Factors Related to Exclusive Breastfeeding During The COVID-19 Pandemic: Literature Review

Background: The COVID-19 pandemic has created several challenges in exclusive breastfeeding, even though WHO has provided recommendations to continue exclusive breastfeeding during the COVID-19 pandemic. Purpose: This study aims to summarize the factors that can affect breastfeeding mothers during the COVID-19 pandemic. Methods: This research is a literature review. Thematic articles were selected from 2020-2023 from the electronic databases Science Direct, PubMed, and Google Scholar. Researchers used the PRISMA method. Result: From 170 articles, 15 studies were reviewed, and finally, only 10 were analyzed. From the articles analyzed, various supports from husbands, families, and health workers, information support, motivation, beliefs, self-efficacy, delivery settings, age, education level, and work situations influence exclusive breastfeeding. Conclusion: The factors that most influence the practice of exclusive breastfeeding are support from husbands, and family, support from health workers, and information support. It is hoped that policymakers and health workers will be more active in making socialization programs about the importance of providing exclusive breastfeeding during the COVID-19 pandemic.


Introduction
The COVID-19 pandemic has created several challenges in providing nutrition and care for newborns, especially regarding breastfeeding.Few parents are afraid to give exclusive breastfeeding during a pandemic because they are worried about the transmission of SARS-CoV-2. 1,2However, WHO has recommended that exclusive breastfeeding should still be given to babies even during a pandemic.WHO has also issued breastfeeding guidelines for mothers suffering from COVID-19. 3,4,5any factors, including cultural factors, sociodemographic, the mother's education level, delivery method, place of delivery, psychosocial factors, self-efficacy, applicable policies, and others, still influence breastfeeding practice. 6Policies that support decision-making for breastfeeding such as maternity leave, including support from the spouse, as well as the availability of professional support for breastfeeding success. 1,7reastfeeding should be encouraged and facilitated so mothers and babies can be cared for together to establish attachment through skin-to-skin contact, even during the COVID-19 pandemic.If the mother is too sick to breastfeed, it is necessary to facilitate and support the breastfeeding process indirectly so the baby can breastfeed.In this case, the need for information and health care from professionals that can be accessed is essential. 8ecause the practice of breastfeeding during the COVID-19 pandemic has decreased, this research is needed to summarize the literature to identify what factors can affect breastfeeding mothers during a pandemic, so that it can become a theory when counseling breastfeeding mothers.

Research design
This research is a literature review.

Setting and samples
The research results according to the theme were selected from 2020-2023.The inclusion criteria of this study were articles with full text, which can be accessed free of charge, in English, and reports with cross-sectional, cohort, case-control, and mixedmethod research designs.Exclusion criteria are articles in the form of conference papers, chapters, editorials, theses and dissertations, and are not open access.

Measurement and data collection
The data sources for this study were articles found in the electronic databases Science Direct, PubMed, and Google Scholar.The researcher used the following search strategy in each database with the keywords "exclusive breastfeeding", "exclusive breastfeeding during the pandemic", and "exclusive breastfeeding during the COVID-19 pandemic".

Data analysis;
Researchers use the Preferred Reporting Items for Systematic Reviews and Metaanalyses Statement (PRISMA) method to follow the correct research steps or protocol, as shown in Figure 1.

Results
Based on the search strategy and selection criteria that have been carried out, from 170 articles in total, 15 studies were reviewed in full.Finally, only 10 studies could be analyzed to the end.The selection process for this study is presented in Figure 1.

Crosssectional
The factor that influences the psychological capital of mothers related to exclusive breastfeeding during the COVID-19 pandemic is motivation.The mother's ability to provide exclusive breastfeeding also dramatically affects the mother's psychology.

Crosssectional
The findings of this study highlight that programs that increase women's participation in education and decisionmaking can improve EBF practices.In addition, during the COVID-19 pandemic, providing breastfeeding mothers with adequate and upto-date breastfeeding information can significantly enhance EBF practices.5
Most research results in the articles reviewed stated that husband support, family support, health worker support, and information support, such as health education and outreach programs, were the factors that most influenced the success of exclusive breastfeeding during the COVID-19 pandemic.

Discussion
During the COVID-19 pandemic, breastfeeding mothers faced various challenges and changes, including breastfeeding practices.This literature study aims to summarize the factors that can affect breastfeeding mothers during the COVID-19 pandemic because the practice of breastfeeding during the COVID-19 pandemic has decreased in Indonesia and other countries.Many mothers are worried about the transmission of COVID-19 to mothers and babies, even though WHO has issued recommendations to continue giving exclusive breastfeeding to babies. 3,4,5HO has recommended that babies born to mothers infected with COVID-19 should still be given breast milk.This is because breast milk contains substances that can increase the body's immunity to protect it from COVID-19.Breastfeeding is still carried out by paying attention to and implementing strict health protocols, so the baby does not contract COVID-19.Breastfeeding protects neonates, infants and children from morbidity and death.The protective effect is powerful against infectious diseases due to the immediate transfer of antibodies and anti-infective factors and the transfer of longlasting immunological competence and memory. 4,19HO stated, in the research that had been conducted, as many as 46 motherinfant pairs had their breast milk samples tested for COVID-19.All mothers were positive for COVID-19, while 13 babies tested positive for COVID-19.Breast milk samples from 43 mothers were negative for the COVID-19 virus, while samples from 3 mothers tested positive for virus particles by RT-PCR.Among the 3 infants whose mothers' breast milk tested positive for virtual RNA particles, not a live virus, one tested positive for COVID-19, but the infant's feeding practices were not reported.Two other babies tested negative for COVID-19; one was breastfed, and the other was given breast milk after the viral RNA particles were no longer detectable.This is evidence that exclusive breastfeeding can still be carried out during the COVID-19 pandemic according to WHO guidelines. 4ased on the results of this literature study, various supports from husbands, families, and health workers, information, motivation, beliefs, self-efficacy, delivery settings, age, educational level, and work situations influence exclusive breastfeeding.Older mothers, lower education levels, and overly tiring work situations can make it difficult for mothers to receive correct information regarding exclusive breastfeeding during the Covid 19 pandemic. 10,15hile most factors related to exclusive breastfeeding are husband and family support, the success of exclusive breastfeeding during a pandemic cannot be separated from the husband's support for breastfeeding mothers.The husband's support is a dominant component of successful exclusive breastfeeding. 20Husband's support can be in the form of emotional, informational, and instrumental support.Mothers will be more capable and confident if they have the support of those closest to them when breastfeeding their babies. 21ext is support from health workers or professional staff.Health workers, especially midwives, have a role as educators and counselors to provide breastfeeding support. 22Support from health workers can also be done by holding health education programs.During the COVID-19 pandemic, health education can be provided via teleeducation.The COVID-19 pandemic creates challenges and requires health workers to innovate in delivering virtual education.This includes support by professionals and providing informational support to mothers. 23ospitalization and place of delivery were also factors related to exclusive breastfeeding during the Covid 19 pandemic.The type of health care provider at birth, professionalism, and promptness of attention was associated with exclusive breastfeeding in a multivariable model.This shows the critical role of healthcare providers in breastfeeding practice.In this case, the critical role of health professionals is needed in providing breastfeeding support during the early postpartum period. 24n addition, the motivation and intentions of the mother also influenced the success of exclusive breastfeeding during the COVID-19 pandemic.Motivation is a psychological force that makes a person able to take action.Motivation is the power of individuals to do what must be done, including when and how to achieve their goals.When an individual has strong motivation and intention, this will make the individual not give up easily.Mothers who have high motivation to give exclusive breastfeeding to their babies will have the desire to continue breastfeeding.Strong motivation can help mothers to stimulate their milk production so that breast milk is sufficient for their babies. 11

Limitation
The limitations of this literature study still need to be improved sources of related articles.

Conclusion
From the several articles reviewed, the factors that most influenced the practice of exclusive breastfeeding were support from husbands, families, health workers, and information support.Motivation, belief, self-efficacy, birth setting, age, education level, and work situation are other influencing factors.It is hoped that policymakers and health workers will be more active in making socialization programs about the importance of providing exclusive breastfeeding during the COVID-19 pandemic.

Ethical Considerations
This research has considered ethical principles.