{"paper_id":"e1e04af5-7546-4bdc-9975-7f8d4a4133f5","body_text":"Dual Standards of Care: COVID-19 Status and Breastfeeding Support Inequities in Brazilian Baby-Friendly Hospitals | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dual Standards of Care: COVID-19 Status and Breastfeeding Support Inequities in Brazilian Baby-Friendly Hospitals Anelise Roosch, Maria Eduarda Vidoto Martins, Davi Casale Aragon, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7032455/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract BACKGROUND: Health crises have constantly widened inequities and increased pressure on the most vulnerable groups. The Baby-Friendly Hospital Initiative (BFHI) establishes consistent global standards for breastfeeding support; however, control measures for COVID-19 revealed differences in how hospitals implemented evidence-based practices for mothers with COVID-19, leading to uncertainty and potentially resulting in unequal care, which could weaken overall health equity. OBJECTIVE To examine disparities in breastfeeding support provided to mother-infant dyads in Baby-Friendly Hospitals during COVID-19, comparing support offered to uninfected mothers versus those infected with SARS-CoV-2. METHOD We conducted a survey between January-May 2021 among BFHI-accredited Brazilian hospitals. A structured questionnaire based on BFHI recommendations, validated with ten hospitals, was sent to neonatology coordinators to assess breastfeeding support implementation for dyads with and without COVID-19. RESULTS Twenty-nine hospitals across all Brazilian regions participated. COVID-19 positive/suspected dyads experienced significantly reduced access to evidence-based practices: only 6.9% of hospitals recommended immediate skin-to-skin contact and 24.1% recommended breastfeeding initiation in delivery rooms for these dyads, compared to 86.2% for COVID-negative dyads (p-value < 0.001). Social support disparities were evident: 89.7% of hospitals allowed companions for women without the virus versus 34.5% for those with confirmed/suspected COVID-19. Alternative support mechanisms were limited, with telemedicine implemented by only 24.1% of centers. Correspondence analysis revealed that COVID-19 referral centers were significantly less likely to implement BFHI practices, creating structural inequities in breastfeeding support. CONCLUSIONS The pandemic exacerbated inequities in breastfeeding support in Brazilian BFHI hospitals, with potentially greater impacts on vulnerable populations. The association between COVID-19 referral center status and lower BFHI adherence illustrates how structural pressures compromise health equity during emergencies. Our findings highlight the urgent need for equity-focused contingency plans for breastfeeding support during public health emergencies to prevent deepening health disparities and protect breastfeeding rights for all mother-infant dyads during crises. COVID-19 Breastfeeding inequities Baby-Friendly Hospital Initiative Health emergency response Maternal-child health Health equity Structural barriers Latin America Pandemic preparedness Implementation science Figures Figure 1 Introduction Health crises historically amplify existing social inequalities, disproportionately affecting vulnerable populations. During such emergencies, infants face significant risks, suffering chronic health and nutritional impacts that can have lasting consequences.[ 1 – 2 ] The pattern of unequal assistance burden underscores the critical importance of examining health crises through an equity lens. Throughout history, pandemics have intensified pre-existing healthcare disparities, often with devastating effects on marginalized groups. Healthcare providers' perceptions of contamination risk significantly influenced disparities in care quality and accessibility [ 3 ], with breastfeeding support frequently among the first affected. [ 4 , 5 ] Breastfeeding protection during health emergencies faces distinct challenges. The H1N1 pandemic (2009) initially created uncertainty before recommendations emerged supporting breastfeeding with hygiene measures, though implementation varied regionally. The polio emergency (2014-present) integrated breastfeeding promotion into its response strategy, recognizing its immunological benefits. During the Zika outbreak (2016), WHO supported continued breastfeeding despite viral detection in breast milk, citing insufficient transmission evidence. [ 6 ] Across these diverse emergencies, common patterns emerged: initial uncertainty leading to unnecessary mother-infant separation, formula industries exploiting crises through aggressive marketing, and response resilience largely determined by pre-existing breastfeeding support infrastructure. [ 7 – 9 ] WHO and UNICEF established the Ten Steps to Successful Breastfeeding in 1989 and launched the Baby-Friendly Hospital Initiative (BFHI) in 1991. This global program aims to secure women's breastfeeding rights across the nations and serves as a key mechanism for reducing inequities in breastfeeding support, potentially decreasing maternal and child health disparities. Brazil adopted the BFHI in 1992 and has significantly advanced supportive maternal-child policies across prenatal, childbirth, and postnatal periods, emphasizing the critical first two years of life. [ 10 ] However, despite these breastfeeding promotion efforts, Brazil still faces substantial socioeconomic and regional disparities. [ 11 , 12 ] The full impact of the COVID-19 pandemic on breastfeeding promotion in BFHI remains insufficiently documented. Our study aims to examine the disparities in breastfeeding support provided to mother-infant dyads during the pandemic, specifically comparing the standard support offered to uninfected mothers with the notably reduced or absent support for those infected with SARS-CoV-2 by analyzing these disparities to identify structural gaps in child health protection that emerged during the emergency response and inform more equitable approaches to future health crises. Methods This multicenter cross-sectional survey study was conducted between January and May 2021, investigating the breastfeeding support practices in Baby-Friendly Hospital Initiative (BFHI) accredited facilities across Brazil during the COVID-19 pandemic. To achieve BFHI accreditation, hospitals must adhere to breastfeeding support guidelines nationally regulated by the Ministry of Health.[ 13 ] The study adhered to the Checklist for Reporting of Survey Studies (CROSS) guidelines and received approval from the Research Ethics Committee of Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Brazil (CAAE 31357320.9.1001.5440–4.066.741/2020). [ 14 ] We identified all hospitals with complete contact data (80 BFHI-accredited hospitals) through a search of the Brazilian Ministry of Health's website. Using non-probability sampling techniques, we contacted these centers via email, messages, or phone calls. Hospital coordinators who provided informed consent were included in the study. The study population comprised all Baby-Friendly Hospital Initiative (BFHI) accredited facilities across Brazil. Although 301 hospitals were registered as BFHI-accredited in the Brazilian Ministry of Health database, only 80 had updated contact information that allowed for communication. We sent invitations to participate in the survey to all 80 contactable hospitals between January and May 2021, using email, WhatsApp messages, or phone calls. Multiple follow-up attempts were made to maximize participation. The COVID-19 screening protocols at participating hospitals identified symptomatic patients (with flu symptoms) for testing, while asymptomatic pregnant women were considered COVID-19 negative. After obtaining consent to participate, we sent the structured questionnaire about local breastfeeding support guidelines, via email and requested a response within 30 days. The coordinators filled out the questionnaire spontaneously, without interference from or targeting by research staff, regarding breastfeeding promotion according to the BFHI for both positive and negative mothers regarding SARCOV-2. The structured questionnaire was developed based on the Baby-Friendly Hospital Initiative guidelines and WHO recommendations for breastfeeding during the COVID-19 pandemic. Initially, a comprehensive item pool was created covering six domains: hospital characteristics, breastfeeding management practices, delivery room protocols, immediate postpartum care, rooming-in practices, and home care recommendations. Content validity was established through review by a multidisciplinary panel of three experts in neonatology, maternal-child health, and breastfeeding support, who evaluated each item for relevance, clarity, and comprehensiveness. The questionnaire was then pilot-tested with neonatology coordinators from ten university hospitals representing different Brazilian regions. This validation process included cognitive interviews to assess item comprehension, response patterns, and completion time (average 25 minutes). Based on pilot feedback, we refined ambiguous questions, simplified complex items, and adjusted the sequence of questions to improve logical flow. The final instrument consisted of 70 items organized in six sections with parallel questions about COVID-positive and COVID-negative dyads (supplementary material). Questions were applied to the practices towards mothers and infants who are either COVID-19 positive or suspected to be positive, as well as those who are negative or not alleged to be positive. We divided the participating centers into two hospital groups: those that followed the BFHI recommended and those that did not during the pandemic for the mother-child positive dyad. [ 10 ]The following hospitals were characterized by their adherence to the Ten Steps of BFHI. In addition to these variables, we also analyzed the association of these two groups of hospitals with the following variables recommended by the BFHI but not included in the Ten Steps: referral center, university hospital, time of umbilical cord clamping, allowing a companion in the delivery room, recommending demand-based breastfeeding, allowing rooming-in, allowing visits for the binomial, and discharging after 24 hours. Participants answered yes or no to categorical questions and, when necessary, described the requested information. During study time ( January – May 2021), the literature and the WHO (World Health Organization) recommended that mothers with suspected or confirmed COVID-19 should be encouraged to initiate or continue to breastfeed; if suspected or confirmed infected mothers are well enough, they should keep skin-to-skin contact with their babies and breastfeed with appropriate precautions; mothers with symptoms of COVID-19 are advised to wear a medical mask, but even if this is not possible, breastfeeding should be continued; for those who are too unwell to breastfeed, expressing milk and donor human milk could be considered. Specific precautions for breastfeeding directly at the breast were washing hands frequently with soap and water or using alcohol-based hand rub, especially before touching the infant; wearing a medical mask during any contact with the infant, including while feeding; sneezing or coughing into a tissue, then disposing of it immediately and rewashing hands; routinely cleaning and disinfecting surfaces that mothers have touched. [ 15 – 17 ] Statistical Analysis: The data was initially described using both absolute and relative frequencies. Following a thorough exploratory analysis of the variables within each group, associations were established through correspondence analysis. To assess differences in BFHI practices implementation between COVID-19 positive/suspected and negative/non-suspected dyads, Fisher's exact test was employed due to the relatively small sample size (n = 29 in each group). This non-parametric test was selected over chi-square analysis. A significance level of α = 0.05 was established, with p-values < 0.05 considered statistically significant. For each BFHI practice, absolute frequencies and percentages were calculated and compared between groups. This multivariate technique enables the creation of a correspondence map, providing a more comprehensive understanding of the relationships between variables. The closer a variable is to another, the stronger their association. In this analysis, the term \"inertia\" refers to the overall variation in the data. This variation is broken down into two dimensions (Dim) and shown on each map axis. The dimensions indicate the extent to which the variability in the data can be explained. The FactoMineR and factoextra packages of the R 4.0.2 software were used. Correspondence analysis is a statistical technique that visualizes complex relationships between categorical variables in a two-dimensional space, making it particularly valuable for identifying patterns that might not be apparent in traditional tabular data. Unlike regression methods that test predefined hypotheses, correspondence analysis is an exploratory method that reveals associations by mapping variables as points on a graph, where proximity indicates relationships between variables. This technique is beneficial for analyzing survey data with multiple categorical responses, as it reduces multidimensional complexity into interpretable visual patterns. In the context of health services research, correspondence analysis can reveal how institutional characteristics (such as referral center status) correlate with practice patterns (such as adherence to clinical guidelines), allowing researchers to identify clusters of related practices and potential structural determinants of care quality without requiring assumptions about causality or linear relationships. We did not perform the analysis of the non-respondents due to a lack of data. Results Eighty centers and hospitals accredited with the Baby-Friendly Hospital Initiative (BFHI) were contacted via email, WhatsApp, or phone. Among those contacted, 29 hospitals participated in the survey (36, 2% response rate) by completing the questionnaire and providing informed consent. The participating hospitals represented diverse regions of Brazil: two from the Midwest, six from the Northeast, four from the North, 11 from the Southeast, and six from the South. Twenty-eight centers (96.6%) had developed specific protocols for managing maternal care in the immediate postpartum period during the pandemic. Only one center (3.4%) reported not having a specific protocol but followed the guidelines of the Brazilian Society of Pediatrics (SBP). Regarding protocol references, ten hospitals (34.5%) did not provide this information. Sixteen hospitals (55.2%) incorporated multiple national and international guidelines, while three hospitals (10.3%) exclusively adhered to the SBP recommendations. Among the participating centers, 17 (58.6%) were designated as referral services for pregnant women with COVID-19. Of these referral centers, only one (5.9%) indicated not having a protocol for managing COVID-19 cases. Additionally, 17 (58.6%) of all participating hospitals were university hospitals, with 11 of them (64.7%) serving as referral centers for pregnant women with COVID-19. All participating hospitals reported treating high-risk pregnancies and were classified as tertiary care facilities. For testing pregnant women and infants with suspected COVID-19, 23 hospitals (79.31%) used the gold standard Reverse Transcription Polymerase Chain Reaction (RT-PCR) test. Of these, four (17.4%) also used IgG/IgM serology. Testing was performed only on symptomatic pregnant women (those with flu-like symptoms). All 29 participating hospitals reported having written infant feeding guidelines that were communicated to staff and parents, with an emphasis on staff training to enhance their knowledge, competence, and skills in breastfeeding support. One center disclosed non-compliance with the current International Code of Marketing of Breast-milk Substitutes. Similarly, only one center reported failing to maintain a continuous system for monitoring and managing breastfeeding-related data. Notably, only two hospitals (6.9%) recommended immediate and uninterrupted skin-to-skin contact for mother-infant dyads with confirmed or suspected COVID-19 (p-value < 0.001), and most hospitals did not provide support to mothers in initiating breastfeeding as soon as possible after birth (p-value = 0.006). Additional results are presented in Table 1 . Table 1 Implementation of Baby-Friendly Hospital Initiative Practices by Maternal COVID-19 Status in Brazilian BFHI-Accredited Hospitals, 2021 (n = 29) BFHI Practices Positive or suspected COVID-19 dyads n (%) Negative or without suspicion of COVID-19 dyads n (%) P-value Discuss the importance and management of breastfeeding with pregnant women and their families 25 (86.2) 28 (96.6) 0.353 Facilitate immediate and uninterrupted skin-to-skin contact 2 (6.9) 28 (96.6) < 0.001 Support mothers in initiating breastfeeding as soon as possible after birth 20 (69.0) 28 (96.6) 0.006 Support mothers to initiate and maintain breastfeeding and manage common difficulties 23 (79.3) 28 (96.6) 0.052 Unless medically indicated, do not provide breastfed newborns any food or fluids other than breast milk 26 (89.7) 27 (93.1) 1.000 Enable mothers and their infants to remain together and practice rooming in 24 hours daily 23 (79.3) 28 (96.6) 0.052 Support mothers to recognize and respond to their infants' cues for feeding 25 (86.2) 28 (96.6) 0.353 Counsel mothers on the use and risks of feeding bottles, teats, and pacifiers 25 (86.2) 28 (96.6) 0.353 Coordinate discharge so parents and their infants have timely access to ongoing support and care 25 (86.2) 28 (96.6) 0.353 Note: Data collected from a survey of 29 Baby-Friendly Hospital Initiative (BFHI) accredited hospitals in Brazil between January and May 2021. Values represent the number and percentage of hospitals implementing each practice. Ten centers (34.5%) permitted companions in the delivery room for pregnant women with confirmed or suspected COVID-19, while 26 centers (89.7%) allowed companions for women without the virus ( p-value = 0.01). Also, the recommendation to delayed umbilical cord clamping was not follow to COVID-19 positive dyads ( p-value = 0,003). Additional findings about delivery room recommendations are detailed in Table 2 . Table 2 Delivery Room Practices and Protective Measures by Maternal COVID-19 Status in Brazilian BFHI-Accredited Hospitals, 2021 (n = 29) Delivery Room Practices Positive or suspected COVID-19 dyads n (%) Negative or without suspicion of COVID-19 dyads n (%) P-value Delayed umbilical cord clamping 14 (48.3) 25 (86.2) 0.003 Presence of a companion 10 (34.5) 26 (89.7) < 0.001 Breastfeeding 7 (24.1) 25 (86.2) < 0.001 Use of full or partial (surgical mask) personal protective equipment for medical staff 28 (96.6) 21 (72.4) 0.026 Use of full or partial (surgical mask) personal protective equipment for pregnant women 25 (86.2) 16 (55.2) 0.012 Distinct protective approach for cesarean deliveries 11 (37.9) 8 (27.6) 0.405 Distinct protective approach for vaginal deliveries 11 (37.9) 5 (17.2) 0.080 Note: Data collected from a survey of 29 Baby-Friendly Hospital Initiative (BFHI) accredited hospitals in Brazil between January and May 2021. Values represent the number and percentage of hospitals implementing each practice. For mother-infant dyads with confirmed or suspected COVID-19, 18 centers (62%) advised mask use during breastfeeding and handwashing before breastfeeding. However, only three centers (10%) extended recommendations to include face washing, changing clothes before breastfeeding, and breast washing. ( Table 2 ) In contrast, five centers (17%) reported no specific recommendations for COVID-negative mother-infant dyads. Ten centers (34%) endorsed the use of masks during breastfeeding and handwashing before feeding for non-symptomatic mothers, while 11 centers (38%) emphasized the importance of handwashing before feeding alone. Additional details can be found in Table 3 . Table 3 Immediate Postpartum Care Practices by Maternal COVID-19 Status in Brazilian BFHI-Accredited Hospitals, 2021 (n = 29) Postpartum Care Practices Positive or suspected COVID-19 dyads n (%) Negative or without suspicion of COVID-19 dyads n (%) P-value Breastfeeding on demand 25 (86.2) 29 (100.0) 0.112 Breastfeeding every three hours 3 (10.3) 1 (3.4) 0.612 Minimum distance between neonate and mother during non-breastfeeding periods 27 (93.1) 2 (6.9) < 0.001 Accommodation with mother-child contact allowance 26 (90.0) 25 (86.0) 1.00 Milking, if necessary (raw milk) 16 (55.0) 23 (79.0) 0.052 Milk pasteurization 13 (44.8) 15 (51.7) 0.596 Mothers to be milk donors 6 (20.7) 26 (89.7) < 0.001 Visits or companies for the mother-child dyad 2 (6.9) 16 (55.2) < 0.001 Discharge of the mother-child dyad within 24 hours 3 (10.0) 3 (10.0) 1.00 Psychological support, if needed 27 (93.1) 28 (96.6) 1,00 Note: Data collected from a survey of 29 Baby-Friendly Hospital Initiative (BFHI) accredited hospitals in Brazil between January and May 2021. Values represent the number and percentage of hospitals implementing each practice. Regarding postpartum care practices (Table 3 ), visits and/or companies were reported by only two centers (6,9%) and even allowed companies, 26 (89.7) recommended maintaining a two-meter distance for mother-child pairs with COVID-19 ( p < 0.001). In the home setting ( Table 4 ), 15 centers (51.7%) advised limiting contact between other children and the newborn, and 26 centers (89.7%) recommended maintaining a two-meter distance for mother-child pairs with COVID-19; two centers (6.9%) extended this recommendation also to include COVID-negative cases ( p-value = < 0.001), while seven centers (24.1%) implemented telemedicine services to care for COVID-positive mother-infant pairs. Table 4 Home Care Recommendations by Maternal COVID-19 Status in Brazilian BFHI-Accredited Hospitals, 2021 (n = 29) Home Care Recommendations Positive or suspected COVID-19 dyads n (%) Negative or without suspicion of COVID-19 dyads n (%) P-value Separating mother and baby 0 (0.0) 1 (3.4) 1,00 Maintaining a distance of 2 meters between mother and baby 26 (89.7) 2 (6.9) < 0,001 Hand washing before breastfeeding 28 (96.6) 24 (82.8) 0,195 Always hand washing before handling the baby 28 (96.6) 24 (82.8) 0,195 Holding the baby in the lap for periods of comfort when it presents with colic and/or crying 20 (69.0) 28 (96.6) 0,012 Other care being carried out by someone else (changing diapers, bathing) 10 (34.5) 5 (17.2) 0,138 Free demand or breastfeeding every 3 hours 25 (86.2) 25 (86.2) 1,00 Home milking and offering raw milk 18 (62.1) 20 (69.0) 0,584 Prescription of formula on discharge if needed 3 (10.3) 3 (10.3) 1.00 Measures to maintain and stimulate lactation and prevent weaning 27 (93.1) 28 (96.6) 1.00 Delivery of guidance material (virtual or printed) on breastfeeding and COVID-19 12 (41.4) 10 (34.5) 0.589 Home visits for mother-child dyads 1 (3.4) 3 (10.3) 0.612 Scheduled telemedicine care for the mothers 7 (24.1) 3 (10.3) 0.299 Psychological assistance (telecare) for these mothers, if necessary 12 (41.4) 8 (27.6) 0.273 Other children are kept away from the new baby 15 (51.7) 3 (10.3) 0.001 Note: Data collected from a survey of 29 Baby-Friendly Hospital Initiative (BFHI) accredited hospitals in Brazil between January and May 2021. Values represent the number and percentage of hospitals recommending each practice. BCG = Bacillus Calmette-Guérin vaccine. sychological support via telecare was available in 12 centers (41.4%) for mothers with COVID-19. Additional findings are detailed in Table 4 . Using correspondence map analysis, we examined the relationship between hospitals that maintained BFHI compliance during the pandemic for COVID-19-positive mother-infant dyads (BFH) and those that did not (nBFH). We observed a correspondence between nBFH status and serving as a referral center for COVID-19 cases (Fig. 1 ). Discussion Our findings regarding disparities in the implementation of the BFHI guidelines between COVID-19-positive and COVID-negative dyads reflect broader patterns that demonstrate how health emergencies affect women through systemic mechanisms [ 18 – 20 ]. This study assessed the impact of the pandemic on breastfeeding support in Brazilian Baby-Friendly hospitals, revealing a significant deterioration in adherence to evidence-based practices for mothers with infections despite official guidelines permitting their implementation. During the study period the WHO, and the Brazilian Pediatric Society published recommendations supporting breastfeeding during the COVID-19 pandemic, including skin-to-skin contact, early breastfeeding initiation, and allowing delivery room companions [ 17 , 21 , 22 ]. Despite these guidelines, only 6.9% of hospitals recommended immediate skin-to-skin contact for COVID-positive dyads versus 86.2% for COVID-negative mothers. These disparities stemmed from structural pandemic responses rather than individual clinical decisions, systematically disadvantaging specific populations.[ 23 ] Our findings parallel similar disruptions to maternal-child services documented during the Ebola epidemic, which produced significant indirect mortality effects typically omitted from pandemic statistics. [ 24 ] The disparities observed in our study provide a compelling illustration of the inverse equity hypothesis in action during a health emergency. This theoretical framework, initially proposed by Victora et al., suggests that new health interventions and protective measures are initially adopted by socioeconomically advantaged populations, temporarily widening health inequities before eventually reaching disadvantaged groups [ 25 ]. In our findings, this pattern was evident through the creation of a two-tiered breastfeeding support system based on COVID-19 status. The stark contrast between support provided to COVID-negative versus COVID-positive dyads reveals how infection control measures functioned as new interventions that disproportionately benefited uninfected mothers. This pattern is particularly concerning because COVID-19 infection rates in Brazil showed socioeconomic gradients, with higher prevalence among vulnerable populations living in crowded conditions with limited access to protective resources. [ 26 ] Consequently, those most likely to be COVID-positive were often from disadvantaged communities, creating a compounding effect where social vulnerability increased both infection risk and subsequent reduction in breastfeeding support [ 27 ]. Similar patterns were observed during the Nepal earthquake, where breastfeeding support systems failed when they were most critical [ 4 ]. The finding that only 24.1% of hospitals implemented telemedicine support for breastfeeding represents a missed opportunity to mitigate disruptions. This low adoption rate of alternative support mechanisms reveals limitations in system resilience and adaptive capacity during crises [ 9 ]. When comparing our findings with international experiences, countries that successfully maintained breastfeeding support during the pandemic often implemented robust initiatives, telehealth services and remote lactation consultations [ 28 – 32 ]. The physical separation due to infection control without addressing structural alternatives (remote support) perpetuates inequities for marginalized populations, creating a form of institutional discrimination with direct health consequences. [ 28 – 32 ] Despite having BFHI certification, 10.3% of hospitals prescribed formula for COVID-positive mothers. Equally concerning, 10.3% also recommended formula for COVID-negative mothers. This finding aligns with global patterns documented by Vu Hoang et al. 2020, who found that the pandemic created opportunities for formula companies to market their products as safer alternatives, potentially undermining breastfeeding efforts. [ 19 ] Our correspondence analysis revealed that COVID-19 referral centers were less likely to implement the BFHI guidelines. This finding highlights how fragmented health systems amplify inequities during emergencies. The structural pressures faced by referral centers—including increased patient volume, staff shortages, and resource constraints—created a situation where, paradoxically, hospitals treating the most vulnerable mothers were least equipped to provide evidence-based breastfeeding support. This demonstrates that health system design itself can create and maintain inequities [ 33 ]. The lower adherence to BFHI practices in referral centers may also reflect competing priorities during crisis response. As Nuzzo et al. [ 9 ] noted in their scoping review of health system resilience, emergency responses often prioritize immediate infection control over maintaining essential services, particularly those perceived as optional rather than life-saving. This false dichotomy between infection control and breastfeeding support reflects a lack of understanding about the critical importance of breastfeeding for infant health outcomes. Table 1 provides intriguing insights; we anticipated universal adherence to BFHI recommendations for uninfected mother-infant pairs in accredited hospitals. However, approximately 3.5% of hospitals deviated from recommended measures, even for those without health complications. This unexpected finding suggests that the pandemic may have disrupted the implementation of BFHI more broadly, affecting care for all mothers, regardless of their COVID-19 status. [ 34 , 35 ] Nevertheless, most studied hospitals maintained the BFHI recommendations for COVID-negative dyads. This study has several methodological limitations that warrant consideration. Our cross-sectional design captured hospital practices during a specific pandemic period (January-May 2021), missing potential protocol evolution over time. The 36.2% response rate (29 of 80 contacted hospitals) introduces potential selection bias that may impact the generalizability of our findings. Hospitals that chose to participate might systematically differ from non-respondents, potentially overrepresenting institutions with more robust breastfeeding support systems or better-established COVID-19 protocols. Additionally, the fact that only 80 of the 300 BFHI-accredited facilities had updated contact information in the Ministry of Health database suggests possible systemic issues in maintaining active engagement with the BFHI network nationally. Our reliance on self-reported data from neonatology coordinators without direct verification may result in reporting bias regarding adherence to BFHI guidelines, potentially leading to overestimation of compliance. Social desirability bias may have influenced respondents to report more favorable practices that were implemented. Finally, we focused on hospital policies rather than actual implementation or maternal experiences. This approach cannot capture the lived experiences of mothers navigating these systems during the pandemic, nor can it account for potential discrepancies between written policies and actual practice. Despite these constraints, our findings provide valuable initial insights into pandemic-related disparities in breastfeeding support across Brazilian BFHI facilities. However, they should be interpreted with caution regarding their representativeness of all BFHI-accredited facilities nationwide. Our research identifies an urgent need for multi-level structural interventions to address health disparities in Brazilian Baby-Friendly Hospital Initiative (BFHI) facilities during crises, protecting and maintaining breastfeeding-supportive policies during pandemics. This proactive approach is essential to prevent the recurring pattern of breastfeeding disruption observed during health crises, thereby preserving the substantial social impact of this intervention. Healthcare institutions must recognize exclusive breastfeeding not as an optional practice that can be suspended during crises but as an essential component of infant care that must be preserved through appropriate infection control measures. This paradigm shift requires immediate action from hospital administrators, policymakers, and healthcare providers to safeguard infants' fundamental right to optimal nutrition through breastfeeding during future health emergencies. Conclusion Our findings indicate that the right to breastfeeding was not adequately safeguarded for all mothers and infants during the health crisis, with potentially greater impacts on vulnerable populations. Lessons from this pandemic must inform the development of more equitable policies and practices. The BFHI urgently needs an equity-focused contingency plan for challenging situations to prevent deepening health disparities during future public health emergencies, ensuring that the right to breastfeeding is protected for all mother-infant dyads, even during crises. Declarations Ethics approval and consent to participate: The study adhered to the Checklist for Reporting of Survey Studies (CROSS) guidelines and received approval from the Research Ethics Committee of Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Brazil (CAAE 31357320.9.1001.5440-4.066.741/2020). Consent for publication: All participating hospital coordinators provided consent for the publication of the aggregated, anonymized survey data presented in this study. Availability of data and materials: The datasets generated during the current study are not publicly available due to confidentiality agreements with participating hospitals but are available from the corresponding author on reasonable request. Authors' contributions : AR: Conceptualization, methodology, investigation, data curation, writing - original draft. DCA: Formal analysis, data visualization, writing - review & editing. Maria Eduarda Vidoto: Data visualization, writing - review & editing. WAGF: Supervision, methodology, validation, writing - review & editing. All authors read and approved the final manuscript. Funding The Article Processing Charge for the publication of this research was funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES (ROR identifier: 00x0ma614). For open access purposes, the authors assigned the Creative Commons CC BY license to any accepted version of the article. Conflict of Interest The authors declare no conflict of interest. Acknowledgments We would like to thank all the participating centers: Hospital Materno Infantil de Brasília, Distrito Federal; Hospital Regional de Ceilândia, Distrito Federal; Maternidade Climério de Oliveira, Bahia; Hospital César Cals, Ceará; Maternidade Escola Assis Chateaubriand, Ceará; Centro Integrado de Saúde Amaury de Medeiros, Pernambuco; Instituto de Medicina Integral Professor Fernando Figueira, Pernambuco; Maternidade Dona Evangelina Rosa, Piauí; Maternidade Ana Braga, Amazonas; Santa Casa de Belém, Pará; Hospital Dom Orione de Araguaína, Tocantins; Hospital e Maternidade Dona Regina Siqueira Campos de Palmas, Tocantins; Santa Casa de Belo Horizonte, Minas Gerais; Maternidade Sofia Feldmann, Minas Gerais; Instituto Fernandes Figueira, Rio de Janeiro; Hospital Pedro Ernesto, Rio de Janeiro; Hospital Estadual de Sumaré, São Paulo; Hospital Geral de Itapecerica da Serra, São Paulo; Centro de Atenção Integral à Saúde da Mulher, São Paulo; Hospital Guilherme Álvaro, São Paulo; Maternidade Ribeirão, São Paulo; Santa Casa de Limeira, São Paulo; Santa Casa de Ponta Grossa, Paraná; Hospital Universitário de Londrina, Paraná; Hospital Regional Universitário de Maringá, Paraná; Hospital Universitário do Oeste do Paraná, Paraná; Hospital Universitário Polydoro Ernani, Santa Catarina; Hospital Femina, Rio Grande do Sul; Hospital das Clínicas de Ribeirão Preto, São Paulo. 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BMC Public Health. 2019;19(1):1310. 10.1186/s12889-019-7707-z . Organization WH. UNICEF. Protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services: the revised baby-friendly hospital initiative 2018. Implementation guidance [Internet]. 2018 [cited 2020 Jul 29]. Available from: https://www.who.int/nutrition/publications/infantfeeding/bfhiimplementation/en/ Gonçalves-Ferri WA, Pereira-Cellini FM, Coca K, Aragon DC, Nader P, Lyra JC, et al. The impact of coronavirus outbreak on breastfeeding guidelines among Brazilian hospitals and maternity services: a cross-sectional study. Int Breastfeed J. 2021;16(1):30. 10.1186/s13006-021-00377-1 . Gonçalves-Ferri WA, Coca KP, Martins-Celini FP, Chang YS, Ferreira RS, de Siqueira Caldas JP, et al. Protective measures feasibility for infants of low-income SARS-CoV-2 positive breastfeeding mothers: a prospective multicentre cohort study. J Nurs Manag. 2022;30(8):4064–70. 10.1111/jonm.13854 . PMID: 36205220; PMCID: PMC9874786. IHAC. Saúde da criança: ações, programas e iniciativas [Internet]. [cited 2022 Nov 21]. Available from: https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z/s/saude-da-crianca/acoes-programas-e-iniciativas Sharma A, Minh Duc NT, Luu Lam Thang T, Nam NH, Ng SJ, Abbas KS, et al. A consensus-based checklist for Reporting of Survey Studies (CROSS). J Gen Intern Med. 2021;36(10):3179–87. 10.1007/s11606-021-06737-1 . Liu X, Chen H, An M, Yang W, Wen Y, Cai Z, et al. Recommendations for breastfeeding during Coronavirus Disease 2019 (COVID-19) pandemic. Int Breastfeed J. 2022;17(1):28. 10.1186/s13006-022-00465-w . Lubbe W, Botha E, Niela-Vilen H, Reimers P. Breastfeeding during the COVID-19 pandemic - a literature review for clinical practice. Int Breastfeed J. 2020;15(1):82. 10.1186/s13006-020-00319-3 . World Health Organization. Breastfeeding and COVID-19 [Internet]. 2020 [cited 2020 Jun 23]. Available from: https://www.who.int/publications/i/item/WHO-2019-nCoVSci_Brief-Breastfeeding-2020.1 Thacker N, Hasanoglu E, Dipesalema J, Namazova-Baranova L, Pulungan A, Alden E, et al. Global emergencies in child health: challenges and solutions-viewpoint and recommendations from the European Paediatric Association and the International Pediatric Association. J Pediatr. 2022;241:266–e63. 10.1016/j.jpeds.2021.10.052 . Vu Hoang D, Cashin J, Gribble K, Marinelli K, Mathisen R. Misalignment of global COVID-19 breastfeeding and newborn care guidelines with World Health Organization recommendations. BMJ Nutr Prev Health. 2020;3(2):339–50. 10.1136/bmjnph-2020-000184 . Gribble K, Marinelli KA, Tomori C, Gross MS. Implications of the COVID-19 pandemic response for breastfeeding, maternal caregiving capacity and infant mental health. J Hum Lact. 2020;36(4):591–603. 10.1177/0890334420949514 . Brazilian Society of Pediatrics. Breastfeeding in the Times of COVID-19 [Internet]. 2020 [cited 2025 Jun 3]. Available from: https://www.sbp.com.br/fileadmin/user_upload/22393c-Nota_de_Alerta_sobe_Aleitam_Materno_nos_Tempos_COVID-19.pdf Brazilian Society of Pediatrics. Recommendations for Care for Newborns in the Delivery Room of Mothers with Suspected or Confirmed COVID-19 [Internet]. 2020 [cited 2025 Jun 3]. Available from: https://www.sbp.com.br/fileadmin/user_upload/22422d-NAlerta-Assist_RN_SalaParto_de_mae_com_COVID-19.pdf Beckfield J, Krieger N. Epi + demos + cracy: linking political systems and priorities to the magnitude of health inequities–evidence, gaps, and a research agenda. Epidemiol Rev. 2009;31:152–77. 10.1093/epirev/mxp002 . Campbell F, Booth A, Carroll C, Lee A, Relton C. Qualitative evidence syntheses of attitudes and preferences to inform guidelines on infant feeding in the context of Ebola Virus Disease (EVD) transmission risk. PLoS Negl Trop Dis. 2022;16(3):e0010080. 10.1371/journal.pntd.0010080 . Victora CG, Vaughan JP, Barros FC, Silva AC, Tomasi E. Explaining trends in inequities: evidence from Brazilian child health studies. Lancet. 2000;356(9235):1093–8. 10.1016/S0140-6736(00)02741-0 . Cestari VRF, Florêncio RS, Sousa GJB, Garces TS, Maranhão TA, Castro RR, et al. Social vulnerability and COVID-19 incidence in a Brazilian metropolis. Cien Saude Colet. 2021;26(3):1023–33. 10.1590/1413-81232021263.42372020 . Baggio JAO, Machado MF, Carmo RFD, Armstrong ADC, Santos ADD, Souza CDF. COVID-19 in Brazil: spatial risk, social vulnerability, human development, clinical manifestations and predictors of mortality - a retrospective study with data from 59695 individuals. Epidemiol Infect. 2021;149:e100. 10.1017/S0950268821000935 . Neo-COVID-19 Research Group, Marín, Gabriel MA, Domingo Goneche L, Cuadrado Pérez I, Reyne Vergeli M, Forti Buratti A et al. Baby Friendly Hospital Initiative breastfeeding outcomes in mothers with COVID-19 infection during the first weeks of the pandemic in Spain. J Hum Lact. 2021;37(4):639 – 48. 10.1177/08903344211039182 Muñoz-Amat B, Pallás-Alonso CR, Hernández-Aguilar MT. Good practices in perinatal care and breastfeeding protection during the first wave of the COVID-19 pandemic: a national situation analysis among BFHI maternity hospitals in Spain. Int Breastfeed J. 2021;16(1):66. 10.1186/s13006-021-00407-y . Chertok IA, Artzi-Medvedik R, Arendt M, Sacks E, Otelea MR, Rodrigues C, et al. Factors associated with exclusive breastfeeding at discharge during the COVID-19 pandemic in 17 WHO European Region countries. Int Breastfeed J. 2022;17(1):83. 10.1186/s13006-022-00517-1 . Quifer-Rada P, Aguilar-Camprubí L, Padró-Arocas A, Gómez-Sebastià I, Mena-Tudela D. Impact of COVID-19 Pandemic in Breastfeeding Consultations on LactApp, an m-Health Solution for Breastfeeding Support. Telemed J E Health. 2022;28(10):1449–57. 10.1089/tmj.2021.0586 . Dudeja N, Sharma D, Maria A, Pawar P, Mukherjee R, Nargotra S, et al. Implementing recommended breastfeeding practices in healthcare facilities in India during the COVID-19 pandemic: a scoping review of health system bottlenecks and potential solutions. Front Nutr. 2023;10:1142089. 10.3389/fnut.2023.1142089 . Melro LMG, Trindade EM, Park M. COVID-19 underpinning the inverse equity hypothesis between public and private health care in Brazil. Crit Care Sci. 2024;36:e20240294en. 10.62675/2965-2774.20240294-en . Koleilat M, Whaley SE, Clapp C. The Impact of COVID-19 on Breastfeeding Rates in a Low-Income Population. Breastfeed Med. 2022;17(1):33–7. 10.1089/bfm.2021.0238 . Moini A, Heidari F, Eftekhariyazdi M, Pirjani R, Ghaemi M, Eshraghi N, et al. Breastfeeding success and perceived social support in lactating women with a history of COVID 19 infection: a prospective cohort study. Int Breastfeed J. 2023;18(1):65. 10.1186/s13006-023-00601-0 . Additional Declarations No competing interests reported. Supplementary Files QUESTIONNAIREONTHEPROTOCOLFORCOVID.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 29 Jan, 2026 Reviews received at journal 27 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviews received at journal 14 Oct, 2025 Reviewers agreed at journal 18 Aug, 2025 Reviewers invited by journal 20 Jul, 2025 Editor assigned by journal 07 Jul, 2025 Submission checks completed at journal 07 Jul, 2025 First submitted to journal 02 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7032455\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":488800697,\"identity\":\"ead40fc1-b2f0-4573-8e7c-05db3a039be4\",\"order_by\":0,\"name\":\"Anelise Roosch\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of São Paulo\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Anelise\",\"middleName\":\"\",\"lastName\":\"Roosch\",\"suffix\":\"\"},{\"id\":488800703,\"identity\":\"acd32fd6-0f6d-4da8-bc68-43d75f39edcf\",\"order_by\":1,\"name\":\"Maria Eduarda Vidoto Martins\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of São Paulo\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Maria\",\"middleName\":\"Eduarda Vidoto\",\"lastName\":\"Martins\",\"suffix\":\"\"},{\"id\":488800707,\"identity\":\"0e75863c-c822-468e-90f0-17eb5d90ed06\",\"order_by\":2,\"name\":\"Davi Casale Aragon\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of São Paulo\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Davi\",\"middleName\":\"Casale\",\"lastName\":\"Aragon\",\"suffix\":\"\"},{\"id\":488800710,\"identity\":\"0d808d2b-4223-4bf0-82d9-2182b5a7a9a2\",\"order_by\":3,\"name\":\"Walusa Assad Gonçalves-Ferri\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYFAC5gYgYcMP5xsQ1sII0pIm2UCqlsMkaDE4frBN8kfNeQnd2WcPMPP8ucNgLn2AgJYziW3SPMduS5idy0tg5m17xmDZl4Bfi9kBoBYGttt1Zmd4DJh5Gw4DDSHgMLPzD4EO+3dOAqyF5w8xWm4ktknwth2AamEjQov9jYfN1rx9yUAtfAkH57Y947HsIaBFsj/54M0f3+yAWngPPnjz546cOQ8BLUiAh+EAA8MBEjSAtADBAVJ0jIJRMApGwQgBAHFSQ8Tb76RDAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"University of São Paulo\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Walusa\",\"middleName\":\"Assad\",\"lastName\":\"Gonçalves-Ferri\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-07-02 20:38:06\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-7032455/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-7032455/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":87663358,\"identity\":\"aff5553d-70f5-454d-a089-20330e2e2e3b\",\"added_by\":\"auto\",\"created_at\":\"2025-07-27 10:53:33\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":152673,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eCorrespondence analysis map of items in the Baby-Friendly Hospital Initiative questionnaire.\\u003c/p\\u003e\\n\\u003cp\\u003eLegend: The correspondence analysis applied to the recommendations of the Baby-Friendly Hospital Initiative (BFHI) revealed distinct groupings among the variables studied. It was observed that hospitals classified as BFH (those adhering to the BFHI) demonstrated a strong association with recommended practices such as on-demand breastfeeding (ODBF), absence of early cord clamping (nECC), allowance of rooming-in (SA), and permitted mother-infant visitation (VD), forming a cluster in the positive quadrant of the map. In contrast, establishments categorized as nBFH were closer to practices not aligned with the guidelines, such as early cord clamping (ECC), absence of on-demand breastfeeding (nODBF), and restricted rooming-in (nSA). Additionally, it was noted that reference centers (RC) tended not to align with BFHI-recommended practices, indicating a possible influence of institutional profile on the adoption of the guidelines. This graphical visualization enabled the identification of association patterns among the categorical variables, revealing the heterogeneity of breastfeeding-related care practices in the institutions analyzed. Variables:\\u003c/p\\u003e\\n\\u003cp\\u003eBFH: the center followed the BFHI; nBFH: the center did not follow the BFH;RC: reference center; nRC: not a reference center;UH: university hospital; nUH: not a university hospital; ECC: early cord clamping; nECC: no early cord clamping;ADR: attendant in the delivery room; nADR: no attendant in the delivery room;ODBF: on-demand breastfeeding; nODBF: no on-demand breastfeeding;3BF: breastfeeding every three hours; n3BF: no breastfeeding every three hours;SA: shared accommodation allowed; nSA: shared accommodation not allowed;VD: visit for the dyad allowed; nVD: visit for the dyad not allowed;D24h: discharge within 24 hours; D\\u0026gt;24h: discharge after 24 hours.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7032455/v1/c739c5415f980b6b3ef22aa8.png\"},{\"id\":87664961,\"identity\":\"649955e6-e4b8-4087-9f52-adc03d2c0505\",\"added_by\":\"auto\",\"created_at\":\"2025-07-27 11:01:39\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":924808,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7032455/v1/d507abde-aa61-49f7-8666-74183df91801.pdf\"},{\"id\":87663365,\"identity\":\"eb56e0ac-d950-44b0-bcaa-e7ebd052bdef\",\"added_by\":\"auto\",\"created_at\":\"2025-07-27 10:53:35\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":263759,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"QUESTIONNAIREONTHEPROTOCOLFORCOVID.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7032455/v1/7f68ee44568da755a5f25f38.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Dual Standards of Care: COVID-19 Status and Breastfeeding Support Inequities in Brazilian Baby-Friendly Hospitals\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eHealth crises historically amplify existing social inequalities, disproportionately affecting vulnerable populations. During such emergencies, infants face significant risks, suffering chronic health and nutritional impacts that can have lasting consequences.[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e] The pattern of unequal assistance burden underscores the critical importance of examining health crises through an equity lens.\\u003c/p\\u003e\\u003cp\\u003eThroughout history, pandemics have intensified pre-existing healthcare disparities, often with devastating effects on marginalized groups. Healthcare providers' perceptions of contamination risk significantly influenced disparities in care quality and accessibility [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e], with breastfeeding support frequently among the first affected. [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]\\u003c/p\\u003e\\u003cp\\u003eBreastfeeding protection during health emergencies faces distinct challenges. The H1N1 pandemic (2009) initially created uncertainty before recommendations emerged supporting breastfeeding with hygiene measures, though implementation varied regionally. The polio emergency (2014-present) integrated breastfeeding promotion into its response strategy, recognizing its immunological benefits. During the Zika outbreak (2016), WHO supported continued breastfeeding despite viral detection in breast milk, citing insufficient transmission evidence. [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]\\u003c/p\\u003e\\u003cp\\u003eAcross these diverse emergencies, common patterns emerged: initial uncertainty leading to unnecessary mother-infant separation, formula industries exploiting crises through aggressive marketing, and response resilience largely determined by pre-existing breastfeeding support infrastructure. [\\u003cspan additionalcitationids=\\\"CR8\\\" citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]\\u003c/p\\u003e\\u003cp\\u003eWHO and UNICEF established the Ten Steps to Successful Breastfeeding in 1989 and launched the Baby-Friendly Hospital Initiative (BFHI) in 1991. This global program aims to secure women's breastfeeding rights across the nations and serves as a key mechanism for reducing inequities in breastfeeding support, potentially decreasing maternal and child health disparities. Brazil adopted the BFHI in 1992 and has significantly advanced supportive maternal-child policies across prenatal, childbirth, and postnatal periods, emphasizing the critical first two years of life. [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e] However, despite these breastfeeding promotion efforts, Brazil still faces substantial socioeconomic and regional disparities. [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]\\u003c/p\\u003e\\u003cp\\u003eThe full impact of the COVID-19 pandemic on breastfeeding promotion in BFHI remains insufficiently documented. Our study aims to examine the disparities in breastfeeding support provided to mother-infant dyads during the pandemic, specifically comparing the standard support offered to uninfected mothers with the notably reduced or absent support for those infected with SARS-CoV-2 by analyzing these disparities to identify structural gaps in child health protection that emerged during the emergency response and inform more equitable approaches to future health crises.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eThis multicenter cross-sectional survey study was conducted between January and May 2021, investigating the breastfeeding support practices in Baby-Friendly Hospital Initiative (BFHI) accredited facilities across Brazil during the COVID-19 pandemic. To achieve BFHI accreditation, hospitals must adhere to breastfeeding support guidelines nationally regulated by the Ministry of Health.[\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e] The study adhered to the Checklist for Reporting of Survey Studies (CROSS) guidelines and received approval from the Research Ethics Committee of Faculdade de Medicina de Ribeir\\u0026atilde;o Preto da Universidade de S\\u0026atilde;o Paulo, Brazil (CAAE 31357320.9.1001.5440\\u0026ndash;4.066.741/2020). [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]\\u003c/p\\u003e\\u003cp\\u003eWe identified all hospitals with complete contact data (80 BFHI-accredited hospitals) through a search of the Brazilian Ministry of Health's website. Using non-probability sampling techniques, we contacted these centers via email, messages, or phone calls. Hospital coordinators who provided informed consent were included in the study.\\u003c/p\\u003e\\u003cp\\u003eThe study population comprised all Baby-Friendly Hospital Initiative (BFHI) accredited facilities across Brazil. Although 301 hospitals were registered as BFHI-accredited in the Brazilian Ministry of Health database, only 80 had updated contact information that allowed for communication. We sent invitations to participate in the survey to all 80 contactable hospitals between January and May 2021, using email, WhatsApp messages, or phone calls. Multiple follow-up attempts were made to maximize participation.\\u003c/p\\u003e\\u003cp\\u003eThe COVID-19 screening protocols at participating hospitals identified symptomatic patients (with flu symptoms) for testing, while asymptomatic pregnant women were considered COVID-19 negative.\\u003c/p\\u003e\\u003cp\\u003e After obtaining consent to participate, we sent the structured questionnaire about local breastfeeding support guidelines, via email and requested a response within 30 days. The coordinators filled out the questionnaire spontaneously, without interference from or targeting by research staff, regarding breastfeeding promotion according to the BFHI for both positive and negative mothers regarding SARCOV-2.\\u003c/p\\u003e\\u003cp\\u003e The structured questionnaire was developed based on the Baby-Friendly Hospital Initiative guidelines and WHO recommendations for breastfeeding during the COVID-19 pandemic. Initially, a comprehensive item pool was created covering six domains: hospital characteristics, breastfeeding management practices, delivery room protocols, immediate postpartum care, rooming-in practices, and home care recommendations. Content validity was established through review by a multidisciplinary panel of three experts in neonatology, maternal-child health, and breastfeeding support, who evaluated each item for relevance, clarity, and comprehensiveness. The questionnaire was then pilot-tested with neonatology coordinators from ten university hospitals representing different Brazilian regions. This validation process included cognitive interviews to assess item comprehension, response patterns, and completion time (average 25 minutes). Based on pilot feedback, we refined ambiguous questions, simplified complex items, and adjusted the sequence of questions to improve logical flow. The final instrument consisted of 70 items organized in six sections with parallel questions about COVID-positive and COVID-negative dyads (supplementary material).\\u003c/p\\u003e\\u003cp\\u003eQuestions were applied to the practices towards mothers and infants who are either COVID-19 positive or suspected to be positive, as well as those who are negative or not alleged to be positive. We divided the participating centers into two hospital groups: those that followed the BFHI recommended and those that did not during the pandemic for the mother-child positive dyad. [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]The following hospitals were characterized by their adherence to the Ten Steps of BFHI.\\u003c/p\\u003e\\u003cp\\u003eIn addition to these variables, we also analyzed the association of these two groups of hospitals with the following variables recommended by the BFHI but not included in the Ten Steps: referral center, university hospital, time of umbilical cord clamping, allowing a companion in the delivery room, recommending demand-based breastfeeding, allowing rooming-in, allowing visits for the binomial, and discharging after 24 hours.\\u003c/p\\u003e\\u003cp\\u003eParticipants answered yes or no to categorical questions and, when necessary, described the requested information.\\u003c/p\\u003e\\u003cp\\u003eDuring study time ( January \\u0026ndash; May 2021), the literature and the WHO (World Health Organization) recommended that mothers with suspected or confirmed COVID-19 should be encouraged to initiate or continue to breastfeed; if suspected or confirmed infected mothers are well enough, they should keep skin-to-skin contact with their babies and breastfeed with appropriate precautions; mothers with symptoms of COVID-19 are advised to wear a medical mask, but even if this is not possible, breastfeeding should be continued; for those who are too unwell to breastfeed, expressing milk and donor human milk could be considered. Specific precautions for breastfeeding directly at the breast were washing hands frequently with soap and water or using alcohol-based hand rub, especially before touching the infant; wearing a medical mask during any contact with the infant, including while feeding; sneezing or coughing into a tissue, then disposing of it immediately and rewashing hands; routinely cleaning and disinfecting surfaces that mothers have touched. [\\u003cspan additionalcitationids=\\\"CR16\\\" citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]\\u003c/p\\u003e\\u003cdiv id=\\\"Sec2\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStatistical Analysis:\\u003c/h2\\u003e\\u003cp\\u003eThe data was initially described using both absolute and relative frequencies. Following a thorough exploratory analysis of the variables within each group, associations were established through correspondence analysis.\\u003c/p\\u003e\\u003cp\\u003eTo assess differences in BFHI practices implementation between COVID-19 positive/suspected and negative/non-suspected dyads, Fisher's exact test was employed due to the relatively small sample size (n\\u0026thinsp;=\\u0026thinsp;29 in each group). This non-parametric test was selected over chi-square analysis. A significance level of α\\u0026thinsp;=\\u0026thinsp;0.05 was established, with p-values\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 considered statistically significant. For each BFHI practice, absolute frequencies and percentages were calculated and compared between groups.\\u003c/p\\u003e\\u003cp\\u003eThis multivariate technique enables the creation of a correspondence map, providing a more comprehensive understanding of the relationships between variables. The closer a variable is to another, the stronger their association. In this analysis, the term \\\"inertia\\\" refers to the overall variation in the data. This variation is broken down into two dimensions (Dim) and shown on each map axis. The dimensions indicate the extent to which the variability in the data can be explained. The FactoMineR and factoextra packages of the R 4.0.2 software were used.\\u003c/p\\u003e\\u003cp\\u003eCorrespondence analysis is a statistical technique that visualizes complex relationships between categorical variables in a two-dimensional space, making it particularly valuable for identifying patterns that might not be apparent in traditional tabular data. Unlike regression methods that test predefined hypotheses, correspondence analysis is an exploratory method that reveals associations by mapping variables as points on a graph, where proximity indicates relationships between variables. This technique is beneficial for analyzing survey data with multiple categorical responses, as it reduces multidimensional complexity into interpretable visual patterns. In the context of health services research, correspondence analysis can reveal how institutional characteristics (such as referral center status) correlate with practice patterns (such as adherence to clinical guidelines), allowing researchers to identify clusters of related practices and potential structural determinants of care quality without requiring assumptions about causality or linear relationships. We did not perform the analysis of the non-respondents due to a lack of data.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eEighty centers and hospitals accredited with the Baby-Friendly Hospital Initiative (BFHI) were contacted via email, WhatsApp, or phone. Among those contacted, 29 hospitals participated in the survey (36, 2% response rate) by completing the questionnaire and providing informed consent.\\u003c/p\\u003e\\u003cp\\u003eThe participating hospitals represented diverse regions of Brazil: two from the Midwest, six from the Northeast, four from the North, 11 from the Southeast, and six from the South.\\u003c/p\\u003e\\u003cp\\u003eTwenty-eight centers (96.6%) had developed specific protocols for managing maternal care in the immediate postpartum period during the pandemic. Only one center (3.4%) reported not having a specific protocol but followed the guidelines of the Brazilian Society of Pediatrics (SBP).\\u003c/p\\u003e\\u003cp\\u003eRegarding protocol references, ten hospitals (34.5%) did not provide this information. Sixteen hospitals (55.2%) incorporated multiple national and international guidelines, while three hospitals (10.3%) exclusively adhered to the SBP recommendations.\\u003c/p\\u003e\\u003cp\\u003eAmong the participating centers, 17 (58.6%) were designated as referral services for pregnant women with COVID-19. Of these referral centers, only one (5.9%) indicated not having a protocol for managing COVID-19 cases. Additionally, 17 (58.6%) of all participating hospitals were university hospitals, with 11 of them (64.7%) serving as referral centers for pregnant women with COVID-19. All participating hospitals reported treating high-risk pregnancies and were classified as tertiary care facilities.\\u003c/p\\u003e\\u003cp\\u003eFor testing pregnant women and infants with suspected COVID-19, 23 hospitals (79.31%) used the gold standard Reverse Transcription Polymerase Chain Reaction (RT-PCR) test. Of these, four (17.4%) also used IgG/IgM serology. Testing was performed only on symptomatic pregnant women (those with flu-like symptoms).\\u003c/p\\u003e\\u003cp\\u003e All 29 participating hospitals reported having written infant feeding guidelines that were communicated to staff and parents, with an emphasis on staff training to enhance their knowledge, competence, and skills in breastfeeding support. One center disclosed non-compliance with the current International Code of Marketing of Breast-milk Substitutes.\\u003c/p\\u003e\\u003cp\\u003eSimilarly, only one center reported failing to maintain a continuous system for monitoring and managing breastfeeding-related data.\\u003c/p\\u003e\\u003cp\\u003eNotably, only two hospitals (6.9%) recommended immediate and uninterrupted skin-to-skin contact for mother-infant dyads with confirmed or suspected COVID-19 (p-value\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), and most hospitals did not provide support to mothers in initiating breastfeeding as soon as possible after birth (p-value\\u0026thinsp;=\\u0026thinsp;0.006). Additional results are presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eImplementation of Baby-Friendly Hospital Initiative Practices by Maternal COVID-19 Status in Brazilian BFHI-Accredited Hospitals, 2021 (n\\u0026thinsp;=\\u0026thinsp;29)\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBFHI Practices\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePositive or suspected COVID-19 dyads\\u003c/p\\u003e\\u003cp\\u003en (%)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eNegative or without suspicion of COVID-19 dyads\\u003c/p\\u003e\\u003cp\\u003en (%)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eP-value\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDiscuss the importance and management of breastfeeding with pregnant women and their families\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e25 (86.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.353\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFacilitate immediate and uninterrupted skin-to-skin contact\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e2 (6.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSupport mothers in initiating breastfeeding as soon as possible after birth\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e20 (69.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.006\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSupport mothers to initiate and maintain breastfeeding and manage common difficulties\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e23 (79.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.052\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eUnless medically indicated, do not provide breastfed newborns any food or fluids other than breast milk\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e26 (89.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e27 (93.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.000\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eEnable mothers and their infants to remain together and practice rooming in 24 hours daily\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e23 (79.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.052\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSupport mothers to recognize and respond to their infants' cues for feeding\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e25 (86.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.353\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCounsel mothers on the use and risks of feeding bottles, teats, and pacifiers\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e25 (86.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.353\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCoordinate discharge so parents and their infants have timely access to ongoing support and care\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e25 (86.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.353\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003eNote: Data collected from a survey of 29 Baby-Friendly Hospital Initiative (BFHI) accredited hospitals in Brazil between January and May 2021. Values represent the number and percentage of hospitals implementing each practice.\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eTen centers (34.5%) permitted companions in the delivery room for pregnant women with confirmed or suspected COVID-19, while 26 centers (89.7%) allowed companions for women without the virus ( p-value\\u0026thinsp;=\\u0026thinsp;0.01). Also, the recommendation to delayed umbilical cord clamping was not follow to COVID-19 positive dyads ( p-value\\u0026thinsp;=\\u0026thinsp;0,003). Additional findings about delivery room recommendations are detailed in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eDelivery Room Practices and Protective Measures by Maternal COVID-19 Status in Brazilian BFHI-Accredited Hospitals, 2021 (n\\u0026thinsp;=\\u0026thinsp;29)\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDelivery Room Practices\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePositive or suspected COVID-19 dyads\\u003c/p\\u003e\\u003cp\\u003en (%)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eNegative or without suspicion of COVID-19 dyads\\u003c/p\\u003e\\u003cp\\u003en (%)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eP-value\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDelayed umbilical cord clamping\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e14 (48.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e25 (86.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.003\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePresence of a companion\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e10 (34.5)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e26 (89.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBreastfeeding\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e7 (24.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e25 (86.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eUse of full or partial (surgical mask) personal protective equipment for medical staff\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e21 (72.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.026\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eUse of full or partial (surgical mask) personal protective equipment for pregnant women\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e25 (86.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e16 (55.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.012\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDistinct protective approach for cesarean deliveries\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e11 (37.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e8 (27.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.405\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDistinct protective approach for vaginal deliveries\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e11 (37.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5 (17.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.080\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003eNote: Data collected from a survey of 29 Baby-Friendly Hospital Initiative (BFHI) accredited hospitals in Brazil between January and May 2021. Values represent the number and percentage of hospitals implementing each practice.\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eFor mother-infant dyads with confirmed or suspected COVID-19, 18 centers (62%) advised mask use during breastfeeding and handwashing before breastfeeding. However, only three centers (10%) extended recommendations to include face washing, changing clothes before breastfeeding, and breast washing. ( Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e)\\u003c/p\\u003e\\u003cp\\u003eIn contrast, five centers (17%) reported no specific recommendations for COVID-negative mother-infant dyads. Ten centers (34%) endorsed the use of masks during breastfeeding and handwashing before feeding for non-symptomatic mothers, while 11 centers (38%) emphasized the importance of handwashing before feeding alone. Additional details can be found in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eImmediate Postpartum Care Practices by Maternal COVID-19 Status in Brazilian BFHI-Accredited Hospitals, 2021 (n\\u0026thinsp;=\\u0026thinsp;29)\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePostpartum Care Practices\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePositive or suspected COVID-19 dyads\\u003c/p\\u003e\\u003cp\\u003en (%)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eNegative or without suspicion of COVID-19 dyads\\u003c/p\\u003e\\u003cp\\u003en (%)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eP-value\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBreastfeeding on demand\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e25 (86.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e29 (100.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.112\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBreastfeeding every three hours\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e3 (10.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e1 (3.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.612\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMinimum distance between neonate and mother during non-breastfeeding periods\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e27 (93.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e2 (6.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAccommodation with mother-child contact allowance\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e26 (90.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e25 (86.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.00\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMilking, if necessary (raw milk)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e16 (55.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e23 (79.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.052\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMilk pasteurization\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e13 (44.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e15 (51.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.596\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMothers to be milk donors\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e6 (20.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e26 (89.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eVisits or companies for the mother-child dyad\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e2 (6.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e16 (55.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDischarge of the mother-child dyad within 24 hours\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e3 (10.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e3 (10.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.00\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePsychological support, if needed\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e27 (93.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1,00\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003eNote: Data collected from a survey of 29 Baby-Friendly Hospital Initiative (BFHI) accredited hospitals in Brazil between January and May 2021. Values represent the number and percentage of hospitals implementing each practice.\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eRegarding postpartum care practices (Table \\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e), visits and/or companies were reported by only two centers (6,9%) and even allowed companies, 26 (89.7) recommended maintaining a two-meter distance for mother-child pairs with COVID-19 ( p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001).\\u003c/p\\u003e\\u003cp\\u003eIn the home setting ( Table \\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e), 15 centers (51.7%) advised limiting contact between other children and the newborn, and 26 centers (89.7%) recommended maintaining a two-meter distance for mother-child pairs with COVID-19; two centers (6.9%) extended this recommendation also to include COVID-negative cases ( p-value\\u0026thinsp;=\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), while seven centers (24.1%) implemented telemedicine services to care for COVID-positive mother-infant pairs.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eHome Care Recommendations by Maternal COVID-19 Status in Brazilian BFHI-Accredited Hospitals, 2021 (n\\u0026thinsp;=\\u0026thinsp;29)\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eHome Care Recommendations\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePositive or suspected COVID-19 dyads\\u003c/p\\u003e\\u003cp\\u003en (%)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eNegative or without suspicion of COVID-19 dyads\\u003c/p\\u003e\\u003cp\\u003en (%)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eP-value\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSeparating mother and baby\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0 (0.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e1 (3.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1,00\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMaintaining a distance of 2 meters between mother and baby\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e26 (89.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e2 (6.9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0,001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eHand washing before breastfeeding\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e24 (82.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0,195\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAlways hand washing before handling the baby\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e24 (82.8)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0,195\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eHolding the baby in the lap for periods of comfort when it presents with colic and/or crying\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e20 (69.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0,012\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eOther care being carried out by someone else (changing diapers, bathing)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e10 (34.5)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5 (17.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0,138\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFree demand or breastfeeding every 3 hours\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e25 (86.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e25 (86.2)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1,00\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eHome milking and offering raw milk\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e18 (62.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e20 (69.0)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0,584\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePrescription of formula on discharge if needed\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e3 (10.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e3 (10.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.00\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMeasures to maintain and stimulate lactation and prevent weaning\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e27 (93.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e28 (96.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.00\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDelivery of guidance material (virtual or printed) on breastfeeding and COVID-19\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e12 (41.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e10 (34.5)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.589\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eHome visits for mother-child dyads\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1 (3.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e3 (10.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.612\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eScheduled telemedicine care for the mothers\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e7 (24.1)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e3 (10.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.299\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePsychological assistance (telecare) for these mothers, if necessary\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e12 (41.4)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e8 (27.6)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.273\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eOther children are kept away from the new baby\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e15 (51.7)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e3 (10.3)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003eNote: Data collected from a survey of 29 Baby-Friendly Hospital Initiative (BFHI) accredited hospitals in Brazil between January and May 2021. Values represent the number and percentage of hospitals recommending each practice. BCG\\u0026thinsp;=\\u0026thinsp;Bacillus Calmette-Gu\\u0026eacute;rin vaccine.\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003esychological support via telecare was available in 12 centers (41.4%) for mothers with COVID-19. Additional findings are detailed in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003eUsing correspondence map analysis, we examined the relationship between hospitals that maintained BFHI compliance during the pandemic for COVID-19-positive mother-infant dyads (BFH) and those that did not (nBFH). We observed a correspondence between nBFH status and serving as a referral center for COVID-19 cases (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eOur findings regarding disparities in the implementation of the BFHI guidelines between COVID-19-positive and COVID-negative dyads reflect broader patterns that demonstrate how health emergencies affect women through systemic mechanisms [\\u003cspan additionalcitationids=\\\"CR19\\\" citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]. This study assessed the impact of the pandemic on breastfeeding support in Brazilian Baby-Friendly hospitals, revealing a significant deterioration in adherence to evidence-based practices for mothers with infections despite official guidelines permitting their implementation.\\u003c/p\\u003e\\u003cp\\u003eDuring the study period the WHO, and the Brazilian Pediatric Society published recommendations supporting breastfeeding during the COVID-19 pandemic, including skin-to-skin contact, early breastfeeding initiation, and allowing delivery room companions [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003e Despite these guidelines, only 6.9% of hospitals recommended immediate skin-to-skin contact for COVID-positive dyads versus 86.2% for COVID-negative mothers. These disparities stemmed from structural pandemic responses rather than individual clinical decisions, systematically disadvantaging specific populations.[\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e] Our findings parallel similar disruptions to maternal-child services documented during the Ebola epidemic, which produced significant indirect mortality effects typically omitted from pandemic statistics. [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]\\u003c/p\\u003e\\u003cp\\u003eThe disparities observed in our study provide a compelling illustration of the inverse equity hypothesis in action during a health emergency. This theoretical framework, initially proposed by Victora et al., suggests that new health interventions and protective measures are initially adopted by socioeconomically advantaged populations, temporarily widening health inequities before eventually reaching disadvantaged groups [\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eIn our findings, this pattern was evident through the creation of a two-tiered breastfeeding support system based on COVID-19 status. The stark contrast between support provided to COVID-negative versus COVID-positive dyads reveals how infection control measures functioned as new interventions that disproportionately benefited uninfected mothers.\\u003c/p\\u003e\\u003cp\\u003eThis pattern is particularly concerning because COVID-19 infection rates in Brazil showed socioeconomic gradients, with higher prevalence among vulnerable populations living in crowded conditions with limited access to protective resources. [\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e] Consequently, those most likely to be COVID-positive were often from disadvantaged communities, creating a compounding effect where social vulnerability increased both infection risk and subsequent reduction in breastfeeding support [\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e]. Similar patterns were observed during the Nepal earthquake, where breastfeeding support systems failed when they were most critical [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe finding that only 24.1% of hospitals implemented telemedicine support for breastfeeding represents a missed opportunity to mitigate disruptions. This low adoption rate of alternative support mechanisms reveals limitations in system resilience and adaptive capacity during crises [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. When comparing our findings with international experiences, countries that successfully maintained breastfeeding support during the pandemic often implemented robust initiatives, telehealth services and remote lactation consultations [\\u003cspan additionalcitationids=\\\"CR29 CR30 CR31\\\" citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e]. The physical separation due to infection control without addressing structural alternatives (remote support) perpetuates inequities for marginalized populations, creating a form of institutional discrimination with direct health consequences. [\\u003cspan additionalcitationids=\\\"CR29 CR30 CR31\\\" citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e]\\u003c/p\\u003e\\u003cp\\u003eDespite having BFHI certification, 10.3% of hospitals prescribed formula for COVID-positive mothers. Equally concerning, 10.3% also recommended formula for COVID-negative mothers. This finding aligns with global patterns documented by Vu Hoang et al. 2020, who found that the pandemic created opportunities for formula companies to market their products as safer alternatives, potentially undermining breastfeeding efforts. [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]\\u003c/p\\u003e\\u003cp\\u003e Our correspondence analysis revealed that COVID-19 referral centers were less likely to implement the BFHI guidelines. This finding highlights how fragmented health systems amplify inequities during emergencies. The structural pressures faced by referral centers\\u0026mdash;including increased patient volume, staff shortages, and resource constraints\\u0026mdash;created a situation where, paradoxically, hospitals treating the most vulnerable mothers were least equipped to provide evidence-based breastfeeding support. This demonstrates that health system design itself can create and maintain inequities [\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe lower adherence to BFHI practices in referral centers may also reflect competing priorities during crisis response. As Nuzzo et al. [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e] noted in their scoping review of health system resilience, emergency responses often prioritize immediate infection control over maintaining essential services, particularly those perceived as optional rather than life-saving. This false dichotomy between infection control and breastfeeding support reflects a lack of understanding about the critical importance of breastfeeding for infant health outcomes.\\u003c/p\\u003e\\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e provides intriguing insights; we anticipated universal adherence to BFHI recommendations for uninfected mother-infant pairs in accredited hospitals. However, approximately 3.5% of hospitals deviated from recommended measures, even for those without health complications. This unexpected finding suggests that the pandemic may have disrupted the implementation of BFHI more broadly, affecting care for all mothers, regardless of their COVID-19 status. [\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e] Nevertheless, most studied hospitals maintained the BFHI recommendations for COVID-negative dyads.\\u003c/p\\u003e\\u003cp\\u003eThis study has several methodological limitations that warrant consideration. Our cross-sectional design captured hospital practices during a specific pandemic period (January-May 2021), missing potential protocol evolution over time. The 36.2% response rate (29 of 80 contacted hospitals) introduces potential selection bias that may impact the generalizability of our findings. Hospitals that chose to participate might systematically differ from non-respondents, potentially overrepresenting institutions with more robust breastfeeding support systems or better-established COVID-19 protocols.\\u003c/p\\u003e\\u003cp\\u003eAdditionally, the fact that only 80 of the 300 BFHI-accredited facilities had updated contact information in the Ministry of Health database suggests possible systemic issues in maintaining active engagement with the BFHI network nationally.\\u003c/p\\u003e\\u003cp\\u003e Our reliance on self-reported data from neonatology coordinators without direct verification may result in reporting bias regarding adherence to BFHI guidelines, potentially leading to overestimation of compliance. Social desirability bias may have influenced respondents to report more favorable practices that were implemented.\\u003c/p\\u003e\\u003cp\\u003eFinally, we focused on hospital policies rather than actual implementation or maternal experiences. This approach cannot capture the lived experiences of mothers navigating these systems during the pandemic, nor can it account for potential discrepancies between written policies and actual practice.\\u003c/p\\u003e\\u003cp\\u003eDespite these constraints, our findings provide valuable initial insights into pandemic-related disparities in breastfeeding support across Brazilian BFHI facilities. However, they should be interpreted with caution regarding their representativeness of all BFHI-accredited facilities nationwide.\\u003c/p\\u003e\\u003cp\\u003eOur research identifies an urgent need for multi-level structural interventions to address health disparities in Brazilian Baby-Friendly Hospital Initiative (BFHI) facilities during crises, protecting and maintaining breastfeeding-supportive policies during pandemics. This proactive approach is essential to prevent the recurring pattern of breastfeeding disruption observed during health crises, thereby preserving the substantial social impact of this intervention.\\u003c/p\\u003e\\u003cp\\u003eHealthcare institutions must recognize exclusive breastfeeding not as an optional practice that can be suspended during crises but as an essential component of infant care that must be preserved through appropriate infection control measures. This paradigm shift requires immediate action from hospital administrators, policymakers, and healthcare providers to safeguard infants' fundamental right to optimal nutrition through breastfeeding during future health emergencies.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eOur findings indicate that the right to breastfeeding was not adequately safeguarded for all mothers and infants during the health crisis, with potentially greater impacts on vulnerable populations. Lessons from this pandemic must inform the development of more equitable policies and practices. The BFHI urgently needs an equity-focused contingency plan for challenging situations to prevent deepening health disparities during future public health emergencies, ensuring that the right to breastfeeding is protected for all mother-infant dyads, even during crises.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate:\\u0026nbsp;\\u003c/strong\\u003eThe study adhered to the Checklist for Reporting of Survey Studies (CROSS) guidelines and received approval from the Research Ethics Committee of Faculdade de Medicina de Ribeir\\u0026atilde;o Preto da Universidade de S\\u0026atilde;o Paulo, Brazil (CAAE 31357320.9.1001.5440-4.066.741/2020).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication:\\u0026nbsp;\\u003c/strong\\u003eAll participating hospital coordinators provided consent for the publication of the aggregated, anonymized survey data presented in this study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials:\\u0026nbsp;\\u003c/strong\\u003eThe datasets generated during the current study are not publicly available due to confidentiality agreements with participating hospitals but are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026apos; contributions\\u003c/strong\\u003e: AR: Conceptualization, methodology, investigation, data curation, writing - original draft. DCA: Formal analysis, data visualization, writing - review \\u0026amp; editing.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eMaria Eduarda Vidoto: Data visualization, writing - review \\u0026amp; editing. WAGF: Supervision, methodology, validation, writing - review \\u0026amp; editing. All authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe Article Processing Charge for the publication of this research was funded by the Coordena\\u0026ccedil;\\u0026atilde;o de Aperfei\\u0026ccedil;oamento de Pessoal de N\\u0026iacute;vel Superior - CAPES (ROR identifier: 00x0ma614). For open access purposes, the authors assigned the Creative Commons CC BY license to any accepted version of the article.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflict of Interest\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no conflict of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe would like to thank all the participating centers: Hospital Materno Infantil de Bras\\u0026iacute;lia, Distrito Federal; Hospital Regional de Ceil\\u0026acirc;ndia, Distrito Federal; Maternidade Clim\\u0026eacute;rio de Oliveira, Bahia; Hospital C\\u0026eacute;sar Cals, Cear\\u0026aacute;; Maternidade Escola Assis Chateaubriand, Cear\\u0026aacute;; Centro Integrado de Sa\\u0026uacute;de Amaury de Medeiros, Pernambuco; Instituto de Medicina Integral Professor Fernando Figueira, Pernambuco; Maternidade Dona Evangelina Rosa, Piau\\u0026iacute;; Maternidade Ana Braga, Amazonas; Santa Casa de Bel\\u0026eacute;m, Par\\u0026aacute;; Hospital Dom Orione de Aragua\\u0026iacute;na, Tocantins; Hospital e Maternidade Dona Regina Siqueira Campos de Palmas, Tocantins; Santa Casa de Belo Horizonte, Minas Gerais; Maternidade Sofia Feldmann, Minas Gerais; Instituto Fernandes Figueira, Rio de Janeiro; Hospital Pedro Ernesto, Rio de Janeiro; Hospital Estadual de Sumar\\u0026eacute;, S\\u0026atilde;o Paulo; Hospital Geral de Itapecerica da Serra, S\\u0026atilde;o Paulo; \\u0026nbsp; Centro de Aten\\u0026ccedil;\\u0026atilde;o Integral \\u0026agrave; Sa\\u0026uacute;de da Mulher, S\\u0026atilde;o Paulo; Hospital Guilherme \\u0026Aacute;lvaro, S\\u0026atilde;o Paulo; Maternidade Ribeir\\u0026atilde;o, S\\u0026atilde;o Paulo; Santa Casa de Limeira, S\\u0026atilde;o Paulo; Santa Casa de Ponta Grossa, Paran\\u0026aacute;; Hospital Universit\\u0026aacute;rio de Londrina, Paran\\u0026aacute;; Hospital Regional Universit\\u0026aacute;rio de Maring\\u0026aacute;, Paran\\u0026aacute;; Hospital Universit\\u0026aacute;rio do Oeste do Paran\\u0026aacute;, Paran\\u0026aacute;; Hospital Universit\\u0026aacute;rio Polydoro Ernani, Santa Catarina; Hospital Femina, Rio Grande do Sul; Hospital das Cl\\u0026iacute;nicas de Ribeir\\u0026atilde;o Preto, S\\u0026atilde;o Paulo.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eWorld Health Organization. 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Front Nutr. 2023;10:1142089. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3389/fnut.2023.1142089\\u003c/span\\u003e\\u003cspan address=\\\"10.3389/fnut.2023.1142089\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMelro LMG, Trindade EM, Park M. COVID-19 underpinning the inverse equity hypothesis between public and private health care in Brazil. Crit Care Sci. 2024;36:e20240294en. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.62675/2965-2774.20240294-en\\u003c/span\\u003e\\u003cspan address=\\\"10.62675/2965-2774.20240294-en\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eKoleilat M, Whaley SE, Clapp C. The Impact of COVID-19 on Breastfeeding Rates in a Low-Income Population. Breastfeed Med. 2022;17(1):33\\u0026ndash;7. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1089/bfm.2021.0238\\u003c/span\\u003e\\u003cspan address=\\\"10.1089/bfm.2021.0238\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMoini A, Heidari F, Eftekhariyazdi M, Pirjani R, Ghaemi M, Eshraghi N, et al. Breastfeeding success and perceived social support in lactating women with a history of COVID 19 infection: a prospective cohort study. Int Breastfeed J. 2023;18(1):65. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1186/s13006-023-00601-0\\u003c/span\\u003e\\u003cspan address=\\\"10.1186/s13006-023-00601-0\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"international-breastfeeding-journal\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ibfj\",\"sideBox\":\"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)\",\"snPcode\":\"13006\",\"submissionUrl\":\"https://submission.nature.com/new-submission/13006/3\",\"title\":\"International Breastfeeding Journal\",\"twitterHandle\":\"@BioMedCentral\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"COVID-19, Breastfeeding inequities, Baby-Friendly Hospital Initiative, Health emergency response, Maternal-child health, Health equity, Structural barriers, Latin America, Pandemic preparedness, Implementation science\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7032455/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7032455/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBACKGROUND:\\u003c/h2\\u003e\\u003cp\\u003eHealth crises have constantly widened inequities and increased pressure on the most vulnerable groups. The Baby-Friendly Hospital Initiative (BFHI) establishes consistent global standards for breastfeeding support; however, control measures for COVID-19 revealed differences in how hospitals implemented evidence-based practices for mothers with COVID-19, leading to uncertainty and potentially resulting in unequal care, which could weaken overall health equity.\\u003c/p\\u003e\\u003ch2\\u003eOBJECTIVE\\u003c/h2\\u003e\\u003cp\\u003eTo examine disparities in breastfeeding support provided to mother-infant dyads in Baby-Friendly Hospitals during COVID-19, comparing support offered to uninfected mothers versus those infected with SARS-CoV-2.\\u003c/p\\u003e\\u003ch2\\u003eMETHOD\\u003c/h2\\u003e\\u003cp\\u003eWe conducted a survey between January-May 2021 among BFHI-accredited Brazilian hospitals. A structured questionnaire based on BFHI recommendations, validated with ten hospitals, was sent to neonatology coordinators to assess breastfeeding support implementation for dyads with and without COVID-19.\\u003c/p\\u003e\\u003ch2\\u003eRESULTS\\u003c/h2\\u003e\\u003cp\\u003e Twenty-nine hospitals across all Brazilian regions participated. COVID-19 positive/suspected dyads experienced significantly reduced access to evidence-based practices: only 6.9% of hospitals recommended immediate skin-to-skin contact and 24.1% recommended breastfeeding initiation in delivery rooms for these dyads, compared to 86.2% for COVID-negative dyads (p-value\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Social support disparities were evident: 89.7% of hospitals allowed companions for women without the virus versus 34.5% for those with confirmed/suspected COVID-19. Alternative support mechanisms were limited, with telemedicine implemented by only 24.1% of centers. Correspondence analysis revealed that COVID-19 referral centers were significantly less likely to implement BFHI practices, creating structural inequities in breastfeeding support.\\u003c/p\\u003e\\u003ch2\\u003eCONCLUSIONS\\u003c/h2\\u003e\\u003cp\\u003eThe pandemic exacerbated inequities in breastfeeding support in Brazilian BFHI hospitals, with potentially greater impacts on vulnerable populations. The association between COVID-19 referral center status and lower BFHI adherence illustrates how structural pressures compromise health equity during emergencies. Our findings highlight the urgent need for equity-focused contingency plans for breastfeeding support during public health emergencies to prevent deepening health disparities and protect breastfeeding rights for all mother-infant dyads during crises.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Dual Standards of Care: COVID-19 Status and Breastfeeding Support Inequities in Brazilian Baby-Friendly Hospitals\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-07-27 10:53:18\",\"doi\":\"10.21203/rs.3.rs-7032455/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-01-29T05:36:04+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-01-27T08:22:46+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"274068173629989093503078309498251751442\",\"date\":\"2026-01-07T07:39:51+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-10-14T17:41:49+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"117545291729969391297625096982227298146\",\"date\":\"2025-08-18T20:10:43+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-07-21T01:50:02+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-07-07T18:00:38+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-07-07T17:59:33+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"International Breastfeeding Journal\",\"date\":\"2025-07-02T20:25:48+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"international-breastfeeding-journal\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ibfj\",\"sideBox\":\"Learn more about [International Breastfeeding Journal](http://internationalbreastfeedingjournal.biomedcentral.com/)\",\"snPcode\":\"13006\",\"submissionUrl\":\"https://submission.nature.com/new-submission/13006/3\",\"title\":\"International Breastfeeding Journal\",\"twitterHandle\":\"@BioMedCentral\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"3a201881-ee9d-4969-89eb-8c511d354887\",\"owner\":[],\"postedDate\":\"July 27th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-17T03:23:43+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-07-27 10:53:18\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7032455\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7032455\",\"identity\":\"rs-7032455\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}