This prospective cohort study was conducted between March and August 2021, during the COVID-19 pandemic. It involved 260 women recruited on the postnatal ward of an academic center affiliated with Tehran University of Medical Sciences. Among them, 130 women had tested positive for SARS-CoV-2 in pregnancy based on a positive nasopharyngeal swab, and gave birth at 34 to 41 weeks. Additionally, 130 healthy women were randomly selected to serve as the control group.

The inclusion criteria for this study encompassed breastfeeding women aged between 20 and 40 years-old who received breastfeeding education, tested positive for COVID-19 but did not require ICU admission, had no history of severe postpartum depression or other psychological problems. Exclusions from the study involved women with preterm neonates requiring neonatal intensive care unit (NICU) admission, contraindications to breastfeeding, previous unsuccessful breastfeeding attempts, underlying maternal disorders that could impact breastfeeding, and the current use of illicit drugs.

This study was approved by the ethics committee of Tehran University of medical sciences (IR.TUMS.MEDICINE.REC.1400.530). Eligible women provided written informed consent before they were enrolled in this study. The participants’ information was collected securely and solely used for the purpose of this study.

Sociodemographic and obstetrics information including maternal age, gravidity, parity, baby’s gestational age (based on week), mode of delivery and the number of live children were collected. For this study, we utilized four validated questionnaires included The Bristol Breastfeeding questionnaire, The Multidimensional of Perceived Social Support (MPSS), The Breastfeeding Self-Efficacy Scale (BSES) and The Postpartum Partner Support Scale (PPSS). In addition, telephone follow-up was conducted eight weeks later to evaluate the success of breastfeeding, assessing whether it remained exclusive or not. In this study, our objective was to assess exclusive breastfeeding based on the World Health Organization (WHO) recommendation [11, 12]. We collected data by asking mothers about their infant’s feeding practices within the previous 24 h. Exclusive breastfeeding is defined as the practice of feeding an infant solely with breast milk, without introducing any other liquids or solid foods [13,14,15].

The PPSS designed by Dennis et al. consists of 20 items that were rated on a 4-point Likert scale, ranging from “strongly disagree” to “strongly agree” [16]. This inventory assessed general partner support and the Iranian version of the PPSS questionnaire has been found to demonstrate good internal consistency and reliability, as confirmed by Eslahi et al. [17].

The MPSS is a 12-item checklist, rated on a 7-point Likert scale, that evaluates perceived social support from friends, family and significant other [18]. Salimi et al. demonstrated that MSPSS is a valid and reliable assessment tool for Iranian population [19].

The Bristol Breastfeeding questionnaire, developed by Ingram et al., is an assessment tool for evaluating different aspects of efficient breastfeeding, including infant positioning, attachment, sucking, swallowing, and comfort. The Cronbach’s alpha coefficient for the Bristol Breastfeeding Scale was reported as 0.96, indicating high internal consistency [20].

The Breastfeeding Self-Efficacy Scale (BSES) is a checklist consisting of 14 items that measure maternal confidence in her ability to breastfeed her infant, using a 5-point Likert-type scale [21]. The validity and reliability of this questionnaire among Iranian women were confirmed by Araban et al. [10, 22].

Data analysis was performed using SPSS software (version 26, SPSS, Chicago, IL, USA). A comparison of the total scores for each questionnaire was conducted between two groups: lactating women with a history of COVID-19 infection and healthy lactating women. For this comparison, an independent t-test or Mann-Whitney U test was employed, as appropriate. The Pearson Correlation Coefficient was used to assess the relationship between breastfeeding wellbeing and questionnaire scores. Maternal factors were compared between the two groups using either a chi-square test or Fisher’s exact test. The significance level was set at P < 0.05.