Breastfeeding has been critical to postpartum and newborn health throughout the COVID-19 pandemic. Currently, all major health organizations, including the World Health Organization (WHO), United States Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP), and the Academy of Breastfeeding Medicine (ABM) recommend breastfeeding along with vaccinations during pregnancy or lactation for optimal protection against SARS-CoV-2 infection and severe COVID-19 disease. However, these recommendations have evolved rapidly and have not always been implemented consistently within the United States or in other countries (Hoang et al., 2020; Tomori et al., 2020).

Early in 2020, as the first wave of the COVID-19 pandemic spread across the U.S., there was limited evidence regarding modes of disease transmission, pathogen history, and disease severity during gestation, parturition, and lactation. In this time of uncertainty, the WHO guidance recommended early breastfeeding initiation, immediate skin-to-skin care, and postpartum lactation support in hospital and community settings (WHO, 2020). However, in the U.S., many recommendations were in direct contradiction to the WHO, which led to the adoption of discordant COVID-19 related perinatal policies in medicine and public health (Hoang et al., 2020). For example, many hospital policies limited support persons during labor and delivery, enacted immediate postpartum separation of mothers with COVID-19 symptoms (Tomori et al., 2020) and limited or prohibited in-person skilled lactation support to postpartum patients in some hospitals (Perrine, 2020). These and similar policies have had significant detrimental effects on lactation outcomes, including timely initiation, exclusivity, and duration (Hoang et al., 2020).

Stay-at-home orders were enacted between March 1 and May 31, 2020, in 42 states and territories. This evidence-based practice significantly reduced movement and reduced community transmission (Moreland, 2020). It also meant that millions of infants and young children had more opportunities for close physical contact with their breastfeeding parent than they would have had were it not for the COVID-19 pandemic, in a country without federally protected paid postpartum/family leave policies.

The full impact of COVID-19 stay-at-home orders on breastfeeding, however, has not been fully appreciated. In low- and middle-income countries (LMIC), immediate postpartum maternal-infant separation policies, in particular, likely resulted in significant excess maternal and infant mortality and morbidity (Rollins et al., 2021). However, there is limited research on these disruptions vis-à-vis infant and young child feeding in high income countries (HIC), such as the U.S., particularly within sociology and anthropology.

The U.S. stands out among HIC, because it has no guaranteed paid leave during the postpartum period (International Labour Organization, 2017; Steurer, 2017). A lack of federally mandated paid postpartum and family leave in the U.S. is a major structural barrier to improving breastfeeding rates maternal and health outcomes across the nation (Griswold and Palmquist, 2018; Kim et al., 2019). This policy failure does not affect all U.S. populations in the same way and contributes to significant breastfeeding disparities that are stratified by race, ethnicity, income, type of employment, and education (CDC, 2022a).

Emergent infectious diseases introduce critical public health challenges related to how rapidly changing scientific information, guidance from health care organizations, and local epidemiological factors influence societal perceptions of disease transmission, interpretation of emerging scientific information, and human behaviors (Hahn and Inhorn, 2008; Farmer et al., 2013). Thus, the purpose of this paper is to describe breastfeeding intentions, practices, and experiences during the first wave of the COVID-19 pandemic in the U.S. We draw upon critical biocultural approaches in anthropological study of breastfeeding (Tomori et al., 2018) to examine the role of social institutions and policies in shaping breastfeeding practices, against the backdrop of the emergent COVID-19 pandemic in the U.S. This study offers insights into how some parents of infants and young children in the U.S. navigated uncertainty in feeding decisions against a backdrop of rapidly changing, and often contradictory guidance, related to COVID-19. Our study contributes to this special issue, and to the broader social science literature, by exploring the intersection of first wave COVID-19 policies and breastfeeding.

A summary of participants' open-ended responses is presented in Table 5. Illustrative verbatim quotes from the survey responses are included. The responses are organized by key themes, which complement the quantitative survey results presented above.

The COVID-19 pandemic has introduced unprecedented challenges for people experiencing pregnancy and postpartum and for parents who are caring for their infants and young children. Our study contributes to a growing literature on how COVID-19 mitigation policies have affected infant and young child feeding practices in the U.S. (Palmquist et al., 2020; Pasadino et al., 2020; Patil et al., 2020; Perrine, 2020; Snyder and Worlton, 2020; Bartick et al., 2021; DeYoung and Mangum, 2021; Gutschow and Davis-Floyd, 2021; Mollard and Wittmaack, 2021; Schindler-Ruwisch and Phillips, 2021; Cohen and Botz, 2022), while offering a unique perspective from the earliest phase of the pandemic.

During the early phase of the COVID-19 pandemic, rapidly changing guidance about maternity care practices in the immediate postpartum period due to suspected or confirmed COVID-19 raised serious concerns about the potential impacts of maternal-newborn separation policies on breastfeeding outcomes (Tomori et al., 2020). During the same period, stay-at-home orders were also imposed, leading to dramatic changes in daily life for millions in the US. While there has been critical analyses of maternity care policies and their consequences for breastfeeding in both high-income (Thomson, 2022; Turner et al., 2022) and low-income countries (Rollins et al., 2021), the full impact of pandemic policies on lactation have not been fully investigated.

In our study, strong breastfeeding intentions during pregnancy appear to be related to a high prevalence of breastfeeding and feeding with expressed human milk during the onset of the COVID-19 pandemic. Nearly all the survey respondents indicated a strong intention to breastfeed or feed their infant with expressed human milk exclusively 0–6 months. Perceptions, worries, and concerns regarding COVID-19 transmission were less apparent among respondents who indicated a strong prenatal intention to breastfeed. Similarly, for two thirds of study participants, breastfeeding frequency and the planned timing of weaning did not change because of COVID-19. In fact, nearly a third of participants delayed weaning. Additionally, findings from the present study point to an increased frequency of breastfeeding, delayed weaning, a strong belief in the role of human milk in protecting infants, and being able to stay-at-home during the postpartum year, as a multi-dimensional buffer against the negative effects of COVID-19 hospital separation policies on lactation.

Qualitative findings illustrate that most respondents were at least partly motivated to continue breastfeeding and delay weaning, due to knowledge and perceptions of human milk as providing immunological protection to their infant, even when there was not yet sufficient data to confirm this. Immune factors in human milk are a cornerstone of U.S. medical and public health education to promote breastfeeding (CDC, 2022b). The immunological factors in human milk have been shown elsewhere to be critical to parents' decisions to breastfeed, to donate milk to milk banks and milk sharing communities, and to accept donor milk and shared milk when available.

In an ethnographic study of community milk sharing in the U.S., the idea of a “super immune system” was salient among mothers feeding their infants with milk from multiple donors (Palmquist, 2018). Similarly, in the present study, the idea of milk “having super powers” is significant to theorizing lactation in medical anthropology.

We now have substantial evidence that human milk is indeed critical to conferring passive immunity to infants when their breastfeeding parent has experienced SARS-CoV-2 infection or when their breastfeeding parent has been vaccinated (Perez et al., 2022; Whited and Cervantes, 2022; Young et al., 2022). Familiarity with the importance of human milk to infants' immune response, combined with strong breastfeeding intentions and economic security were also significant in respondents' decisions to continue breastfeeding and delay weaning during the first wave of COVID-19 in the U.S. This points to the continued importance of emphasizing the protective effects of breastfeeding against infectious disease in public health messaging, incorporating lactation in public health emergency planning, and providing structural support for realizing breastfeeding intentions, especially during emergencies.

Relatively few respondents indicated that they had weaned earlier than planned or would stop breastfeeding if they were diagnosed with COVID-19. At the same time, participants who reported that they would, indeed, stop breastfeeding if diagnosed with COVID-19 noted that they had heard that this was their pediatrician's policy or a public health recommendation they had heard. Only a small number of study participants indicated they were diagnosed with COVID-19. At the time of the survey community public health COVID-19 testing centers and at-home testing kits were not widely available or accessible, which may have contributed to underdiagnosis of infection. More respondents who reported a confirmed COVID-19 diagnosis stopped breastfeeding or feeding with expressed milk than those who reported continuing to breastfeed or offering their infant expressed milk. Some participants may have been discouraged from breastfeeding by CDC recommendations and hospital policies that undermined breastfeeding.

Only 13% of our study respondents gave birth during the pandemic, therefore, our findings are skewed toward those who experienced the onset of the pandemic after they already initiated their infant feeding journey, with most having already established lactation at the time of taking the survey. However, even among respondents whose infants were born after stay-at-home orders were implemented nationally, breastfeeding initiation and exclusivity 0–6 months was higher than the typical national averages prior to COVID-19 (CDC, 2022a). The study sample was also comprised of a majority of racially privileged, well-educated, partnered, and employed respondents. These characteristics are commonly associated with populations that have more resources and power to overcome structural barriers in breastfeeding initiation in the U.S. (CDC, 2022a).

Our study sample had much more positive breastfeeding experiences than more representative studies, especially among those who gave birth after the declaration of the pandemic in the U.S. when maternity care policies were significantly disrupted. For example, a survey of 1,344 U.S. hospitals between July 15 and August 20, 2020 revealed that while a majority of hospitals reported no significant change in breastfeeding initiation rates, COVID-19 impacted postpartum lactation support for mothers with suspected or confirmed COVID-19 (Perrine, 2020). Moreover, the report identified a number of hospitals that either prohibited or discouraged skin-to-skin contact, direct breastfeeding, and milk expression when COVID-19 was suspected or confirmed. The report also noted the trend to accelerate hospital discharge to <48 h after birth among a majority of hospitals, suggesting a critical need for postpartum follow-up and remote monitoring (Perrine, 2020). Other studies using longitudinal cohort data showed that even when mother-infant dyads initiated breastfeeding in the hospital during the COVID-19 pandemic, they were less likely to have continued breastfeeding after discharge (Popofsky et al., 2020; Bartick et al., 2021; Mollard and Wittmaack, 2021). Similarly, a study examining California WIC data compared breastfeeding outcomes of infants prior to and after March 2020 in Los Angeles County (Koleilat et al., 2022) concluded that, among this low-income population, breastfeeding initiation and any breastfeeding at 3 and 6 months decreased significantly among infants born during the COVID-19 pandemic. Finally, recent work demonstrated that direct breastfeeding in hospital was associated with 5.7 times greater likelihood of any human milk feeding and 8 times greater odds of direct breastfeeding post discharge (Rostomian et al., 2022), demonstrating the detrimental impacts of early separation policies.

Although we did not find significant differences in infant feeding based on geography, hospitals in communities with a high burden of COVID-19 infection early in the pandemic reported more significant declines in breastfeeding initiation rates in hospital and after returning home, suggesting some geographic variability in how separation policies affected lactation support services (Popofsky et al., 2020). Qualitative and mixed-methods studies have shown that perinatal mental health and psychosocial support, access to remote/telehealth health care services, and skilled lactation support were all important to buffering against COVID-19 separation policies and supporting breastfeeding during this time (Snyder and Worlton, 2020; DeYoung and Mangum, 2021; Schindler-Ruwisch and Phillips, 2021; Cohen and Botz, 2022). These findings warrant further inquiry into the ways that different populations parse conflicts between their own lived experience, perceptions of risk, social constructions of risk, and biomedical or public health authority in the wake of emergent infectious diseases and other emergencies. These emergencies are predicted to accelerate driven by climate change (IPCC, 2022), therefore, infant and young child feeding in emergencies (IYCF-E) policy planning and implementation are urgently needed.

Previous research has demonstrated both positive and negative impacts of the stay-at-home orders on perinatal and postpartum outcomes and experiences (Davis-Floyd et al., 2020; Farewell et al., 2020; Gildner and Thayer, 2020; Hynan, 2020; Premkumar et al., 2020; Kotlar et al., 2021). In our study we only explored stay-at-home orders in relation to COVID-19 and infant and young child feeding goals, practices, and experiences. Stay-at-home orders enabled a third of parents in our study to spend more time with their infants, which gave them an opportunity to feed their babies more frequently and to breastfeed for longer durations than would have been possible otherwise. There were immediate positive effects of stay-at-home policies on breastfeeding and human milk feeding practices, even during a time when there was considerable uncertainty about the safety of breastfeeding and the transmissibility of SARS-CoV-2 in human milk, constrained access to health care services and COVID-19 testing, and no effective COVID-19 vaccines (Hoang et al., 2020; Tomori et al., 2020).

There is a strong relationship between paid leave and the ability to realize breastfeeding desires and achieving more equitable breastfeeding outcomes (Vilar-Compte et al., 2022). Studies examining the impact of enacting paid parental leave on breastfeeding in California and New Jersey demonstrated that these state-level policies were associated with increased rates of both breastfeeding and exclusive breastfeeding (Huang and Yang, 2015; Hamad et al., 2019). After California introduced the first paid family leave program in the U.S., exclusive breastfeeding increased by 3–5 percentage points for the first three and 6 months, and then 10–20 percentage points for breastfeeding through three, six, and nine months (Huang and Yang, 2015). Comparing California and New Jersey, two states that implemented paid family leave policies, with the rest of the United States, Hamad et al. (2019) found that these policies were associated with a 1.3 percentage point increase in exclusive breastfeeding at 6 months. Notably, these benefits were more pronounced for higher-income, married, and white parents (Huang and Yang, 2015; Hamad et al., 2019). In contrast, we know from other research that childbearing people in communities of color are most negatively affected by structural racism in the U.S. and have fewer opportunities to leverage political economic, social, and legal resources that might buffer against the harmful effects of extreme economic pressures that force a return to work soon after giving birth (Ehrenreich and Siebrase, 2014; Hawkins et al., 2015; Johnson et al., 2015; Asiodu et al., 2021; Butler et al., 2021; Hemingway et al., 2021; Morrow et al., 2021). COVID-19 has only exacerbated these longstanding structural inequities that contribute to ongoing breastfeeding disparities in the U.S.

Our study participants, who were predominately economically secure, non-Hispanic/Latina white postpartum parents were able to sustain their breastfeeding intentions, initiation, or continuation. Across all levels of household income, white respondents indicated they were able to breastfeed or feed their infants with expressed milk as they had intended. Juxtaposed against reports of the disproportionate burden of COVID-19 related perinatal morbidity and mortality among minoritized and marginalized racial/ethnic groups in the U.S. (Woodworth, 2020), our study illustrates that breastfeeding as intended is another way that racial privilege was experienced during COVID-19 pandemic (Bassett et al., 2020; Gravlee, 2020; Poteat et al., 2020; APM Research Lab, 2021).

Breastfeeding has been integral to supporting perinatal and newborn health outcomes throughout the COVID-19 pandemic. Federally mandated paid postpartum and family leave is essential to achieving more equitable lactation outcomes, and ultimately, improved maternal, child, and family health, population health, and economic prosperity (Rollins et al., 2016; Tomori et al., 2022). COVID-19 stay-at-home orders provided a natural experiment in which to document the potential impacts of paid leave for a socioeconomically diverse breastfeeding population in the U.S.

Around March 2020, it was unclear how long stay-at-home policies would be required and what the trajectory of the pandemic would be for the U.S. In September 2022, at the of writing this publication, COVID-19 continues to significantly impact the U.S. Since 2020 we have experienced multiple waves of critical rises in infection rates, emergence of variants, sustained high levels of community transmission, and over 1,051,389 deaths (National Center for Health Statistics (NCHS), 2022). Ongoing research is needed to understand the biocultural dimensions of breastfeeding as an adaptation to public health emergencies, including COVID-19. There is an urgent need to document how to respond to public health emergencies in ways that allow all communities to overcome structural barriers to breastfeeding and reduce breastfeeding inequities. In addition to supporting the basic human rights of all childbearing people, in the U.S., federally mandated policy for postpartum leave would greatly strengthen lactation outcomes, breastfeeding equity, and all associated maternal and infant health indicators across the life course and generations.

The datasets presented in this article are not readily available because we do not have permission to share the data. Requests to access the datasets should be directed to equinn@wustl.edu.

The studies involving human participants were reviewed and approved by Institutional Review Board, Washington University in St. Louis. The patients/participants provided their written informed consent to participate in this study.

AP, EQ, and CT designed the study. EQ, CF, and SC prepared the data for analysis and conducted the analyses. AP, EQ, CT, and KT verified the analytic methods. AP took the lead in writing the manuscript. All authors provided critical feedback and helped shape the research, analysis, and finalizing the manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.