Dual Standards of Care: COVID-19 Status and Breastfeeding Support Inequities in Brazilian Baby-Friendly Hospitals

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.