It has been reported that the virus that appeared in the Wuhan province of China in December 2019 is 80% similar to SARS-CoV, but it is a new virus that has never been encountered so far. This recent virus, which affected the whole world in a short time, was defined as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The World Health Organization (WHO) proposed that the disease caused by SARS-CoV-2 was temporarily called "novel coronavirus (2019-nCoV)" in January 2020, and named COVID-19 (coronavirus disease-2019) in February 2020, and declared it as a pandemic in March 2020.1 It is a known fact that the pandemic, beginning to appear in Turkey as of March 2020, and the treatment of which has not still been found although the intense isolation and quarantine measures have been taken, poses a great risk for all countries around the world.2 As of September 10, 2021, according to the WHO report, the number of cases was reported as 223022538 and the number of those who died due to pandemic was 4602882.3 The reporting of statistics on persons tested, infected, under care, and dying has been shown that the pandemic is a risk factor for individuals in all age groups. Furthermore, weakness of the immune system, chronic disease, smoking status, and age factors are important factors in terms of both transmission and spread rate and mortality.4
Breastfeeding women with a higher risk of getting infection depending on physical, hormonal, and mental alterations in their body during pregnancy and the postpartum period are among the groups where SARS-CoV-2 may pose a risk.5 The Centers for Disease Control and Prevention (CDC) reported the increased risk of severe illness and death in pregnant and recently pregnant women infected with SARS-CoV-2 compared with nonpregnant counterparts.6 However, when the studies conducted in the specific SARS-CoV-2 are examined, no evidence, that women who are in pregnancy or the postpartum period have higher ratios of getting an infection than other people, is found.5-8 Especially due to the pandemic, women experience many concerns regarding the pregnancy and postpartum period. Besides its contribution to the immunity, growth, development, and health of the child, the protective effect of breastfeeding against obesity and noncommunicable diseases in the later life, which is vital for mother and infant health during the postpartum period, supports the importance of breastfeeding.9 Many studies were reported that umbilical cord blood, placenta, and/or amniotic fluid tests for SARS-CoV-2 were found to be negative.10-12 Studies and reports, conducted regarding breastfeeding during the pandemic, state that in consideration of limited scientific evidence, human milk alone cannot be considered a vector for transmission of SARS-CoV-2.4,7,9,10,13,14 However, it should be considered that breastfeeding may increase the risk of transmission through droplet infection as a proxy for closer contacts if mothers with suspected or proven infection breastfeed their infants directly.15 In various studies, it is stated that if the suspected mother and her breast milk test are negative for 2019-nCoV there is no objection to fed infants with breast milk, and there is no obstacle in breastfeeding even in the presence of 2019-nCoV contact or infection.16-18 In other words, when the risk-benefit ratio is examined, it is stated that the benefits of human milk are higher than the risk of transmission.19 Current recommendations of United Nations International Children's Emergency Fund (UNICEF), United Nations Population Fund (UNFPA), Academy of Breastfeeding Medicine (ABM), WHO, and CDC are also for the mother and infant to stay in the same room and to continue skin contact and breastfeeding. Even in severe cases of COVID-19, it is recommended to encourage and support the mother in breastfeeding by stating that there will be no problem with breastfeeding after taking the necessary respiratory, hand-washing measures, and providing the necessary distance rule.5,7,18,20,21
While there is little and fragile evidence for SARS-CoV-2 and breastfeeding,20 allowing infants to room in with their mothers and direct breastfeeding are recommended as safe procedures if correct hygiene precautions are undertaken.22 Although some studies provide little evidence that SARS-CoV-2 RNA has been detected in breast milk samples, there is no sufficient evidence that breast milk contains an infectious virus or that breastfeeding represents a risk factor for transmission of infection to infants.23,24 So, allowing infants to room in with their mothers and direct breastfeeding are recommended as safe procedures if correct hygiene precautions are undertaken.22 Although viral respiratory infections are the main reason for hospitalization in children younger than 5 years,15 it is important to determine the breastfeeding behaviors and approaches of breastfeeding mothers in SARS-CoV-2 infection, which does not have precise information about which age group it affects in the short and long term. Although it has been expressed by many sources and institutions that the SARS-CoV-2 pandemic is a great challenge for breastfeeding mothers,12,19,25 studies evaluating mothers' breastfeeding behavior during the SARS-CoV-2 are also needed in the literature.
In this study, it was aimed to determine the level of stress caused by the events experienced due to the SARS-CoV-2 pandemic to breastfeeding women and to evaluate the breastfeeding practices influenced by women's life events and the breastfeeding women compliance with the rules established against the risk of SARS-CoV-2.
Research questions are as follows:
* What is the level of impact of the events during SARS-CoV-2 pandemic on breastfeeding women?
* What is the level of breastfeeding women compliance with the rules established against the risk of coronavirus during the SARS-CoV-2 pandemic?
* How is the reflection of the SARS-CoV-2 pandemic on breastfeeding behaviors of women?
METHODS
Study design
A prospective cross-sectional online survey design was used. This design was preferred due to its advantage in providing useful insights into a population's characteristics at a single point in time and a quick status determination in the SARS-CoV-2 pandemic.
Setting and sample
This study was conducted entirely online. Data collection work was conducted throughout Turkey between the dates of April 21 and May 10, 2020. In Turkey, the prevalence of breastfeeding in the first 6 months is 41%, and the ratio of infants who are breastfed only decreases with age. This ratio decreases to 59% among 0 to 1 month old infants, 45% between 2 and 3 months old infants, and 14% among 4 to 5 months old infants. While the median breastfeeding period for children younger than 3 years is 16.7 months, the median breastfeeding period of infants who are breastfed only is 1.8 months.26
All mothers who were breastfeeding during the study date composed the target population of the study. Sample size calculation was not made at the beginning of the study, and mothers older than 18 years, who agreed to participate in the research, and were literate, were invited over the Internet. A total of 339 breastfeeding mothers participated in the study. The post hoc power, obtained for the achievable sample size, was calculated through the G*Power 3.1 program.27 In the analysis made with .05 [alpha] error margin, 339 sample volume and moderate effect size (d = 0.25), the strength of the study (1 - [beta]) was determined to be 90%, and it was observed that the number of samples was sufficient.
Data collection
Data collection work was conducted via the web-based survey link prepared on Google Forms between the dates of April 21 and May 10, 2020. Individuals were invited to participate in the study by a research invitation link to the web-based survey. The research invitation link, which was created, was shared on social media platforms that breastfeeding mothers intensely follow such as pregnancy, birth, and breastfeeding. In addition, by contacting with doulas (birth coach) and breastfeeding counselors, which are mostly followed by breastfeeding mothers, they were asked to share the research invitation link with their followers from their own accounts. Participation was based on voluntariness. The web-based survey was fully anonymous. The potential participants were required to read an informed consent form that includes an explanation of the purpose of the study, what the data will be used for, how the data will be stored, and any potential benefits or risks incurred by participating, prior to accessing the web-based survey. Participants consented for their data to be used for research to the study by filling the web-based survey and clicking the submit button at the end. The survey was completed in approximately 10 minutes.
Within the scope of the study, the web-based survey consisted of the following parts: (I) the Impact of Events Scale-Revised and (II) the sociodemographic characteristics and breastfeeding behavior data form.
The Impact of Events Scale-Revised
It was used to determine the stress of breastfeeding women experienced due to the trauma caused by the SARS-CoV-2 pandemic. It is a self-reported scale with 22 items, developed to measure subjective tension and strain caused by traumatic events. The scale was prepared by Weiss and Marmar28 according to the American Psychiatric Association (1994) Post Traumatic Stress Disorder criteria. It is a revised version of the older version, the 15-item IES.27 The IES-R contains 7 additional items related to the hyperarousal symptoms of posttraumatic stress disorder, which were not included in the original IES.28 The scale, the original name of which is "Impact of Event Scale-Revised (IES-R)," was adapted to Turkish by Corapc[latin dotless i]oglu et al.29 It consists of 3 subscales, namely intrusion, avoidance, and hyperarousal. There are 22 items, where the severity of symptoms in the last 7 days was scored between 0 and 4, on the scale. The scores that can be obtained from the scale vary between 0 and 88. High scores indicate high levels of traumatic stress. The cut-off value for the scale was determined between 24 and 33, and both sensitivity and specificity were over 70%. The IES-R has good diagnostical performance for cut-off points between 24 and 33. Cronbach [alpha] internal consistency coefficient of the scale is 0.93.29 In this study, Cronbach [alpha] internal coefficient of the scale is 0.91.
The sociodemographic characteristics and breastfeeding behavior data form
It was prepared by the researchers to determine the sociodemographic characteristics and breastfeeding behaviors of the participants. It consisted of the following 10 questions: participants' age; level of education; infant's age; infant's diet; infant's feeding frequency with breast milk; the situation of concerning about the possibility of transmitting SARS-CoV-2 to the infant through human milk; the situation of stopping giving human milk to their infant after SARS-CoV-2 pandemic; the situation of thinking that human milk was protective against SARS-CoV-2 by strengthening the infant's immune system; the situation of altering the infant's diet after the SARS-CoV-2 pandemic; and measures taken against coronavirus risk during the SARS-CoV-2 pandemic.
Ethical considerations
For the study, the approval of the Ministry of Health Scientific Research Platform dated April 29, 2020, and the ethical permission dated April 8, 2020, and numbered 2020-08 from Eskisehir Osmangazi University, Social and Humanities Research and Publication Ethics Committee were obtained.
Data analysis
In the analysis of the data, in addition to descriptive statistics such as frequency, mean, standard deviation, and median, the [chi]2 test was used to determine the relationships between nominal variables. The statistical significance level was taken as P < .05.
RESULTS
The average age of the mothers participating in the study was 30.90 +/- 4.48 (min 18.00; max 44.00) years and 62.2% (n = 211) of them were bachelor's degrees. It was observed that 60.2% (n = 204) of the breastfeeding mothers were affected by the SARS-CoV-2 pandemic. The distribution of the scores of breastfeeding mothers on the IES-R and the subdimensions is presented in Table 1.
Only 4.1% (n = 14) of breastfeeding mothers stated that they complied with all 14 rules that the Ministry of Health has established as a protector against SARS-CoV-2 risk. The ratio of compliance with all 12 rules, excluding the seventh and twelfth rules, which are related to international travel, is 13.9% (n = 47). The most common rule applied by breastfeeding mothers was to wash their hands frequently with soap and water for at least 20 seconds with 97.6% (n = 331). The distribution of breastfeeding women to apply the rules established against coronavirus risk during the SARS-CoV-2 pandemic is presented in Table 2.
The infants of breastfeeding mothers are on average 10.38 +/- 8.01 (min 1.00; max 53.00) months old, 54.9% (n = 186) of mothers feed their infants with human milk + supplementary food, and 78.2% (n = 265) of them feed their infants whenever they want; 69.4% (n = 93) of infants in the first 6 months are breastfed and 79.9% (n = 271) of the mothers stated that human milk would be protective against SARS-CoV-2 by strengthening the infant's immune system, while 23.9% (n = 81) were concerned about the possibility of transmitting SARS-CoV-2 to the infant through human milk. After the SARS-CoV-2 pandemic, 33.6% (n = 114) of the mothers stated that they altered their infant's diet and 2.1% (n = 7) of them stated that they stopped giving human milk to their infant.
The ones, a bachelor's degree, whose infant is older than 6 months, feeding their infants with human milk + supplementary food, washing their clothes with normal detergent at 60[degrees] to 90[degrees], cleaning frequently used surfaces such as door handles, armatures, and sinks with water and detergent every day, were not concerned about the possibility of transmitting SARS-CoV-2 to their infants through human milk (for each, P < .05; see Table 3). The ones, a bachelor's degree, avoiding close contacts such as handshaking and hugging, not contacting the elderly and chronic patients, not going out without wearing a mask in case of cold symptoms, did not stop giving human milk to their infant after SARS-CoV-2 pandemic (for each, P < .05; see Table 3).
The ones, a bachelor's degree, feeding their infant with human milk whenever they want during the day, frequently ventilate the environments, think that human milk was protective against SARS-CoV-2 by strengthening their infant's immune system (for each, P < .05; see Table 4). The ones, feeding their infant with human milk whenever they want during the day, covering the mouth and nose with disposable wipes when coughing or sneezing and using the inside of their elbows in case of not having wipes, not using any personal belongings (daily items such as towels) in common, did not alter their infant's diet after the SARS-CoV-2 pandemic (for each, P < .05; see Table 4).
DISCUSSION
The SARS-CoV-2 pandemic, which affects the whole world, continues to negatively affect public health. Many factors related to the host and the environment, such as age, gender, pregnancy status, nutrition, presence of chronic disease, presence of trauma, socioeconomic conditions, and mental state, are determinants in the resistance against infectious diseases30; events during the pandemic affect each age group and health status in different ways. There are various concerns especially about whether human milk, which affects the physical, mental health, and immune system of the individual throughout the lifetime, should be given during the pandemic. In our study, it was observed that 39.2% of breastfeeding mothers were traumatically affected by the events experienced as a result of the pandemic, and 23.9% of them were concerned about the possibility of transmitting SARS-CoV-2 to the infant through human milk. In their systematic review, Martins-Filho et al31 have stated that there are fear and uncertainty about the care of children in pregnant women, even mothers who are not exposed to the virus tend to reduce breastfeeding, and this may have bad health consequences for the infant. In this direction, one of the important findings in our study was that mothers, a bachelor's degree, were not concerned about the possibility of transmitting the virus to their infants through human milk, and continued to give human milk to their infants during the pandemic. It is important to continue to breastfeed during the SARS-CoV-2 pandemic because it is known that breastfed infants have a lower risk of acute respiratory infections and the risk of infant morbidity decreases in relation to the duration of breastfeeding.14,32
When the literature was examined, there was no evidence that the virus transmits to the infant through human milk.10,33-35 Studies and reports on this subject recommend that it is necessary to continue to breastfeed by providing the necessary hygiene rules for the health of the infant; SARS-CoV-2-confirmed or symptomatic mothers breastfeed after taking the measurements, necessary to reduce the possibility of the risk of viral infection, such as washing hands before touching the infant, wearing a mask when breastfeeding, avoiding kissing infant, etc.5,7,36 In our study, it was observed that only 13.9% of breastfeeding mothers complied with all 12 other rules, excluding the seventh and twelfth rules, which are related to international travel. The first 3 of the most followed rules were determined to be to wash hands by rubbing with water and soap for at least 20 seconds with 97.6%, to frequently ventilate the environment with 92.9%, and to avoid close contact such as shaking and hugging with 91.7%.
The risk of infants getting acute respiratory infections decreases 0.56 times if they are breastfed for 3 months and 0.45 times if they are breastfed for 6 months.32 In our study, it was observed that 69.4% of the infants, who were in the first 6 months, were breastfed only. In a study conducted on infants younger than 6 months, it has been shown that although breastfeeding at the onset of symptoms is associated with a higher risk of viral respiratory infections, protection against viral respiratory infections increases as breastfeeding time increases.15 In addition, studies reveal that breastfeeding is effective not only in strengthening the immune system in the first years of life, but also in less caught up with childhood cancers in the later years of life, and less exposure to obesity and diabetes in adolescence and adulthood.37,38 In our study, 33.6% of the mothers after the SARS-CoV-2 pandemic stated that they altered their infant's diet and 2.1% of them stated that they stopped giving human milk to their infant. However, human milk contains natural immune factors such as neutrophils, macrophages, T and B lymphocytes, along with multiple oligosaccharides and virus-protective interferons that reduce the effect of viral infections.25 The importance of feeding only with human milk appears once more, especially considering that pandemic affects individuals with a weak immune system. Also, not giving human milk to the infant can make the infant more vulnerable to serious respiratory infections, including SARS-CoV-2, in the first year of life.15,25 Concordantly, in our study, it was observed that mothers, who breastfeed their infants whenever they want during the day, though that human milk would be protective against SARS-CoV-2 by strengthening their infant's immune system and did not alter the infant's diet after the pandemic. Since the production and release of human milk is adjusted according to the frequency and intensity of breastfeeding,26 it is observed that mothers take the right approach about not altering their infant's diet.
After the first 6 months, human milk is insufficient to meet the infant's nutritional needs. In addition to breastfeeding, supplementary foods suitable for 2 years and older should be given.38 In our study, it is observed that those whose infants were older than 6 months were not concerned about the possibility of transmitting SARS-CoV-2 to their infants through human milk. This case may be caused by the fact that 85% of children in Turkey are commenced on the supplementary food in 6 to 8 months.26 When the current literature is examined, no study has been found that addresses the reduction of concerns about virus transmission through breast milk in the transition to the complementary food process.
LIMITATION OF THE STUDY
Since the research was conducted at the time of the effects of the pandemic, the quarantine, and restrictions, mothers who could be reached through social media platforms compose the study sample. For this reason, the study results cannot be generalized to all breastfeeding women.
CONCLUSION
The study results reveal that breastfeeding mothers were affected by the events experienced as a result of the SARS-CoV-2 pandemic and concerned about the risk of transmission to their infants through human milk or breastfeeding, and the ratios of compliance with the recommended protective measures were low. Policymakers and healthcare providers should not ignore this situation. It may be beneficial to conduct consciousness-raising and awareness studies to increase the compliance ratios of breastfeeding women with the recommended measures to prevent SARS-CoV-2 transmission. Breastfeeding needs to be promoted throughout the SARS-CoV-2 pandemic.
References