Six hundred and sixty-nine women responded to the survey, of which 580 women were included in the analysis (Fig. 1). All closed questions required a response, whereas the open questions were not mandatory' There were very few incomplete questionnaires, and these were not included in the analyses. Characteristics of the study population are presented in Table 1. Participant’s mean age was 32.5 ± 4.2, and mean infant age was 3.04 ± 1.7 months. The majority of participants were multiparous (65%) and were still on maternity leave at the time of the survey.

Study population flow diagram

An analysis was carried out to assess correlation between rooming in following birth, and the length of breastfeeding. There was no statistical significance (p = 0.687).

One hundred and twenty-seven participants (22% of the study population) reported changes in their breastfeeding plans; 85 (15%) reported the COVID-19 pandemic prolonged their period of breastfeeding and 42 (7%) reported it shortened it.

The respondents who extended the breastfeeding period could cite one or more reasons for this extension. The reasons included belief that breastfeeding would protect again infection (70%), increased availability of the mother (66%), the breastfeeding relaxed the mother (33%), and for economic reasons (14%). Among those who shortened the breastfeeding period, 65% said it was due to lack of time because of other children at home, 34% cited stress and fear, 27% cited mood changes and 7% because of non-availability of breastfeeding counselling.

Participants’ report of support from friends, family, and/or lactation consultants since they gave birth, is depicted in Table 2. Most of the women had not been in quarantine due to COVID-19 disease or exposure to a confirmed patient since they gave birth. Of the 51 participants who were infected or exposed to a confirmed patient, only 4 reported separations from their baby (< 1% of the study population). Most women reported support from their partner, mother, mother-in-law, and friends. At the time of survey completion, 74% of the children were breastfed. Women reported lactation counselling during their hospital stay (67.8%), or after discharge (45.0%). Only 37.2% of mothers received both lactation counselling at the hospital and after discharge.

Participants were given the opportunity to provide free-text answers regarding breastfeeding during the COVID-19 pandemic. Out of 580 participants, 96 women answered this question and discussed challenges they faced during the first lockdown. The main issues raised were lack of spare time due to other children in the house, financial difficulty, mental stress, and dissatisfaction with the lactation counselling which they had received (Table 3).

Table 4 shows the results of a multivariate logistic regression analysis of factors associated with longer than planned breastfeeding due to the pandemic. We adjusted for all demographic variables, namely mother’s age, baby’s age and education level. Marital status was left out because of the lack of variation in this variable. Mother's age was analyzed as a continuous variable, while the baby's age was analyzed as a binary variable, with two categories: below age 3.5 months and above. The cutoff age of 3.5 months was chosen as this is the duration of the paid maternity leave in Israel. Returning to work later than expected (vs. as expected) was significantly associated with prolonged breastfeeding, with those mothers being 2.38 (95% CI 1.46,3.87) times more likely to breastfeed for a longer period than expected.

In response to which factors could help in encouraging breastfeeding, mothers could answer either based on their current experiences or on what they consider could help, or a combination (experience and ideas regarding future desirable actions). High proportions of the study participants reported breastfeeding encouragement in prolonged maternity leave (96.0%), having the possibility to work from home (86.0%), receiving lactation counselling at home (93.5%) and/or in the hospital (92%), and in watching training videos on breastfeeding (81.0%). However, only 72.5% of the participants believed virtual meeting groups with other mothers would encourage breastfeeding (Table 5).