key: cord-0877023-r0z49xvh
authors: Vazquez-Vazquez, A.; Dib, S.; Rougeaux, E.; Wells, J.c.; Fewtrell, M.S.
title: The impact of the Covid-19 lockdown on the experiences and feeding practices of new mothers in the UK: Preliminary data from the COVID-19 New Mum Study
date: 2020-10-07
journal: Appetite
DOI: 10.1016/j.appet.2020.104985
sha: 813d080aafa5aa6215404e064f1917f8d63d065c
doc_id: 877023
cord_uid: r0z49xvh

BACKGROUND: The COVID-19 New Mum Study is recording maternal experiences and infant feeding during the UK lockdown. This report from week 1 of the survey describes and compares the delivery and post-natal experiences of women who delivered before (BL) versus during (DL) the lockdown. METHODS: Women living in the UK aged ≥18 years with an infant ≤12 months of age completed an anonymous online survey (https://is.gd/covid19newmumstudy). Information/links are shared via websites, social media and existing contacts. RESULTS: From 27.5 to 20-3.6.20, 1365 women provided data (94% white, 95% married/with partner, 66% degree/higher qualification, 86% living in house; 1049 (77%) delivered BL and 316 (23%) DL. Delivery mode, skin-to-skin contact and breastfeeding initiation did not differ between groups. DL women had shorter hospital stays (p < 0.001). 39% reported changes to their birth plan. Reflecting younger infant age, 59% of DL infants were exclusively breast-fed/mixed fed versus 39% of BL (p < 0.05). 13% reported a change in feeding; often related to lack of breastfeeding support, especially with practical problems. Important sources of feeding support were the partner (60%), health professional (50%) and online groups (47%). 45% of DL women reported insufficient feeding support. Among BL women, 57% and 69% reported decreased feeding support and childcare, respectively. 40% BL/45% DL women reported insufficient support with their own health, 8%/9% contacted a mental health professional; 11% reported their mental health was affected. 9% highlighted lack of contact/support from family and distress that they had missed seeing the baby. CONCLUSION: Lockdown has impacted maternal experiences, resulting in distress for many women. Our findings suggest the need for better infant feeding support, especially ‘face-to-face’ support for practical issues; and recognising and supporting mothers who are struggling with mental health challenges or other aspects of their health. The effectiveness of online versus face-to-face contact is currently uncertain, and requires further evaluation.

restrictions introduced to reduce transmission of SARS-CoV-2 would have a negative impact 125 on mothers' experience of delivery, and support with their infant as well as with their own 126 health. We aimed particularly to highlight aspects that could be of immediate relevance to 127 health providers and groups supporting pregnant women and new mothers. A secondary 128 aim was to assess whether the survey sample is representative and identify under-129

represented groups who should be targeted in the ongoing recruitment strategy. 3. Birth experience, infant feeding and behaviour, and changes due to Questions in this section ask about the birth, infant feeding practices, and sources of 173 information and support. If the baby was born before lockdown (BL) started, the 174 mother is asked how this has changed any aspect of infant feeding, the infant's 175 behaviour (irritability, sleep, appetite), and access to infant feeding support and 176 childcare support including contact with health care professionals. If the baby was 177 born during the lockdown (DL), the mother is asked if this led her to change her birth 178 and/or feeding plans, and the current support she is receiving. Ethical approval was obtained from the UCL Research Ethics committee (0326/017). The first 198

page of the survey provides information about the study and, having read this, participants 199 are asked to provide consent to participate before proceeding. They are reminded not to 200 provide any information in the free-text boxes that could allow identification. 

Between May 27 th and June 3 rd , 1457 participants provided complete or partially complete 215 and their geographical distribution in Figure 1 . Notably, 94% of participants self-identified as 219 white, 95% were married or living with a partner and 66% had a degree or higher 220 professional qualification. 86% lived in a house or bungalow and 13% in a flat. 11% (n=111) 221 of BL mothers and 10% (n=32) of DL mothers were born outside the UK, and the median 222 (25 th . 75 th centile) time living in the UK for these women was 11 (8,17) and 11 (6,26) years, 223

respectively. There were no significant differences in background characteristics between BL 224 and DL mothers. Compared to women included in this analysis, those who did not provide 225 details of their delivery experience and infant feeding were significantly younger, less likely 226 to self-identify as white, less likely to be married or living with a partner, less likely to have a 227 degree or higher qualification and more likely to have a male infant (data not shown). proportion of those in both groups practiced skin-to-skin contact shortly after delivery, with 238 no difference in timing or duration between groups. Most women intended to breast-feed 239 and initiated breastfeeding within the first hour after delivery. 76% (n=754) versus 72% 240 (n=212) of BL and DL women reported receiving enough help and support with feeding 241 whilst in hospital, and 71% (n=697) versus 67% (n=198) had help from a health professional 242 in positioning the infant during breastfeeding (Table 2) . Among DL women, 39% (n=124) reported that their birth plan had changed due to the 249 pandemic. The main changes reported as free-text (more than one could be given) were: (1) 250

Having to give birth in hospital rather than in a low-risk/ midwife-led unit (34 women); (2) 251

Only being allowed one birth partner (24 women); (3) Limited support from their birth 252 partner, who could only be present during active labour but not during induction, early 253 labour or after delivery (40 women); (4) No partner being present (11 women; various 254 reasons given for this including problems with childcare); (5) Water birth not being available 255 (11 women); (6) Not being allowed a home birth (9 women). 256 257 258

Infant feeding practices at the time of survey completion are shown in Table 3 . As expected, 261

reflecting the younger age of the infants of DL mothers, a significantly higher proportion 262 were exclusively breast-fed or fed a combination of breast milk and infant formula (59% 263 versus 39%), whereas a higher proportion of older infants born before lockdown were also 264 consuming solid foods. 265

Thirteen % of mothers in both groups (BL n=138, DL n=39) reported having changed their 267 mode of infant feeding in response to the lockdown. Of the mothers who were 268 breastfeeding, 60% (n=465) reported no change in feed frequency, whilst 30% (n=234) 269

reported an increase and 10% (n=73) a decrease. 68% (n=524) reported no change in the 270 duration of feeds, whilst 17% (n=120) reported an increase and 15% (n=117) a decrease. 271

Four % (n=42) of women reported they had stopped breastfeeding. Of the mothers who 272 were formula feeding, 66% (n=243) reported no change, 18% (n=67) an increase, 13% 273 (n=49) a decrease and 3% (n=11) that they had stopped formula feeding during lockdown. 274

Most women reported no change to their plans for introducing solid foods as a result of the 275 lockdown (89% n=929), although 8% (n=81) had introduced solid foods earlier than planned 276 and 3% (n=32) later. 277 278 DL mothers had the opportunity to provide free-text responses about how their feeding 279 plans had changed. The most frequent responses related to a lack of breastfeeding support 280 (n=21), especially face-to-face help with practical problems such as latching, resulting in the 281 mother expressing milk, introducing formula or stopping breastfeeding. Six women reported 282 that they had breastfeeding problems because their infant had a tongue-tie which could not 283 be dealt with surgically due to the pandemic. Seven women reported a change to both their 284 birth plan and feeding plans. The main reported sources of infant feeding support in both groups of women ('where do 291 you get support with infant feeding') were the partner (60%), health professional (50%) or 292 an online support group (such as Facebook, 47%), followed by friends and family (37%), and 293

infant feeding support groups such as NCT, La Leche league (32%). There were no significant 294 differences between groups. In free-text responses under the 'other' category, 28 women 295 mentioned support from a lactation consultant or counsellor. In responses to the question 296 'who is most helpful or influential with infant feeding', the highest proportion of women 297 reported this was their partner (38%), with lower but similar results for health professionals 298 (20%), friends and family (19%), support groups (19%) and online groups (20%). Significantly 299 fewer women from the DL group reported that online groups were a main influence on 300 infant feeding compared to those from the BL group (16% v 22%, p=0.02). 301 302 59% (n=185) of DL women reported that they had received professional help with 303 breastfeeding in the first few days after delivery, whilst 40% (n=126) received support from 304 family and friends. In response to the question ' did you feel you got or are getting enough 305 support and help with feeding your baby', overall, 45% (n=141) DL mothers felt they had not 306 received enough support and help in feeding their infant from delivery to completing the 307 survey. 308

Mothers were able to provide free-text information on how COVID-19 had affected them. In 315 response to this, 146 women (11%) indicated that lockdown had adversely affected their 316 mental health, citing anxiety, depression, isolation and loneliness. 119 women (9%) 317 mentioned consequences of not being able to see their family, highlighting the lack of 318 practical support but also distress that family members had missed seeing the new baby; 62 319 (5%) highlighted the lack of social support from their friends, and missing attending mother 320 and baby groups and activities; while 26 (2%) highlighted the lack of face to face GP and 321 health visitor visits. Several women mentioned that their experience of late pregnancy, birth 322 and early motherhood had been completely different from what they had expected and that 323 they and their extended family were missing out on experiences that could never be 324 regained. Two women also highlighted positive aspects of increased bonding with their 325 other children. 326

Contact with a health professional during lockdown was significantly more frequent in DL 328 mothers, who had younger infants than those in the BL group. Similarly, these women were 329 more likely to have had contact with a mother and baby or breastfeeding support group 330 (33% (n=345) versus 26% (n=97), p=0.018). Of the 350 women who reported these contacts, 331 9 episodes were reported to have been 'in person' with the rest online or by phone. 92 332 women (8% BL and 9% DL) reported an appointment with a mental health professional; four 333 in person, 11 both in person and remotely, and the rest just remotely. The proportion of 334 women who reported that they received enough support with their own health was 60% 335 (n=624) versus 55% (n=175) for BL and DL groups. Our data suggest that, despite difficulties imposed by the pandemic, hospital facilities are 349 continuing to implement measures such as promoting early mother-baby contact and 350 initiation of breastfeeding, thus following guidelines that encourage the continuation of 351 these practices during the pandemic 2,10,11,13 . Eighty-seven % of BL mothers and 89% of DL 352 mothers practised skin-to-skin contact, and almost all did so within the first hour after birth. 353

Similarly, 86% of BL mothers and 89% of DL mothers intended to breastfeed, and 82% 354 reported that they did not receive help with positioning the infant and a quarter perceived 367 that they did not get enough support with feeding in the hospital. This could be due to the 368 increased burden on healthcare systems and pressure placed on healthcare professionals to 369 discharge mothers sooner to minimise infection risks 13,21 , which might result in less 370 opportunity to support mothers with infant feeding. The shorter length of hospital stays 371 after births during the lockdown compared to those before the lockdown might provide 372 further evidence of this. However, since there was no significant difference in the support 373 received by mothers who delivered before or during the lockdown, they may not reflect Overall, breastfeeding rates in the survey population appear relatively high, but direct 404 comparisons with UK data are difficult given the wide age-range of infants. Only 13% of 405 women reported changes to infant feeding as a result of the lockdown. Of women who were breastfeeding, 30% reported an increase in the frequency and 17% an increase in the 407 duration of feeds, which could reflect more time spent at home, experiencing more 408 frequent support from the partner and/or being able to invest more time in childcare. 409

Conversely, 10% of women reported a decrease in breastfeeding frequency and 15% a 410 care. Of mothers who delivered during the lockdown, 45% felt they were not getting enough 429 support with feeding (beyond hospital assistance), whilst 57% of those who delivered before 430 lockdown had experienced a decrease in infant feeding support during this period. This is of 431 concern given evidence that the quality of breastfeeding support is important for maternal 432 mental health. In a prospective study of Canadian women with breastfeeding difficulties, 433 those who did not report a negative breastfeeding support experience were at decreased Reliance on support from online groups was significantly lower for women who delivered 444 during lockdown, possibly because their infants were younger and they needed more 445 practical support for the establishment of breastfeeding or other aspects of care. Women 446 from this group also reported more frequent contact with health professionals. 447

In an online survey conducted by the Australian Breastfeeding Association to assess the 448 concerns of mothers seeking breastfeeding support during the pandemic, mothers reported 449 that their main concerns were related to insufficient milk or weight gain, painful breasts, re-450 lactation, and reducing supplemental milk (infant formula). Notably, concerns were 451 exacerbated by the lack of health care access as well as the lack of face-to-face health 452 services because of fear or unavailability 30 . There is evidence that COVID-19 and resulting lockdown measures disproportionately affect 491 BAME and disadvantaged groups 19 . Women in BAME groups are also at higher risk of 492 becoming significantly unwell with COVID-19 in pregnancy and requiring hospital admission, 493 although this study did not look at other socio-economic differences 37 . COVID-19 and 494 lockdown measures may also exacerbate existing food inequalities for families with 495 children 38 . While many explanations have been advanced for the observed COVID-19 ethnic 496 disparities, it is likely that pre-existing social and health inequalities and differences in the 497 usage of and need for health services are an important factor 39.40 . It is vital that the 498 experiences of these groups are represented in the survey, and we are taking advice and 499 joining efforts with other groups to reach these groups and increase the representativeness 500 of our survey sample. 501

Our findings highlight the impact of the current pandemic and lockdown measures on the 506 birth experiences, infant feeding and support experienced by mothers. Some practical steps 507 suggested by the findings are improving infant feeding support, especially 'face-to-face' 508 support for practical issues such as latching, and recognising and supporting mothers who 509 are struggling with mental health challenges or indeed other aspects of their health. 510

Interestingly, a recent qualitative study in 14 women 41 , 11 with young infants, reported 511 similar issues regarding feelings of loss and the lack of face-to-face support. It highlighted 512 the 'digital pivot' that is taking place with perinatal support organisations moving online. 513

However, the effectiveness of online versus face-to-face contact is currently uncertain, and 514 it may not be accessible to all women. Ultimately, it is likely that some of the challenges 515 being reported by mothers will be alleviated by the relaxation of lockdown measures so that 516 they can resume contact with their extended families and friendship groups. However, it is 517 also important to consider whether the altered birth experiences and challenges 518 experienced by these women will have later consequences for them and/or their infants. A 519 qualitative study of mothers in the UK and Israel in 2011-12 found that women described 520 their experiences of motherhood as 'ideal', 'good enough' or as a 'burden', often connected 521 to their experience of feeding. Whether the experience of the pandemic and lockdown 522 restrictions will alter these perceptions represents an interesting research topic, although 523 beyond the scope of the current survey 42 . 524 525 Future analyses of the survey data will explore whether experiences change as restriction 526 measures lift, ideally in a larger and more diverse sample. Analyses will also include more 527 data about participants' living conditions as well as the effects of the lockdown on everyday 528 life, finances and maternal mood and how these factors are associated with infant feeding 529 decisions and support. Daily or more 1 (<1) 4 (1) *p<0.05, **p<0.005 +more than one response allowed J o u r n a l P r e -p r o o f are asked to provide consent to participate before proceeding. They are reminded not to provide any information in the free-text boxes that could allow identification.

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