English (pdf)
Article in xml format
Article references
Automatic translation
Send this article by e-mail
Cited by SciELO 
Cited by Google 
Similars in
SciELO 
Similars in Google 
Permalink
Introduction
The scientific literature points out that the COVID-19 pandemic has exerted an important effect on delivery care and breastfeeding, both in the clinical context and the home environment. Lack of knowledge about the transmission mechanisms and potential risks for mothers and newborns, even when vertical contagion of the virus has not been proved, has led to abandoning practices such as skin-to-skin contact and early breastfeeding initiation, which offer major benefits for maternal-child health. Considering the available scientific evidence and the protective effect of breastfeeding, in case of suspected or confirmed coronavirus infection in the mother, the World Health Organization (WHO) and other bodies recommend maintaining contact with the child and breastfeeding him/her, adopting specific preventive measures to minimize the contagion risk. It is also advised that, if temporary mother-child separation is required, the newborn should be exclusively fed with breast milk, as the presence of IgA antibodies against SARS-CoV-2 has been confirmed in the milk from infected mothers, the reason why breastfeeding might reduce the clinical impact of the disease on the infant, in case he/she became infected 1,2,3.
On the other hand, Bonvecchio et al. published a consensus with some recommendations made by a group of experts in nutrition from different Latin American countries, based on the current scientific evidence for vulnerable population segments, including newborns and breastfeeding infants aged less than 2 years old, given the imminent increase in food insecurity due to COVID-19 and the potential impact of the pandemic on the nutritional status of these groups. One of the recommendations is maintaining exclusive breastfeeding during the first six months of life, in economic deprivation and health emergency contexts such as the one imposed by COVID-19 4.
It is worth noting that, although systematic reviews have been conducted on interventions related to breastfeeding promotion and practices 5, with contributions given the increase in the exclusive breastfeeding rates, the reduction in the non-breastfeeding rates, the relevance of education and/or support regarding the increase in these practices, and the way individual and group counseling combined show greater benefits than each modality alone, the impact of these interventions has been studied in other contexts. However, to the present day, there is no scientific evidence of these interventions in pandemic times.
Such sanitary situation brought about variations in the way of providing care to newborns hospitalized in neonatal intensive, intermediate, and basic care units, changes that implied visit time restrictions and communication with health teams via video calls, imposing limitations for the training and education processes to be offered to the parents, as well as difficulties for breastfeeding and establishing mother-child attachment ties.
Given all of the aforementioned, the following research question emerged: What is the experience undergone by mothers of hospitalized breastfeeding infants considering educational strategies regarding breastfeeding maintenance during the COVID-19 post-pandemic period?
To answer this question, the objectives defined were to describe the meaning attributed by mothers of newborns hospitalized in intensive, intermediate, and basic care units to the educational strategies for breastfeeding maintenance during the post-pandemic period and to reflect on the mothers’ life experiences concerning breastfeeding in pandemic times.
Methodology
This is a qualitative study with a phenomenological approach that explored and described the concepts expressed by mothers of newborns hospitalized in intensive, intermediate, and basic care units regarding breastfeeding maintenance during pandemic times. According to Husserl (as cited in Fuster Guillen, 2019), the phenomenological approach consists of a paradigm that intends to explain the nature of things and the essence and veracity of phenomena, to understand the experience underwent in its complexity; therefore, it seeks awareness raising and to elucidate the meanings around a phenomenon 6,7.
The population was comprised of 39 mothers of newborns hospitalized in the neonatal care unit of the Susana López de Valencia hospital, Popayán (Cauca). The inclusion criteria were as follows: mothers of newborns hospitalized in neonatal intensive, intermediate, and basic care units; the women excluded were underage mothers, with cognitive deficits and presenting any health condition that limited knowledge acquisition or communication.
Semi-structured interviews and a discussion group were employed as data collection techniques. The discussion group consisted of randomly selected mothers who did not know each other. Group discussion is approached to enhance understanding of the participants’ experiences and beliefs. As pointed out by Morgan 8, when employing this methodology, we can study how different phenomena or situations affect people; in turn, it can also be used to explain and deepen the perceptions, feelings, and thoughts of the subjects involved.
The guiding questions used in the instrument were formulated based on the pre-existing theory and from the results of applying a survey, which allowed the generation of the first coding matrix and the selection of the key informants based on the topic of interest; these mothers were subsequently identified using codes. Data saturation was defined when most of the mothers showed agreement with the answers given to the interviews. Table 1 presents the categories and guiding questions.
Table 1 Categories and questions
| Category | Triggering question |
| Breastfeeding | What do you know about breastfeeding? What would you like to learn about breastfeeding? |
| Educational strategy | What has your experience been in terms of breastfeeding education? Which barriers or problems were identified in the breastfeeding educational process? Which aspects have eased the breastfeeding educational process? How would you like to be instructed on breastfeeding? |
| The pandemic | What did the COVID-19 pandemic and breastfeeding mean to you? |
Source: Prepared by the authors.
Ethical Considerations
The study was approved by the Research Ethics Committee of the Susana López de Valencia hospital and the participating mothers signed the informed consent form. This research considered the ethical considerations as outlined in Resolution No. 008430 of 1993 issued by the Ministry of Health from the Republic of Colombia, thereby establishing that the study corresponds to low-risk research. In addition, the ethical principles of autonomy, reciprocity, vulnerability, beneficence, non-maleficence and veracity of the information were considered 9,10.
Results
Five analysis categories were created with the information collected: 1) Mothers’ knowledge about breastfeeding; 2) Barriers identified by the mothers in the educational process; 3) Nurses’ willingness to provide support, listen, and help; 4) Best strategy regarding breastfeeding education, and 5) The pandemic as a factor that increases fear and apprehension during hospitalization of a child.
Mothers’ Knowledge about Breastfeeding
Regarding the “Breastfeeding properties and benefits” category, the mothers participating in the study stated that breast milk is the best food option for the first six months of life and that it increases defenses. The aforementioned was indicated by some of the study participants:
I know that it’s good for the baby because it helps him grow faster and have better defenses, because you can pass vitamins on to him through milk, then it’s much better. (P2)
Breast milk is the best food option, the fullest for children, it passes antibodies on to them, it has everything the baby needs, and the affective bond created with the baby is stronger. (P8)
It’s just that it’s crucial food for them, nothing can compare, and it’s highly recommendable for them to have good defenses, and... and what?, that you can give them all the time you want, then I’m thinking about giving him as much as I can. (P13)
It’s the best nutrition our baby can get during the first 6 months of life because it helps his defenses, it improves development during his growth stage. (P25)
No, because breastfeeding is very important for the child to gain weight and defenses, for him to be lively because breast milk is not the same as giving him other types of food. (P39)
On the other hand, twelve (21 %) of the participating mothers stated knowing about breastfeeding techniques and how to store breast milk.
In general, the mothers consider they know breastfeeding techniques but mention them as a practice to be improved through guidance and counseling from the health personnel to correct other aspects such as milk production, comfort, and positions, even easing this interaction for the family during the educational process.
Some of the experiences mentioned by the mothers are indicated below:
I need to release his gases when I breastfeed him, give him every two hours, perhaps more, that’s what I’ve heard. (P12)
Likewise, they also stated the desire to learn aspects about breastfeeding positions and how to milk the breasts and breastfeed the infant.
Another important aspect that mothers should be informed about is the benefits that breastfeeding offers to their health. The mothers in the study made no comments in this sense because they were not aware of what their bodies go through during this period. This practice exerts medium- and long-term effects such as a reduction in the development of ovarian and breast cancer and cardiovascular changes, among others.
Barriers Identified by the Mothers in the Educational Process
Most of the mothers of children hospitalized in the ICU stated not perceiving any barriers in the educational process (n=25); others (n=13) identified phone calls as the only way to communicate with them, whereas they pointed out technical language, time, poor memory, lack of information, and commuting to the hospital as barriers or problems in the educational process.
The mothers reported the following in this study:
When they at least tell you things, they talk to you about, how do you say it? Well, language that people like me don’t understand, then I go back and ask… (P15)
Well, the truth is that I forget, it’s because of stress, because the child is here. (P11)
Let’s say it was with the practice that I gradually learned, let’s say they help you but then it’s not so easy for you to do it on your own. (P8)
The only complication was that they called me and it was raining, so I barely heard anything. (P23)
Nurses’ Willingness to Provide Support, Listen, and Help
The mothers participating in this research reported that nurses’ willingness, listening, and support are aspects that eased their educational process about breastfeeding and stated the following:
Well, they’re patient. (P1)
They’ve taught me about nipple latch and position. (P2)
Hmm… well it’s given me more confidence with the child and let’s say, on my part, because you start and it seems that nothing comes out, then when they tell you not to worry, what is to be done, and then what we’re doing right here and now with the breast thing, then it’s already progress. (P13)
Hmm… fluency, the information as handled by the person, I find it suitable, and the interaction they create, the possibility of being able to express myself and make sure that I understand what they’re telling me, it’s awesome. (P20)
Best Strategy Regarding Breastfeeding Education
The mothers mention the following among the educational strategies that might ease their learning: booklets, videos, hands-on learning with the newborn, allowing a family member to enter and help them, direct monitoring by the health personnel, and using a doll. All of the aforementioned adapting individual care plans targeted at improving and/or maintaining breastfeeding.
The mothers state the following in their own words:
With booklets to take it into account, because you leave here and perhaps you forget. (P21)
I’d really like it in booklets because I’m actually very forgetful and I’d remember more by seeing the booklet. (P23)
However, they also state:
It can be a video, and a family member might come in to help because I get tired. (P8)
Booklets, primers, especially because when you go home you become another brick in the wall because you have nobody to tell you “Look, this is how you should do it”, but it’d be really good to have some kind of reminder. (P27)
Other mothers asserted the following:
First of all, monitoring by nurses or personnel that know about breastfeeding. (P4)
Kind of that they sit down with you at least for two minutes and tell you “Look, it’s like this” and end of the story. (P32)
In person as we’re doing now, because doubts are solved once and for all. (P26)
The Pandemic as a Factor that Increases Fear and Apprehension during Hospitalization of a Child
Regarding the meanings of the COVID-19 pandemic situation and breastfeeding, the mothers mentioned the following: restrictions and protocols (n=18); fear of contagion (n=10); no impact (n=6), mother-child distancing (n=4); and need for selfcare (n=1).
The mothers reported the following in this regard:
Well, the only barrier is always fear, of the people coming here not following, even myself, not following the right protocols, knowing that we’re handling too vulnerable babies […]. The restrictions here, because they control times and you can’t come in with them and, as for breastfeeding, well it also affects them, because if you can’t be here so much time with them then you can’t give them all the milk they need every day. (P31)
They also state:
Let’s say it’s been really hard for me not to see my baby, it’s been very difficult with this pandemic, that’s why they didn’t let me in; oh no, it’s been, no better, these seven days have been like an eternity for me, but I only come to see him today, but I already have him since today. (P18)
Horrible, because you can’t be here with the child all the time; it’s been tough for me because I got depressed about not being able to have the child home; I’ve cried until my eyes were dry, but I know it’s for his sake, but it’s been tough as I tell you, it’s horrible not having him with me and, well, in the pandemic issue the only thing I know is that we all have to take care of ourselves and of the baby, for all children’s sake. (P21)
Well, really hard, first of all, because I don’t have him by my side, I miss him a lot and, well, it’s hard for me to be home with them here. (P11)
I feel sad because they used to tell me that they’d let me stay here, then that’d be very good because I could stay with them all the time, but now it’s time to leave. (P37)
The restrictions here, because they control times and you can’t come in with them and, as for breastfeeding, well it also affects them, because if you can’t be here so much time with them then you can’t give them all the milk they need every day. (P27)
The participants directly state the need for an educational intervention involving the use of primers, booklets and videos for breastfeeding maintenance and, on the other hand, they highlight the importance of monitoring by the health personnel and hands-on explanations with the newborns.
The mothers who participated in the study assert that the COVID-19 pandemic implied following restrictions and protocols; they were afraid of becoming infected and also perceived distancing from their newborns.
Discussion
The mothers state that breast milk is the best food option for their children up to 6 months old; they assert that it increases their defenses and helps them grow and develop faster.
Various authors assert that breast milk is the ideal food choice for infants’ development and that all the properties it offers are undeniable, in addition to being the only one that contributes benefits for breastfeeding children’s growth and development 11,12. To the aforementioned, we should add the fact that it prevents childhood mortality in the first year of life, as it increases the immune system defenses and helps prevent gastrointestinal and respiratory infections, even contributing to preventing COVID-19 infection 13.
In their study, Odalis Tamayo et al.14 mention that the benefits of breast milk are still somehow unknown and that, although education is provided to mothers during the gestational period and to the community in general, it is necessary to continue promoting this feeding practice to raise awareness and commitment among mothers, as well as to contribute to maximizing physical and emotional well-being in the mother-child dyad.
On the other hand, the mothers consider that they know the breastfeeding techniques but mention them as a practice to be improved through guidance and counseling from the health personnel to correct other aspects related to milk production, comfort, and positions, even easing this interaction for the family during the educational process.
Regarding the design of breastfeeding maintenance strategies, some studies 14,15,16 conclude that it is not only important to recognize the properties and benefits of breast milk but also to ensure skills in the mothers to support, foster, and protect breastfeeding by teaching adequate techniques that ease the feeding process in terms of milk production, well-being, contact, and improved breastfeeding times.
The study by Castelo-Rivas et al.17 identified difficulties during breastfeeding, such as the following: insufficient breast milk production (29.45 %), no suckling (18 %), and breast refusal (16 %); situations that might have been corrected by teaching breastfeeding techniques.
Referring to the benefits for maternal health during this practice, Bazzarella reports that the bond established in the mother-child dyad during breastfeeding is beneficial for the mother’s health because it promotes well-being and relieves stress and anxiety. It also assists in her prompt recovery after birth and reduces the hemorrhage and postpartum depression risks, allowing her to easily lose the weight gained during pregnancy and decreasing the risk of developing anemia after delivery 18.
It has other beneficial effects on maternal health in the medium- and long-term, such as a reduction in the development of ovarian and breast cancer and cardiovascular changes, among others 19.
Access to medical care is an important challenge faced by health systems in middle- and low-income countries 20; this is affected by the geographical area and by cultural, economic, educational, and transportation aspects, to which the conditions of forced displacement victims or vulnerable populations are added, even more considering that commuting and accessibility to health centers were hindered during the pandemic. All of the aforementioned was reflected in mothers exclusive breastfeeding whose children were hospitalized in neonatal units.
Breastfeeding is a topic of global importance; however, its implementation and proper use rates are way below the WHO guidelines, which is why health teams need to apply educational strategies to promote its benefits, to improve and strengthen the affective and nutritional bonds, as well as children’s adequate development, managing to exert a positive impact on reducing morbidity and mortality in breastfeeding infants 21,22.
When asked about the best breastfeeding education strategies, the mothers mention the following: booklets, videos, hands-on learning with the newborn, allowing a family member to enter and help them, direct monitoring by the health personnel, and using a doll.
In a study conducted by Moore, Linares and Ashford, it was found that creating an environment that supports breastfeeding might include training postpartum nurses on how to incorporate ten steps into their practice, as a way to improve exclusive breastfeeding 23. In our study, the mothers indicated difficulties in the breastfeeding practice while their children were hospitalized, for the following reasons: fear of infection, living far away and problems accessing public transportation and entering the hospital; however, the importance of nurses’ monitoring, support, patience, and help during this stage was highlighted.
Developing countries present a greater burden in their health services, hence the need for optimal leverage of resources and technologies to find creative solutions at the individual and community levels, favoring the mother-child bond with the help of tools such as telemedicine for prenatal counseling, or for breastfeeding education and support during hospitalization 24.
As a result, given the barriers identified by the mothers in the educational process, some participants stated not noticing such obstacles whereas others reported hindrances such as the following: phone calls as the only way to communicate with them, use of technical language, the time devoted to the educational process, the perception of having poor memory, and commuting.
In this sense, the research paper by Samano found barriers to the breastfeeding practice in a group of adult mothers with and without paid work activities, evidencing that they considered their milk production insufficient to feed their newborns. The authors point out that one of the reasons why not enough milk is produced is deficient latch; another limiting factor noticed in this study was the lack of information regarding breastfeeding 25.
The mothers participating in this research also reported the nurses’ willingness to listen to them, support them, offer them their time, and understand them eased their breastfeeding educational process.
The aforementioned coincides with what was found in the study by Samano, where the following were reported among the facilitating aspects in the breastfeeding educational process: good nutrition in the mother, counseling by the health personnel, conviction, help from the family, and adequate rest 25.
After birth, the mother-child dyad can be affected by multiple perinatal causes, reason why hospitals should implement maternal education actions regarding breastfeeding initiation in the first hour of life 25. The maternal perception of in-hospital education that supports breastfeeding might generate positive results for women and newborns alike 26.
In the study by Martín-Iglesias 26 on the efficacy of an educational group intervention in primary care for exclusive breastfeeding maintenance, it is concluded that group education favors acquiring skills and changing already acquired behaviors, which turns it into a potential first-choice method to improve the exclusive breastfeeding rates.
Many participants directly state the need for an educational intervention involving the use of primers, booklets, and videos for breastfeeding maintenance. On the other hand, they highlight the importance of monitoring by the health personnel and hands-on explanations with the newborns. In this sense, a study based on applying an educational intervention on the immunological benefits of breastfeeding for newborns concludes that the strategy was effective, as high knowledge and practice levels were achieved in most of the women and almost all mothers breastfed their infants for a minimum of six months 27.
Regarding the meanings of the COVID-19 pandemic situation and breastfeeding, the mothers pointed out how difficult it was for them to stay away from their children for fear of infecting them, in addition to the increase in the number of restrictions and protocols that affected the limited time they were able to be with their newborns.
It is reported that COVID-19 affects pregnant and breastfeeding women at the global level, both due to infection by the virus and to the changes in medical care resulting from the specific social, economic, and health care policies implemented in each country 8.
Different studies have shown that the coronavirus pandemic has exerted a significant impact on delivery care and breastfeeding, highlighting the global benefits of ensuring that mothers and newborns are not separated despite the uncertainty and limited knowledge about COVID-19, along with the essential support for breastfeeding mothers, which allows achieving science-based results. The presence of barriers and/or difficulties in the provision of Nursing and Obstetrics care was also evident during the COVID-19 pandemic, including breastfeeding support 1,28,29,30,31,32,33,34,35.
Conclusions
Knowing the experiences undergone by the mothers of hospitalized children concerning the educational strategies for breastfeeding during the post-pandemic period allows recognizing mothers as the main actresses in the educational process, amid a situation that generates vulnerability, fear and apprehension, among other feelings experienced during hospitalization.
The COVID-19 pandemic became a major challenge that, in addition to knowing the disease, allowed uniting efforts among health professionals (especially from the Nursing area) to devise care strategies for breastfeeding mothers and newborns, identifying new education modalities.
On the other hand, the mothers stated that the nurses were always available to listen to them and support them during breastfeeding. It is important to mention that health teams are capable of monitoring this process; however, Nursing professionals play a fundamental role because of their constant presence in the neonatal unit.
In this study, it was found that the mothers also need help. The professionals should value the mothers’ presence and their importance in the evolution of their newborns’ health status; in addition, their presence should be considered as a crucial element in the therapy provided.
The results of the current study served as input for us to prepare five videos lasting between four and five minutes that will be projected while the mother-child dyad is hospitalized, along with the creation of a booklet that will be handed to all mothers with hospitalized children.
This study allows expanding knowledge about the breastfeeding process during the post-pandemic period and opens possibilities for us to research couples’ and families’ experiences concerning breastfeeding, as the mothers unveiled the relevance of these people in the process as well.
