BREASTFEEDING MEDICINE

Volume 17, Number 1, 2022

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2021.0238

The Impact of COVID-19 on Breastfeeding Rates

in a Low-Income Population

Maria Koleilat,1,i Shannon E. Whaley,2 and Cindy Clapp3

Abstract

Objective: To examine the impact of the coronavirus disease 2019 (COVID-19) pandemic on breastfeeding
outcomes among participants of the Special Supplemental Nutrition Program for Women, Infants, and Children
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(WIC) in Southern California.

Materials and Methods: Data from the 2020 Los Angeles County triennial WIC Survey were used to examine
the impact of COVID-19 on breastfeeding outcomes among WIC participants. Chi-square tests were used to
explore the association between the COVID-19 pandemic and breastfeeding outcomes along with hospital-
friendly practices.
Results: Compared with infants born before March 2020, the percentage of infants who received any breast-
feeding at 1 month decreased from 79.66% to 76.96% ( p = 0.139). The percentage of infants who received any
breastfeeding at 3 and 6 months significantly decreased from 64.57% to 56.79% ( p = 0.001) and from 48.69% to
38.62% ( p = 0.0035), respectively. The percentage of infants fully breastfed at 1, 3, and 6 months significantly
decreased at all time points. Examining hospital practices, there were no differences between the before and
during COVID-19 groups.
Conclusions: The prevalence of any breastfeeding at 3 and 6 months and fully breastfeeding at 1, 3, and 6
months was significantly lower among mothers who gave birth during the pandemic compared with mothers
who gave birth before the pandemic. The shift to remote services delivery and the corresponding reduction in
live support of WIC services owing to the pandemic may explain the decline in the breastfeeding rate. As the
nation and the WIC program prepare for the postpandemic life, it is critical to ensure that breastfeeding support
is met in a hybrid of remote and face-to-face settings.

Keywords: COVID-19, breastfeeding, WIC, low-income

Introduction breastfeeding women and infants and children up to the age of 5

T he Novel Coronavirus Disease 2019 (COVID-19)
pandemic has resulted in many public health nutrition
crises, including decreased access to nutritious food and
increased food insecurity.1 With low-income populations
already disproportionately affected by such problems,
COVID-19 has further exacerbated these disparities.2 In
response, federal nutrition programs have introduced
waivers, extending flexibility to support the nutritional
health status of low-income participants during the
COVID-19 pandemic.3,4
The Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC) is a federal supplemental nutrition
assistance program that serves pregnant, postpartum, and
years who live in households at or <185% of the federal poverty
level and are at nutritional risk.5 Participants of the program
receive nutrient-dense supplemental food, nutrition and
breastfeeding education, and social/medical services referrals.5
Breastfeeding education is one of the pillars of the WIC
program. In addition to providing staff with the proper lac-
tation training, the WIC program promotes and supports
breastfeeding by supplying breast pumps to participants,
providing less or no formula to breastfeeding mothers espe-
cially during the first month of life, providing a larger WIC
food package to breastfeeding mothers, and providing access
to lactation support staff and peer counselors.6 Peer lactation
counseling has been associated with increased rates of
breastfeeding initiation, duration, and exclusivity.7

1
Department of Public Health, College of Health and Human Development, California State University, Fullerton, California, USA.
2
Division of Research and Evaluation, PHFE WIC Program, a Program of Heluna Health, Irwindale, California, USA.
3
Breastfeeding Services, PHFE WIC Program, a Program of Heluna Health, Irwindale, California, USA.
i
ORCID ID (https://orcid.org/0000-0002-3244-7793).

1
 2 KOLEILAT ET AL.
With unwavering dedication and commitment, the WIC
program has made great strides in breastfeeding promotion and
support over the years, leading to a steady increase in breast-
feeding rates among its participants.8,9 As the COVID-19
pandemic unraveled, WIC services began to operate remotely
to safeguard the health of its staff and participants. How the
COVID-19 pandemic and the resulting remote services impact
breastfeeding outcomes among WIC participants is not well
understood. On the one hand, given that participants were
spending more time at home and the nation was experiencing a
widespread formula shortage,10 partly owing to panic buying,
an increase in breastfeeding could be expected. On the other
hand, isolation, lack of hands-on support and clear guidance,
and mixed messages from media outlets about breastfeeding
safety during COVID-1911,12 could be associated with a decline
in breastfeeding.
This study examines the impact of COVID-19 on breast-
feeding outcomes among WIC participants in Southern Ca-
lifornia, utilizing data from the 2020 Los Angeles County
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(LAC) WIC survey. A greater understanding of these impacts
will guide practice and policy on how to best support WIC
mothers in times of crisis.
Materials and Methods
Data sources and study sample
Data for this study were from the 2020 LAC triennial WIC
Survey. The LAC triennial WIC survey is a cross-sectional
computer-assisted telephone interview survey that asks WIC
families about their WIC services, health care, and public
service experiences in addition to their home and commu-
nity environments. The survey was conducted among a
randomly selected sample of pregnant and breastfeeding
mothers and mothers of children up to their fifth birthday
who were enrolled in WIC at the time of the survey between
July and December 2020. To be eligible to participate, the
respondent also had to be an LA County resident, at least 17
years of age, and be able to complete the survey in English
or Spanish.
To ensure that certain races and ethnicities were not un-
derrepresented in the sample, this random countywide sam-
ple was augmented with additional random samples of Asian
WIC families, Black WIC families, and WIC families re-
siding in target communities within the county. A total of
6,753 surveys were completed, with a response rate of 53%.
Up to 16 calls were made to reach and interview eligible
subjects from each usable telephone listing dialed. Primary
reasons for nonresponse included repeated failure to respond
to calls, invalid phone numbers, ineligible respondents, and
refusals. For this study, we restricted the sample to infants
born in LAC hospitals, younger than 2 years of age at the time
of the survey, and whose biological mothers were inter-
viewed, resulting in a final sample size of 2,426.
The survey was reviewed and approved by the Committee
for the Protection of Human Subjects for the California
Health and Human Services Agency.
Study variables
Mothers were asked to report if their babies were breastfed.
Any breastfeeding was defined as whether the child was ever
breastfed. Any breastfeeding duration (at 1, 3, and 6 months)
was computed using the child’s age in months at which the
mother stopped breastfeeding her child. A child was con-
sidered fully breastfed if they were fed only breast milk at the
hospital and afterward without any supplemental food or
drink. Fully breastfeeding duration (at 1, 3, and 6) was cal-
culated by the age at which the child was given anything
besides human milk.
Breastfeeding outcomes were examined dependent on
whether their baby was born before or during the pandemic
using the cut-off date of March 2020. Stay-at-home ordi-
nances owing to the COVID-19 pandemic were issued for
both the City of LA and the State of California on March 19,
2020. For parents of infants born since March 2020, partici-
pants were asked whether the COVID-19 pandemic made
them more likely to breastfeed, less likely to breastfeed, or
had no influence on their decisions around breastfeeding.
Sixty birthing hospitals were identified at the time of the
survey, and 21 had a baby-friendly designation. LAC hos-
pitals’ baby-friendly designation status, where WIC infants
were born, were obtained from Baby-friendly USA.13
Mothers were asked about 3 baby-friendly hospital practices
related to the 10 steps to successful breastfeeding—whether
the child was ‘‘breastfed in the first hour after birth’’ (Step 4),
‘‘The hospital gave the respondent formula to take home’’
(Step 6), and ‘‘the hospital gave a telephone number to call
for help with breastfeeding’’ (Step 10).
According to the Baby-Friendly Hospital Initiative (BFHI)
Ten Steps to Successful Breastfeeding,14 mothers should be
supported to initiate breastfeeding as soon as possible after
birth; hospitals should not provide mothers formula to take
home, and hospitals should coordinate discharge so that
mothers have timely access to breastfeeding support and care.
Mothers’ binary responses to these questions were used to
examine changes in baby-friendly hospital practices during
the COVID-19 pandemic.
Sociodemographic characteristics used to describe the
sample included the child’s gender and age, mother’s age,
education, and ethnicity.
Data analysis
Data were weighted to align the distributions of the WIC
recipients interviewed to demographic and geographic
characteristics of the overall WIC recipient population’s
demographic and geographic characteristics. Data were an-
alyzed using SAS 9.4. Descriptive statistics explored demo-
graphics and breastfeeding outcomes before and during the
COVID-19 pandemic. Chi-square tests explored the associ-
ation between COVID-19 and breastfeeding outcomes, and
between COVID-19 and hospital-friendly practices.
Results
At the time of the 2020 survey, children’s mean (standard
deviation) age was 12.12 (6.44) months, and 48.51% were
women. About 72.43% of children had mothers who were
Hispanic, and 77.2% had mothers with at least a high school
education. The mothers’ mean (standard deviation) age was
30 (6.35) years. In addition, 52.56% of WIC children were
born in a baby-friendly hospital. Mothers of infants born
since March 2020 were asked whether the COVID-19 pan-
demic made them more likely to breastfeed, less likely to
breastfeed, or had no influence on their decisions around
 COVID-19 AND BREASTFEEDING AMONG WIC PARTICIPANTS
Table 1. Did the Coronavirus Disease Pandemic
Make you More Likely to Breastfeed, Less Likely
to Breastfeed, or did it Have no Influence on
Your Decisions Around Breastfeeding?
% (n)
More 16.53% (119)
Less 6.97% (50)
No influence 74.59% (536)
Missing 1.92% (14)
breastfeeding, and the majority of respondents (75%) said
that COVID-19 did not influence their decisions around
breastfeeding (Table 1).
Table 2 shows that, compared with infants born before
March 2020, the percentage of infants who received any
breastfeeding at 1 month decreased from 79.66% to 76.96%.
Although this decrease at 1 month was not statistically sig-
nificant ( p = 0.139), the percentage of infants who received
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any breastfeeding at 3 and 6 months significantly decreased
from 64.57% to 56.79% ( p = 0.001) and from 48.69% to
38.62% ( p = 0.0035), respectively. The percentage of infants
fully breastfed at 1, 3, and 6 months significantly decreased at
all time points. Comparing fully breastfeeding rates pre-
COVID-19 to during COVID-19, rates of fully breastfeeding
dropped from 41.79% to 28.09% ( p < 0.0.0001) at 1 month,
28.51% to 18.06% ( p < 0.0001) at 3 months, and 15.66% to
10.38% ( p = 0.0318) at 6 months.
Examining hospital practices, there were no differences
between the two groups. The percentage of infants breastfed
in the first hour was not statistically different between chil-
dren born before the pandemic and those born during the
pandemic. Similarly, the percentage of mothers reporting not
receiving a formula pack to take home was not statistically
different between mothers giving birth before the pandemic
and those giving birth during the pandemic. In addition, the
percentage of mothers reporting receiving a phone number to
the breastfeeding helpline was not statistically different be-
tween mothers giving birth before the pandemic and those
giving birth during the pandemic (Table 3).
Discussion
This study explored breastfeeding outcomes comparing
mothers who gave birth before the pandemic (March 2020)
with those who gave birth during the pandemic (after March
2020). Although the majority (74.6%) of WIC mothers ex-
pressed that the COVID-19 pandemic did not have an influ-
ence on their decisions around breastfeeding, the prevalence of
Table 2. Breastfeeding Outcomes Among Special Supplemental Nutrition Program for Women, Infants,
and Children Participating Born Before and After March 2020
Total (N = 2,426)
Any breastfeeding at 1 month 78.89% (1925)
Any breastfeeding at 3 months 62.72% (1430)
Any breastfeeding at 6 months 47.47% (942)
Fully breastfeeding at 1 months 37.89% (924)
Fully breastfeeding at 3 months 26.06% (594)
Fully breastfeeding at 6 months 15.02% (298)
3
any breastfeeding at 3 and 6 months and fully breastfeeding at
1, 3, and 6 months was significantly lower among mothers who
gave birth during the pandemic compared with mothers who
gave birth before the pandemic. This decline was not unique to
WIC mothers, as similar results were reported in other stud-
ies.12,15 For example, Brown and Shenker found that mothers
with lower education, more challenging living circumstances,
and Black and minority ethnic groups were more likely to find
the impact of lockdown challenging and stop breastfeeding.15
In addition, studies have shown that disruption of the baby-
friendly hospital practices in some institutions at the begin-
ning of the pandemic adversely affected breastfeeding.16
However, this was not the case in our study. The percentage
of mothers reporting baby-friendly practices at the hospital
where they gave birth was not statistically different between
mothers who gave birth before the pandemic and those who
gave birth during the pandemic.
Although in-depth qualitative research is needed to under-
stand the reasons for the decline in breastfeeding outcomes
among WIC mothers, the following are possible explanations.
It is well understood that breastfeeding is best supported by
high-quality professional and peer support.17–19 A study con-
ducted in the United Kingdom to understand the impact of the
pandemic upon breastfeeding outcomes found that the most
common reason for breastfeeding cessation was insufficient
professional support.15 Women were affected by not seeing
their health professionals face to face, especially during the
early weeks of breastfeeding when care needs are the highest.15
Breastfeeding support is a priority in the WIC program.
However, the shift to remote services delivery and the cor-
responding reduction in live support of WIC services owing
to the pandemic may explain the decline in breastfeeding
rates and the increase in early weaning in 2020.
Another possible explanation is the mixed messages that
new parents received regarding the safety of COVID-19 and
breastfeeding. Early on, the American Academy of Pediatrics
recommended separating mother and baby with suspected in-
fection.16 That guidance was changed as evidence emerged that
mother-to-infant transmission of COVID-19 during pregnancy
and after birth is unlikely and that the rates of infection and risk
of severe disease in infants are very low.20 In fact, given the
antimicrobial and anti-inflammatory properties of breast
milk,21 the World Health Organization (WHO) recommends
that women with COVID-19 breastfeed their babies and that
direct breastfeeding (i.e., feeding directly from the breast) is the
preferred infant feeding option during the pandemic.22
Although the message is clear now, those early mixed
messages likely led to fears around safety and resulted in
breastfeeding cessation.15 A survey conducted in Mexico
Children born before Children born after
March 2020 (n = 1,740) March 2020 (n = 686)
79.66% (1390) 76.96% (534), p = 0.1396
64.57% (1127) 56.70% (303), p = 0.001
48.69% (850) 38.62% (92), p = 0.0035
41.79% (729) 28.09% (195), p < 0.0001
28.51% (498) 18.06% (97), p < 0.0001
15.66% (273) 10.38% (25), (p = 0.0318)
 4 KOLEILAT ET AL.
Table 3. Baby-Friendly Hospital Practices Reported by Mothers of Special Supplemental Nutrition
Program for Women, Infants, and Children Participating Born Before and After March 2020
Total
Child breastfed in the first hour 74.73% (n = 1842)
Not given formula pack to take home 50.91% (n = 1255)
Given phone number to breastfeeding helpline 84.06% (n = 2072)
Chi-square tests were not significant.
found that, despite positive messaging promoted by the
government about breastfeeding during the pandemic, most
respondents expressed that an infant should not be breastfed
if the mother is infected with COVID-19.12 Such beliefs were
especially common among lower socioeconomic groups.12
Another explanation could be the increased rate of perinatal
depression that emerged during COVID-19 because of social
isolation, financial difficulties, and health worries.23 Studies
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have shown that mothers who experience postpartum de-
pression are at increased risk of breastfeeding cessation.24
However, research has not yet examined the rates of perinatal
depression among WIC participants during the pandemic.
The question arises as to how to move forward. Before the
pandemic, there had been a steady increase in breastfeeding
rates among WIC participants.25 Comparing the postpan-
demic breastfeeding rates to our previous work in 2019,26
prepandemic breastfeeding rates (children born before March
2020) were generally higher than breastfeeding rates at 3 and
6 months in 2017 (data not shown), suggesting that pandemic
may have disrupted an improving trend in the duration of any
and fully breastfeeding. Owing to the COVID-19 pandemic,
these improvements may slow down if actions to promote and
protect breastfeeding are not taken.
Although the intersection of the challenges created by the
COVID-19 pandemic and new remote technologies has led
the WIC program to a place with unexpected service delivery
opportunities, in-person care is still invaluable when it comes
to breastfeeding. Although some studies have shown that tel-
emedicine support can improve breastfeeding outcomes,27,28 it
is well known that what women value most is the emotional
care and warmth of professionals and peers, and that is more
likely to occur during face-to-face interactions.29,30 Through
in-person care, counselors can provide more than just practical
breastfeeding support. Counselors can clear up any mixed
messages regarding COVID-19 and breastfeeding and screen
WIC mothers for signs of depression.
It is recognized that remote access has been essential for
keeping the WIC program accessible to the thousands of
families in need of nutrition support during the pandemic.4 In
fact, with the onset of the COVID-19 pandemic, the USDA
granted states waivers to deliver WIC operations remotely
through telephone, video-conferencing, and online education
options.3 As a result, participation in the program increased in
many regions. For example, data from the Public Health
Foundation Enterprises WIC (PHFE WIC) program in
Southern California showed a 24% increase in participation
between February and June 2020.4
However, as the nation and the WIC program prepare for the
postpandemic life, it is critical to ensure that breastfeeding
support is met in a hybrid of remote and face-to-face settings. In
addition, as it becomes safe to return to live WIC support, our
Children born before Children born after
March 2020 (n = 1,740) March 2020 (n = 686)
75.16% (n = 1312) 73.69% (n = 530)
47.18% (n = 823) 49.68% (n = 357)
84.32% (n = 1472) 83.42% (n = 600)
findings suggest that the live support of breastfeeding dyads is a
priority. It is also critical to follow-up with mothers who could
not meet their breastfeeding goals owing to the COVID-19
pandemic, as studies have shown that mothers can experience
complications and an increased risk of depression, grief, and
trauma if they cannot meet their breastfeeding goals.15
Our study shows an association between the pandemic and
breastfeeding outcomes among WIC participants but cannot
support causality or address the participants’ breastfeeding
experiences. Another limitation is our examination of only 3
baby-friendly hospital practices versus the 10 steps. Finally, all
data were self-reported; thus, there is a possibility that ma-
ternal self-report for the period before the pandemic began was
different than for the period since the pandemic started.
However, to minimize poor recall and recall bias, we restricted
our sample to mothers of children younger than 2 years.
More research, particularly qualitative research, is needed
to understand the breastfeeding experiences of WIC partici-
pants. The WIC program and health care professionals can
use such insights to ensure that breastfeeding women are
better supported should future events arise that limit face-to-
face contact with pregnant and postpartum women.
Authors’ Contributions
M.K. conducted the analyses, interpreted the results, and
wrote the article. S.E.W. conceptualized the study, worked
closely with M.K. on the analysis plan, and reviewed and
revised all aspects of the article. C.C. provided her expertise
on breastfeeding services and reviewed and revised all as-
pects of the article.
Disclosure Statement
The authors declare that they have no competing interests.
Funding Information
Funding for this work was provided by a grant from First 5
LA to PHFE WIC.
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Address correspondence to:
Maria Koleilat, DrPH, MPH
Department of Public Health
College of Health and Human Development
California State University
800 N. College Blvd
Fullerton, CA 92831
USA
E-mail: mkoleilat@fullerton.edu