only 13% expressed milk while in the hospital; as a result, 63% of infants born to infected mothers were fed with breastmilk substitutes (BMS). Moreover, 76% of the dyads were separated at birth and 95% of mothers were left unaccompanied during delivery and the postpartum birth hospitalization period, which could possibly have disrupted mother-child bonding (28).
Diverse socio-cultural beliefs about breastfeeding, uncertainty and social anxiety (9), and the marketing strategies from the BMS industry might have also prompted healthcare providers and mothers to not start or discontinue breastfeeding during the pandemic. Furthermore, the initial United Kingdom (UK) vaccination policy that denied access to vaccines to breastfeeding women due to safety concerns, because they were not included in the vaccine trials, very likely led providers and mothers to decide to not breastfeed their infants (29), even if it was later reversed (30). Indeed, it has been noted that federal and local governments and certain COVID-19 vaccination centers in several countries, such as Spain (31), Canada (32), United States of America (USA) (33), or the UK (34), are handing out consent forms or publishing factsheets stating that breastfeeding is contraindicated or that women should contact their health care providers to further discuss the safety of the vaccine during breastfeeding, even though now there is evidence that the vaccine is not harmful for the baby nor the breastfeeding mother (31) and that actually is beneficial to both (17). In fact, evidence states that the vaccine-induced immune responses in pregnant and lactating women are equivalent to the vaccine-induced immune response in non-pregnant women (17). Nonetheless, these messages may negatively affect mothers’ decisions regarding both vaccination – for example, they may decide to not receive the COVID-19 vaccine or voluntary postpone vaccination – and infant feeding decisions, such as breastfeeding termination or non-disclosure of breastfeeding status at vaccination centers (31).
Separation of mothers from their infants during the birth hospitalization and suggesting mothers not to initiate or discontinue breastfeeding to reduce the risk of COVID-19 in infants may widen existing disparities in breastfeeding. Prior to the COVID-19 pandemic there were enormous differences in access to quality maternity services and infant feeding information by socio-economic status (8). Furthermore, socio-economically marginalized groups are least able to follow lockdowns and social distancing guidelines to reduce the spread of COVID-19, due to the nature of their jobs (35). These groups are, therefore, least able to minimize their viral exposure. They might also be more likely to suffer the adverse consequences of mother-infant separation during the birth hospitalization, and in turn, to face barriers to breastfeeding (36). Indeed, vulnerable groups have also suffered disproportionately from the adverse economic consequences of the pandemic (35). Hence, the protection afforded to infants through breastfeeding in the context of COVID-19 – as a public health emergency – is of increased importance to mitigate household food insecurity, due to the high cost of BMS and the stress this can imply to families’ food expenditure (8). Breastmilk provides the cleanest, safest and most affordable form of infant and young child nutrition during crises, and it is the normative standard for infant nutrition (3). Hence, breastfeeding should be considered as a fundamental protective and health promotion measure for infants during the pandemic (22).
The aims of this study were to (a) describe how the support from the Mexican government in adhering to the WHO recommendations on breastfeeding during COVID-19 was communicated in media outlets, (b) to assess the beliefs among Mexican adults regarding breastfeeding among mothers infected with COVID-19, and (c) address if there are differences in views by socioeconomic status, with the goal of understanding whether socio-economically disadvantaged families might be more likely to hold views that do not align with current scientific recommendations regarding breastfeeding.
This research is needed because Mexico has been severely affected by the COVID-19 pandemic; it has the third highest number of COVID-19 related deaths in the world (37). The public health emergency in Mexico has had sustained negative effects on household income, employment, food insecurity, and mental health since the beginning of the pandemic in March 2020 (38, 39). Prior to the pandemic, there had been a steady increase in breastfeeding rates in Mexico. For example, the exclusive breastfeeding rate among infants under six months improved from 14.4% in 2012 to 28.3% in 2018 (40, 41). Due to the COVID-19 pandemic, however, these improvements may slow down and widen breastfeeding inequities if actions to promote and protect breastfeeding during this public health emergency are not taken.