This study complemented the existing literature regarding the barriers and facilitators of EBF by identifying three factors associated with successful six-month EBF, namely giving birth in a public hospital, the self-rated impact of COVID-19, and the support from family and friends. Such factors could be targeted by policymakers for designing EBF interventions.
Our qualitative results indicated a high prevalence of breastfeeding problems in both public and private maternity wards, suggesting that neonatal support for breastfeeding in both public and private hospitals were generally insufficient and ineffective. In particular, giving birth in private hospitals was associated with a lower likelihood of successful six-month EBF, both in general and during the pandemic period; our qualitative results identified four potential reasons for such a phenomenon. First, the inappropriate recommendation of formula supplementation by nurses in private hospitals likely reinforced PIMS amongst mothers, hence discouraged them from in-hospital EBF (BFHI Step 6) and responsive breastfeeding (BFHI Step 8) . As demonstrated in both our study and other international studies, PIMS is a major factor for discontinued breastfeeding and EBF cessation [22–24]. Moreover, while in-hospital EBF has been demonstrated to be positively associated with continued breastfeeding or EBF in both local and international studies, in-hospital formula supplementation is a risk factor for early breastfeeding cessation worldwide [25–28]. Second, compared to public hospitals, private hospitals were less supportive of early in-hospital breastfeeding initiation (BFHI Step 4), a finding consistently implied from both local and international studies [8, 21, 29]. Yet, early in-hospital breastfeeding initiation is a factor strongly positively associated with breastfeeding establishment, in-hospital EBF, and continued breastfeeding worldwide [21, 28, 30]. Third, private hospital staff tended to offer conflicting and incomprehensive breastfeeding advice to mothers. This is likely due to the relatively poor communication of hospital breastfeeding policies (BFHI Step 1) and insufficient staff training (BFHI Step 2) in private hospitals as compared to public hospitals [8, 21]. Fourth, private hospitals are generally unsupportive of rooming-in practice (BFHI Step 7), a factor significantly positively associated with in-hospital EBF [21, 31]. The poor rooming-in practice of private hospitals, as compared to public hospitals which all practised rooming-in, was observed in another local survey . Overall, our results suggested that private hospitals were less supportive of in-hospital EBF and less committed to the BFHI than public hospitals, although public hospitals experienced labour shortage and lack breastfeeding support in SCBUs and NICUs. Further investigation is needed to assess whether similar trends are observed internationally.
We also found the pandemic in Hong Kong to have a generally positive self-rated impact on breastfeeding, which was positively associated with successful six-month EBF. Our qualitative results indicated that this is likely due to a combination of having work-from-home arrangements, more flexible work schedules, and leaving home less. Many mothers also hoped to protect their children from COVID-19 by transferring anti-infective factors and immune boosters through breast milk. In contrast, a study in Italy found lockdown and home confinement measures during COVID-19 to reduce EBF . Such contrasting findings were likely due to two reasons. First, the more severe COVID-19 situation in Italy and uncertainties around vertical transmission of SARS-CoV-2 during the study period (March 2020 to Aug 2020) at the early stages of the pandemic made mothers and healthcare workers alike wary of breastfeeding [32, 33]. Second, due to stringent lockdown restrictions in Italy that resulted in complete home confinement and reduced transportation, new families could not access breastfeeding support easily, including those from family and friends . Meanwhile, the pandemic also presented unique difficulties to breastfeeding. A small proportion of mothers expressed worries regarding breastfeeding and expressing breast milk in public premises due to concerns of exposing the infant to possible infection. Moreover, the temporary suspension of postnatal services in MCHCs during pandemics could deprive mothers of critical breastfeeding support, hence negatively impact breastfeeding practice amongst mothers. Furthermore, during the pandemic, most antenatal classes and breastfeeding coaching services were cancelled, while some were moved online with the implementation of social distancing measures. Some participants further complained that online antenatal classes did not facilitate interactive teaching and effective learning; similar findings were observed in the UK .
Results of logistic regression models further indicated that breastfeeding support from family and friends was positively associated with successful six-month EBF, both in general and during the pandemic period. This is consistent with previous studies that emphasised the importance of the husband’s preference for EBF and having peers who have had breastfeeding experience, as well as the positive impact of paternity leave on breastfeeding duration [36–39]. In the Chinese society, it is traditional for the grandparents to provide assistance to new mothers during the first month postpartum and as such, the attitude of grandparents strongly influences feeding practices . The notion that EBF is not enough for the baby’s satiety is strong amongst the older generation and reinforces PIMS in new mothers, a circumstance that often convinces new mothers to supplement with or switch to formula feeding [40, 41].
Both local and international studies have demonstrated that the exclusivity of breastfeeding and the duration of EBF are positively associated with maternal education level, breastfeeding knowledge, and household income [42–44]. However, due to our purposive sampling approach, our participants had a higher education level and socioeconomic status compared to the general population, and were more committed to breastfeeding . As such, these associations were not observed in this study.
Strengths and limitations
Our study adopted a purposive sampling approach and targeted members of breastfeeding support groups and organisations, who were committed to breastfeeding, experienced with breastfeeding, and exposed to a wide range of breastfeeding services provided by different health care providers, organisations, and professionals. This allowed wide-ranging exploration on the barriers and facilitators of six-month EBF to help inform future research efforts. In addition, this is the first study undertaken to explore the impact of COVID-19 on breastfeeding practice in Hong Kong.
However, our study had some limitations. Due to the voluntary nature of this study, it was possible that those who participated had more positive attitudes towards breastfeeding, subjecting it to volunteer response bias. In addition, the purposive sampling approach limited the generalisability of our findings. Moreover, the deductive and inductive methods adopted in our qualitative analysis could oversimplify the individual breastfeeding experience of participants. Furthermore, self-reporting responses of participants were subject to recall bias. Lastly, responses regarding participants’ perceived helpfulness of different health organisations and professionals might be influenced by the reduced accessibility of antenatal classes and MCHC services during the COVID-19 pandemic.
In view of our findings, we propose six areas which the government and hospitals should address to further promote in-hospital and six-month EBF in Hong Kong.
First, staff training in private hospitals should be strengthened. Written notice of breastfeeding policies should be well-communicated to all staff (BFHI Step 1), while standard training should be mandated for staff (BFHI Step 2), especially for nurses and midwives in private maternity wards .
Second, a postpartum home-based programme should be implemented, as recommended by other local studies [17, 46]. Although our qualitative results suggested that practical, comprehensive, extensive, and interactive antenatal classes were welcomed by the mothers, the evenly divided rating of participants suggested that the helpfulness of existing antenatal classes was controversial. Results from other high-income countries consistently suggest that the efficacy of antenatal classes is uncertain . In addition, mothers in Hong Kong may find it difficult to leave home during the early postpartum period due to the overwhelming workload and the cultural practice of “doing-the-month” . Hence, the practical challenges of breastfeeding should be addressed postnatally in a home setting.
Third, breastfeeding support in SCBUs and NICUs of public hospitals should be strengthened. SCBUs and NICUs of public hospitals should offer clear breastfeeding guidance and support milk pumping, bottle-feeding, and breastfeeding as appropriate.
Fourth, MCHC services should be continued during pandemics and be further promoted on discharge. The provision of information regarding breastfeeding support on discharge (BFHI Step 10) was associated with continued breastfeeding both locally and internationally [21, 26, 28]. While most public and private hospitals in Hong Kong self-reported that they provided such support, our qualitative results indicated that some participants were unaware of such services , suggesting a communication gap which should be addressed through active promotion.
Fifth, the spouse and the grandparents should be included in breastfeeding education and antenatal classes. Since family members play a significant role in the choice and duration of EBF, it is important to cultivate their knowledge on breastfeeding through family-centred breastfeeding education [48, 49].
Sixth, flexible work-from-home arrangements should be provided to parents following the end of existing parental leaves. Our qualitative results suggested that returning to work from maternity leave is a major reason for EBF cessation, while other studies indicated that parents’ return to work was a significant predictor of early weaning [39, 46, 50]. Yet, the recent extension of statutory maternity leave to 14 weeks in Hong Kong still falls short of the six-month target, while statutory paternity leave lasts for five days only [7, 51]. With the experience of large-scale work-from-home arrangements during COVID-19, similar arrangements could be considered as an alternative to extending existing parental leaves.