Association of Socio-economic and Mental Health Determinants with Breastfeeding Practices among a Population of Moroccan Women during the COVID-19 Pandemic: A Cross-sectional Study

Document Type : Original Article


1 1.Higher Institute of Health Sciences of Settat, Health Sciences and Technology Laboratory, Hassan First University, Settat, Morocco 2. Health and Nutrition Research Team of the Mother-child Couple, Faculty of Medicine, Mohammed V University, Rabat, Morocco

2 3.Higher Institutes of Nursing Professions and Health Techniques, Rabat, Morocco 4.Joint Research Unit in Nutrition and Food, Regional Designated Center of Nutrition, Ibn Tofaïl University, Kenitra, Morocco

3 Higher Institute of Health Sciences of Settat, Health Sciences and Technology Laboratory, Hassan First University, Settat, Morocco

4 Health and Nutrition Research Team of the Mother-child Couple, Faculty of Medicine, Mohammed V University, Rabat, Morocco

5 5. Laboratory of Pharmacology, Neurobiology, Anthropology, Environment and Behaviorm, Faculty of Science of Semlalia, Cadi Ayad University, Marrakesh, Morrocco


Background: The worldwide pandemic imposed by SRAS-CoV-2 affected all aspects of daily life including those of pregnant and breastfeeding women. This work aims to explore the impact of socio-economic determinants and mental health on breastfeeding practices among a group of Moroccan women during this pandemic.
Methods: This is a descriptive and observational study carried out over 6 months in a maternity hospital. Data relating to the practices and the state of stress of women were collected via an interview and a questionnaire on post-traumatic stress disorder (PTSD).
Results: Early breastfeeding and skin-to-skin practice were significantly elevated among educated women (p <0.001) and housewives (p = 0.028). Compliance with respiratory and body hygiene rules was significantly higher among women: of urban origin, educated, housewives, and those with medium or high socioeconomic levels. The study of the impact of stress on breastfeeding practices revealed a statistically significant difference in early breastfeeding (p = 0.004), compliance with respiratory and body hygiene rules (p <0.001), and skin-to-skin practice (p <0.001) between the group of normal women and the group of stressed women.Our results showed the impact of socio-economic determinants and mental health on breastfeeding practice during this pandemic.
Conclusion: This represents a great challenge for the health system to promote breastfeeding and reduce the consequences of psychological disorders for mothers and unborn children in Morocco.


  1. COVID-19 Strategy. 2020. Available from:*
  2. Juan J, Gil MM, Rong Z, Zhang Y, Yang H, Poon LC. Effects of coronavirus disease 2019 (covid-19) on maternal, perinatal and neonatal outcomes: a systematic review of 266 pregnancies. Ultrasound Obstet Gynecol. 2020; 56(1):15–27.
  3. Renfrew MJ, Cheyne H, Dykes F, Entwistle F, McGuire W, Shenker N, et al. Optimising mother-baby contact and infant feeding in a pandemic. 2020. Available from:
  4. Ravaldi C, Wilson A, Ricca V, Homer C, Vannacci A. Pregnant women voice their concerns and birth expectations during the COVID-19 pandemic in Italy. Women Birth. 2021; 34(4):335-43.
  5. Twenge J. New study shows staggering effect of coronavirus pandemic on America’s mental health. The Conversation; 2020.
  6. Roberton T, Carter ED, Chou VB, Stegmuller AR, Jackson BD, Tam Y, et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. Lancet Glob Health. 2020; 8(7):901-8.
  7. Briefing note: COVID-19 and universal
    health coverage. 2020. Available from:
  8. Ding W, Lu J, Zhou Y, Wei W, Zhou Z, Chen M. Knowledge, attitudes, practices, and influencing factors of anxiety among pregnant women in Wuhan during the outbreak of COVID-19: a cross-sectional study. BMC Pregnancy Childbirth. 2021; 21(1):80.
  9. Maternal, newborn, child and adolescent
    health, breastfeeding. 2021. Available from:
  10. Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016; 387(10017):475-90.
  11. Scott JA, Binns CW. Factors associated with the initiation and duration of breastfeeding: a review of the literature. Breastfeed Rev. 1999; 7(1):5‑16.
  12. Li L, Zhang M, Scott JA, Binns CW. Factors associated with the initiation and duration of breastfeeding by Chinese mothers in Perth, Western Australia. J Hum Lact Off J Int Lact Consult Assoc. 2004;20(2):188‑95.
  13. Cooke M, Sheehan A, Homer CS. Initial infant feeding decisions and duration of breastfeeding in women from English, Arabic and Chinese-speaking backgrounds in Australia. Breastfeed Rev. 2002; 10(2):27‑32.
  14. Ryan AS, Zhou W, Arensberg MB. The effect of employment status on breastfeeding in the United States. Womens Health Issues. 2006; 16(5):243‑51.
  15. Lotfi M, Hamblin MR, Rezaei N. COVID-19: Transmission, prevention, and potential therapeutic opportunities. Clin Chim Acta. 2020; 508:254‑66.
  16. Cochran WG. Sampling techniques. 3rd ed. NewYork, NY, USA; 1977.
  17. Ardilly P. Survey Sampling Techniques. 2nd ed.  France: Edition Technip; 2006.
  18. Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. In annual convention of the international society for traumatic stress studies, San Antonio, TX; 1993.
  19. Post-traumatic stress disorder" in "behavioral and cognitive psychotherapies. Elsevier ; 2011.
  20. COVID-19 pregnancy plan guide. 2022. Available from: Manuels/Documents/2020/PLAN%20GUIDE%20COVID-19%20GROSSESSE.pdf
  21. Laamiri FZ, Barich F, Bennisa A, Redouania MA, Azzaouia S, Bentahila N, et al. Knowledge and practices of mothers regarding breastfeeding. J de Pediatrie et de Pueric. 2019; 32:128-39.
  22. Breastfeeding and COVID-19. 2020. Available from:
  23. Safely breastfeeding during the COVID-19 pandemic. How to feed your child according to expert recommendations. 2020. Available from:
  24. Dumas L, Lepage M, Bystrova K, Matthiesen AS, Welles-Nystroem B, Widstroem AM. Influence of skin-to-skin contact and rooming-in on early mother–infant interaction: a randomized controlled trial. Clinical. Clin Nurs Res. 2013; 22(3):310-36.
  25. Care for Pregnant People. interim guidance on breastfeeding and breast milk feeds in the
    context of COVID-19. 2020. Available from:
  26. The state of food security and nutrition in the world. FAO, IFAD, UNICEF, WFP and WHO.2020. Available from:
  27. Bertin M, Touvier M, Dubuisson C, Dufour A, Havard S, Lafay L, et al. Dietary patterns of French adults: associations with demographic, socio‐economic and behavioural factors. J Hum Nutr Diet. 2015; 29(2):241-54.
  28. Habibi M, Laamiri FZ, Aguenaou H, Doukkali L, Mrabet M, Barkat A. The impact of maternal socio-demographic characteristics on breastfeeding knowledge and practices: An experience from Casablanca, Morocco. Int J Pediatr Adolesc Med. 2018; 5(2):39-48.
  29. WHO. Capture the moment EIBF 2018. 2022. Available from:
  30. Silverman ME, Burgos L, Rodriguez ZI, Afzal O, Kalishman A, Callipari F, et al. Postpartum mood among universally screened high and low socioeconomic status patients during COVID-19 social restrictions in New York City. Sci Rep. 2020; 10(1):22380.
  31. Briscoe L, Lavender T, McGowan L. A concept analysis of women’s vulnerability during pregnancy, birth, and the postnatal period. J Adv Nurs. 2016; 72(10):2330‑45.
  32. Antenatal and postnatal mental health: the NICE guideline on clinical management and service guidance. British Psychological Society; 2021.
  33. Ostacoli L, Cosma S, Bevilacqua F, Berchialla P, Bovetti M, Carosso AR, et al. Psychosocial factors associated with postpartum psychological distress during the Covid-19 pandemic: a cross-sectional study. BMC Pregnancy Childbirth. 2020; 20(1):703.
  34. Spinola O, Liotti M, Speranza AM, Tambelli R. Effects of COVID-19 epidemic lockdown on postpartum depressive symptoms in a sample of Italian Mothers. Front Psychiatry. 2020; 11:589916.
  35. Aouade H. The prevalence of posttraumatic stress disorder in postpartum period. Morocco: Cadi Ayad University; 2020.
  36. Molenda S. The state of posttraumatic stress disorder and its associated disorders. Revue francophone du Stress et du Trauma. 2009; 9(4):205-9.
  37. Chaves C, Marchena C, Palacios B, Salgado A, Duque A. Effects of the COVID-19 pandemic on perinatal mental health in Spain: Positive and negative outcomes. Women Birth. 2022; 35(3):254-61.
  38. COVID-19 FAQs for obstetrician-gynecologists, obstetrics. 2021. Available from:

     39.NCIRD. Division of viral diseases. if you are pregnant, breastfeeding, or caring for young children. 2020. Available from: