Introduction: Due to the SARS-CoV-2 pandemic, adjustments in patient and visitor traffic were made in hospitals to limit viral exposure. The primary objective of our study was to compare the breastfeeding success of healthy newborns in a maternity ward during the 2020 lockdown period compared with the same period in the previous year. Material and Methods: Single-center comparative study based on prospectively collected data. All neonates born alive, from a single pregnancy, and with a gestational age greater than 36 weeks were considered for this study. Results: 309 infants born in 2020 and 330 born in 2019 were included. Among women who desired to exclusively breastfeed, the rate of exclusive breastfeeding at discharge from the maternity ward was higher in 2020 than in 2019 (85 vs. 79%; p = 0.078). After logistic regression analysis adjusted for potential confounders (i.e., maternal BMI, parity, mode of delivery, gestational age, and size at birth), study period remained significantly and independently associated with exclusive breastfeeding at discharge (OR [95% CI] = 1.645 [1.005; 2.694]; p = 0.046). Newborns born in 2020 were less likely to have weight loss ≥10% than those born in 2019 (OR [95% CI] = 2.596 [1.148; 5.872]; p = 0.017) but had similar need for phototherapy (p = 0.41). Conclusion: The success of exclusive breastfeeding during the 2020 lockdown period was increased compared with the same period in 2019.

© 2023 The Author(s). Published by S. Karger AG, Basel

Introduction

The year 2020 was marked by the emergence of the SARS-CoV-2 coronavirus infection (COVID-19), which resulted in a significant number of deaths worldwide [1]. Governments responded to the pandemic in different ways. In France, a total lockdown was imposed on March 16, 2020, to limit human-to-human transmission of the virus [2, 3]. At the same time, restrictions were put in place in hospitals to limit the risk of infection [4]. In addition to protocols to protect caregivers, measures were introduced to protect patients. These included postponing nonemergency care, shortening the length of hospital stay when possible, and limiting and/or prohibiting visits from friends and family to hospitalized patients [5–8].

Maternity wards are traditionally wide open to visitors. To reduce exposure of mothers and their babies to COVID-19, measures were taken in our maternity ward from the first day of lockdown. These measures aimed at reducing the length of hospital stay after birth, restricting patients’ movement within the maternity ward, and prohibiting hospital visits. Initially, we were concerned about the impact of the pandemic on general maternal stress and the potential negative impact on breastfeeding success. On the other hand, we hypothesized that mothers would be more likely to exclusively breastfeed because of the known anti-infective properties of breastfeeding and because rooming-in during the lockdown may have promoted breastfeeding success.

The abrupt changes due to the lockdown provided us with a unique opportunity to test the hypothesis that limiting patient and visitor traffic in the maternity ward may favor the establishment of an early and close mother-infant relationship, with potential positive effects on breastfeeding success and infant health. Therefore, the primary objective of our study was to compare the rate of exclusive breastfeeding at discharge during the 2020 lockdown period with the same period in the previous year. The secondary objectives were to investigate the potential impact of the lockdown on newborn health.

Materials and MethodsType of Study

We performed a single-center comparative study to compare data collected during the lockdown period (March 17-May 11, 2020) with those collected during the same period in the previous year (March 17-May 11, 2019). Data were retrieved from our institutional and certified software specifically designed for the follow-up of pregnant women and their newborns (DIAMM®; Micro6 SARL, Villers-les-Nancy, France). All data are prospectively entered into this database, by 2 dedicated midwives throughout the year.

The primary outcome was exclusive breastfeeding at discharge from the maternity ward in women who desired to exclusively breastfeed their infant at the time of delivery. Secondary outcomes were neonatal morbidities, which included weight loss ≥10% and phototherapy.

Protocol Established in the Maternity Ward during the Lockdown Period

Prior to lockdown, visits to the maternity ward were allowed for fathers, family, and friends. Visiting hours for fathers were 24 h a day, 7 days a week, and for family and friends from 1:00 p.m. to 8:00 p.m. Mothers had the option of entrusting their newborn to the nursery for part of the night, depending on their preference and state of postpartum fatigue. Parents were free to move around within the maternity ward. The duration of postpartum hospitalization was ∼3 days after vaginal delivery and ∼5 days after caesarean section. For mother-infant pairs at low medical, psychological, and social risk, early discharge could be organized on the 2nd day after delivery in the case of vaginal delivery and on the 3rd or 4th day in the case of caesarean section according to the conditions specified in national guidelines [9]. Briefly, these criteria for early discharge were singleton, eutrophic full-term newborn, normal clinical examination 48 h after birth, normal and stable body temperature, established feeding (if breastfed: observation of at least 2 feedings ensuring effective transfer of milk recognized by the mother), and a weight loss <8% compared to birth weight.

During the lockdown period, sick mothers or mothers who were carriers of COVID-19 were isolated in a ward different from the maternity ward. The protocol at the maternity was modified to promote early discharge of mothers and infants at low medical, psychological, and social risk, according to the national recommendations [9]. During this period, only the father or a trusted person designated by the mother was allowed to enter the maternity ward, in accordance with the recommendations of the World Health Organization (WHO) [10]. He was asked either to stay in the mother’s room or to go home, without the possibility of coming back. If there were no contraindications, the newborns remained in the mother’s room day and night. The mother and the trusted person were instructed to stay in the mother’s room. Information on breastfeeding during pregnancy and after delivery was similar in both periods, and no specific actions were taken to promote breastfeeding between the two study periods.

Inclusion and Exclusion Criteria

All neonates who were born alive after a single pregnancy and had a gestational age greater than 36 weeks were considered for this study. Inclusion criteria included a length of hospital stay in the maternity ward of ≥1 day and <8 days, longer hospitalizations being usually associated with maternal pathology or precariousness.

All neonates who were transferred to the neonatology unit, whose medical records were incomplete, whose sex was undetermined, who had blood group incompatibility or congenital hemolytic anemia, or who had a malformation or symptomatic CMV infection that affected general health, feeding capabilities, or growth, and those whose mother had COVID-19 infection were excluded. Conversely, infants with an isolated minor malformation were left in the study (i.e., unilateral cryptorchidism, supernumerary finger, low-grade hydronephrosis, hypospadias, ovarian cyst, ectopic kidney, or nonsymptomatic CMV infection).

Data Collection

Maternal data included maternal age (categorized as ≥33 or <33 years), marital status (couple or single), body mass index above or below 25 kg/m2, parity (0, 1, 2, or more), and social precariousness defined by the lack of a permanent home. Delivery data included type of delivery (cesarean or vaginal), presence or absence of hemorrhagic delivery, defined as uterine bleeding that occurred within 24 h of delivery and had an estimated blood loss greater than 500 mL.

Gestational age at delivery was categorized as 36–38 weeks (i.e., late preterm and early term) and 39–41 weeks (i.e., full-term). Birth weight (BW) was categorized as 2,500–2,999 g, 3,000–3,499 g, 3,500–3,999 g, and ≥4,000 g. Size at birth was classified as small (BW <10th percentile), appropriate (10th percentile ≤ BW ≤90ème percentile), or large for gestational age (BW >90th percentile). Gender, Apgar score above or below 8 at 5 min, and umbilical arterial pH below or above 7.2, length of stay in the maternity ward (<3, 3, 4, or ≥5 days), weight loss greater >10% during hospitalization, and jaundice requiring phototherapy were also collected.

As part of the routine procedure, mothers were asked by the midwife in charge at the time of delivery about their desire to breastfeed their infant. Their responses were classified as a desire for exclusive breastfeeding, formula feeding, or mixed feeding. The type of feeding the newborn actually received at the time of discharge was recorded and classified as exclusive breastfeeding or not. The success of exclusive breastfeeding among women who desired to exclusively breastfeed their infant was considered only if exclusive breastfeeding was observed at discharge from the maternity unit.

Statistics

Data were analyzed with Minitab 18.1 software (Minitab Inc. USA). Maternal and infant characteristics were compared across the two study periods (2019 and 2020) using χ2 tests. A p value of less than 0.05 was considered statistically significant.

To examine relationship between study periods and outcomes, we performed logistic regression analyzes and quantified associations by ORs and their 95% CIs. We included in the model potential confounders expected to affect outcomes. In addition, we included in the analyses covariates that were associated with outcomes in univariate analyses. Covariates were included in the logistic regression model if they were associated with outcomes in the univariate analysis with a p value of <0.2.

For breastfeeding success, we included maternal BMI, parity, mode of delivery, gestational age, and size at birth as potential confounders. Because Apgar score and length of stay were significantly associated with breastfeeding success, we included these factors as covariates.

For weight loss ≥10%, we included parity, precariousness, mode of delivery, size at birth, length of hospital stay, and exclusive breastfeeding as potential confounders and Apgar score and duration of hospital stay as covariates. Only those variables that remained statistically associated with outcomes are reported.

ResultsClinical Characteristics

A total of 639 newborns were included in the study, 330 in 2019 and 309 in 2020 (Fig. 1). There was no significant difference between the two periods in maternal and infant characteristics at birth, except for the distribution of birth weight (p = 0.015) and mode of delivery (p = 0.03) (Table 1). Length of hospital stay differed significantly between the two study periods showing that infants were discharged significantly earlier in 2020 than in 2019 (p < 0001).

Fig. 1.Table 1.

Characteristics of the infants included during the 2020 lockdown period and the same period of the previous year (i.e., 2019)

2019 (n = 330), n (%)2020 (n = 309), n (%)p valueMothersAge ≥33 years201 (61)170 (55)0.13BMI ≥25 kg/m281 (25)88 (29)0.27Single mother13 (4)12 (4)0.96Parity 0150 (46)148 (48) 1107 (32)104 (34)0.51 2 or more73 (22)57 (18)Precariousness21 (6)15 (5)0.41DeliveryCaesarean section58 (18)76 (25)0.03Postpartum hemorrhage16 (5)24 (8)0.12NewbornGender (girl)172 (52)149 (48)0.32Gestational age (weeks) 36–3874 (22)83 (27) 39–41256 (78)226 (73)0.19Birth weight, g 2,500–2,99968 (21)91 (29)0.015 3,000–3,499152 (46)145 (47) 3,500–3,99992 (28)59 (19) ≥4,00018 (5)14 (5)Size at birth Appropriate for gestational age272 (83)260 (84) Small for gestational age41 (12)39 (13) Large for gestational age17 (5)10 (3)0.48pH at birth <7.256 (17)43 (14)0.30Apgar score at 5 min ≥8325 (98)303 (98)0.68Mode of feeding wished by the mother at time of delivery Exclusive breastfeeding261 (79)228 (74)0.22 Mixed feeding16 (5)23 (5) Formula feeding53 (16)58 (19)Jaundice requiring phototherapy25 (8)29 (9)0.41Weight loss ≥10%21 (6)9 (3)0.04Length of hospital stay <3 days30 (9)59 (19)0.001 3 days169 (51)129 (42) 4 days495 (29)79 (26) ≥5 days36 (11)78 (12)Impact of Study Period on the Success of Breastfeeding

At the time of delivery, the percentage of women who desired to exclusively breastfeed was similar in 2020 and 2019 (p = 0.22) (Table 1). Among women who wanted to exclusively breastfeed, the rate of exclusive breastfeeding at discharge was higher in 2020 than in 2019 (85 vs. 79%; p = 0.078) (Table 2).

Table 2.

Perinatal factors associated with the success of exclusive breastfeeding in 489 women who expressed their desire to exclusively breastfed at time of delivery

Exclusively breastfed at dischargep valueno (n = 89), n (%)yes (n = 400), n (%)Period201955 (62)206 (52)0.078202034 (38)194 (49)MothersAge ≥33 years48 (54)237 (59)0.36BMI ≥25 kg/m235 (40)87 (22)<0.001Single mother3 (3)13 (3)0.92Parity 039 (44)199 (50)0.094 126 (29)133 (33) 2 or more19 (27)68 (17)Precariousness7 (28)18 (72)0.194DeliveryCaesarean section24 (27)77 (19)0.104Postpartum hemorrhage6 (7)22 (6)0.64NewbornGender (girl)43 (48)204 (51)0.65Gestational age (weeks) 36–3829 (33)86 (22)0.026 39–4160 (67)314 (78)Birth weight, g 2,500–2,99928 (31)94 (24)0.36 3,000–3,49941 (46)187 (47) 3,500–3,99916 (18)97 (24) ≥4,0004 (4)22 (5)Size at birth Appropriate for gestational age67 (17)338 (83)0.023 Small for gestational age19 (31)43 (69) Large for gestational age3 (14)19 (86)pH at birth <7.212 (14)60 (15)0.67Apgar score at 5 min ≥885 (96)395 (99)0.039Length of hospital stay <3 days13 (15)47 (12)0.053 3 days32 (36)196 (49) 4 days27 (30)115 (29) ≥5 days17 (19)42 (11)

After logistic regression analysis adjusted for potential confounders (i.e., maternal BMI, parity, mode of delivery, gestational age, and size at birth), study period was significantly and independently associated with exclusive breastfeeding at discharge from the maternity ward (OR [95% CI] = 1.645 [1.005; 2.694]; p = 0.046) (Table 3). Similar results were obtained when gestational age was used as a continuous variable (OR [95% CI] = 1.695 [1.032; 2.783]; p = 0.035). Further logistic regression analysis adjusted for potential confounders and including as covariates factors that were significantly associated with exclusive breastfeeding at discharge in the univariate analysis (i.e., Apgar score and length of hospital stay) did not change the results.

Table 3.

Logistic regression model to analyze the association between breastfeeding success and time period (2019 vs. 2020), adjusted for potential confounders (i.e., maternal BMI, parity, mode of delivery, gestational age, and size at birth)

Category (n = 228)Reference (n = 261)OR [95% CI]p value202020191.645 [1.005; 2.694]0.046Mother’s BMI ≥ 25Mother’s BMI <250.359 [0.215; 0.599]<0.001SGAAGA0.344 [0.182; 0.650]0.004LGAAGA1.537 [0.428; 5.526]0.00436–38 weeks GA39–41 weeks GA0.480 [0.283; 0.816]0.008Impact of Study Period on Weight Loss ≥10%

Newborns born in 2020 were less likely to have a weight loss ≥10% than in 2019 (3% and 6%, respectively; p = 0.04) (Table 1). After logistic regression analysis adjusted for potential confounders (i.e., parity, precariousness, mode of delivery, size at birth, length of hospital stay, and exclusive breastfeeding), study period remained significantly and independently associated with weight loss ≥10% (OR [95% CI] = 2.596 [1.148; 5.872]; p = 0.017). Further logistic regression analysis adjusted for potential confounders and including as covariates factors that were significantly associated with breastfeeding success in the univariate analysis (i.e., Apgar score and length of hospital stay; online suppl. Table 1; for all online suppl. material, see www.karger.com/doi/10.1159/000530080) did not change the results.

Impact of Study Period on Phototherapy Treatment

The proportion of infants who required phototherapy was similar in 2020 and 2019 (p = 0.41). No further analysis was performed on this outcome.

Discussion

Our study shows that the widespread lockdown and associated measures within the maternity ward to reduce exposure of mothers and their newborns significantly improved the success of exclusive breastfeeding. These measures restricted the mother-infant dyad or mother-trusted person-infant triad to the mother’s room and prohibited visits from family members and friends, thus increasing rooming-in practice. These changes could be a plausible reason for the observed effect. Indeed the literature shows that mother-infant closeness and prolonged breastfeeding moments in the early postpartum period are important for milk production and breastfeeding success [11]. Maternal rest and quiet time in the postpartum period are known to increase the likelihood of breastfeeding [12]. The number of visitors and noise in the maternity ward has a negative impact on the postpartum period, a time that should be dedicated to the mother’s recovery, the establishment of the mother-infant bond, and the newborn’s well-being [13]. The lack of confidentiality and privacy because of external visitors also affects breastfeeding initiation [14]. It has been shown that skin-to-skin contact was facilitated during the pandemic, which may also have been the case in our study due to the 24-h rooming-in that was a consequence of the measures implemented [15]. Fewer periods of separation between mother and infant may have reduced the risk of bottle-feeding by health care staff while the mother is resting, e.g. [16], which is a known cause of breastfeeding failure [17]. Finally, the longer time spent by the companion in the maternity ward increases maternal well-being and may have indirectly promoted breastfeeding [18]. Overall, our study supports the concept of family- and baby-centered care and the Baby Friendly Hospital Initiative, which promotes rooming-in practice [19]. It also supports the concept that visits in maternity hospitals should be open to fathers or trusted persons, but more limited for other visitors [20].

Excessive weight loss, defined as a weight loss >10% may affect up to 10% of neonates in the well-newborn nursery [21]. There are numerous factors associated with excessive weight loss, including maternal or infant morbidities, low gestational age, cesarean section, exclusive breastfeeding, and breastfeeding difficulties [22, 23]. Our study shows that changes in the maternal environment in the maternity ward significantly reduced the risk of excessive weight loss. Our study does not allow us to determine exactly which factor(s) was (were) the predominant one(s). However, we hypothesize that 24-h rooming-in, which was a consequence of the measures implemented, may have favored early milk production through an early skin-to-skin contact [24]. Limiting visits also reduces interruptions in care and results in the mother having more time to carry and care for her newborn [25].

We recognize that our study has some limitations. The measures implemented have significantly shortened the length of hospital stay in our maternity unit, with the aim of reducing the risk of exposure of mothers and their newborns. Because infants and mothers were not followed up after discharge, we were unable to report severe weight loss or breastfeeding failure that may have occurred after discharge. Because the study used data from a database that was not specifically designed to identify factors associated with breastfeeding, some factors associated with breastfeeding failure (e.g., induced labor and epidural analgesia) or success (e.g., earlier breastfeeding, birth plan, initiation of breastfeeding within the first hour, and skin-to-skin contact) were not examined.

In conclusion, our study showed a significant increase in the success of exclusive breastfeeding and a significant decrease in infant weight loss ≥10% during hospitalization in the maternity ward during the period of lockdown because of the COVID-19 pandemic compared with the same period in 2019.

Acknowledgments

We thank Zanoubia Darwich and Mengrithy Ngor for their input in the data analysis, and Frédérique Quetel for her help in collecting data.

Statement of Ethics

According to French law, the study has been declared at the “Commission Nationale de l’informatique et Liberté” as corresponding to the reference methodology (MR-004) (https://www.cnil.fr/fr/declaration/mr-004-recherches-nimpliquant-pas-la-personne-humaine-etudes-et-evaluations-dans-le). The protocol was reviewed, approved, and registered in the institutional register of the Assistance Publique-Hôpitaux de Paris under the number 20201002153913. The reference methodology (MR-004) is a simplified procedure, which does not require an approval by an Ethics Committee. Informed consent was not required per se but parents were informed by a note at the end of all hospitalization and consultation reports of the possibility of collecting clinical data for research purposes and of their right to refuse such research. The processing of the data has been carried out in accordance with the EU Regulation 2016/679 of the European Parliament and of the Council of April 27, 2016, on the protection of individuals with regard to the processing of personal data and free circulation of such data.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This study has been supported by the nonprofit organization ARFEN but this organization played no role in the study design, preparation, and interpretation of data, or writing of the manuscript.

Author Contributions

Alexandre Lapillonne designed the study, had access to the data, performed the analysis, and drafted the manuscript. Christine Pichon and Muriel Nicloux were involved in conception and design of the study and critically revised the manuscript. Benoit Renaudin was involved in data collection, quality control of the data, and critically revised the manuscript. Yves Ville and Virginie Rigourd provided substantial intellectual input critically revised the manuscript. Alexandre Lapillonne, Christine Pichon, Benoit Renaudin, Muriel Nicloux, Virginie Rigourd, and Yves Ville approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Data Availability Statement

Data are available on request to the corresponding author. All data analyzed during this study are included in this article and its supplementary materials. Further inquiries can be directed to the corresponding author.

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