Deborah McCarter-Spaulding examines the research on the intersection of breastfeeding and postpartum depression.

Adapted from Advancing Breastfeeding: Forging Partnerships for a Better Tomorrow.

It is frequently reported that there is a relationship between postpartum depression (PPD) and breastfeeding. However, the relationship remains unclear in several domains, including breastfeeding intention, initiation, duration, and pattern.

Depressed and the Breast How Breastfeeding and Postpartum Depression Intersect
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Intention. Very little is written about the relationship of a history of depression and the intent to breastfeed one’s infant, even though it is well accepted that intention to breastfeed is a predictor of breastfeeding. Bogen, Hanusa, Moses-Kolko and Wisner (2010) reported that depression during pregnancy did not predict intention to breastfeed, but receiving medication during pregnancy did predict an increased likelihood of intending to formula feed. McKee, Zayas, and Jankowski (2004) also found no relationship between depression during pregnancy and feeding intent. However, Fairlie, Gillman, and Rich-Edwards (2009) did find that prenatal depression symptoms, as well as prenatal anxiety, were associated with planning to formula feed.

Initiation. Many studies reported initiation of breastfeeding was not influenced by prenatal depression (Bogen et al., 2010; Fairlie et al., 2009; Pippins, Brawarsky, Jackson, Fuentes-Afflick, & Haas, 2006), but some did report that prenatal depression decreased breastfeeding initiation (Dennis & McQueen, 2009; Figueiredo, Canario, & Field, 2013; Hamdan & Tamin, 2012).

Duration. Many studies report that there is an association with breastfeeding and postpartum depression, with higher depression scores associated with shorter duration (Dunn, Davis, McCleary, Edwards, & Gaboury, 2006; Henderson, Evans, Straton, Priest, & Hagan, 2003; Pippins et al., 2006; Watkins, Meltzer-Brody, Zolnoun, & Stuebe, 2011). Some studies did not find an association (Bogen et al., 2010; McKee et al., 2004). Some found an association at some time points, but not others (Dennis & McQueen, 2009).

Exclusivity/pattern. Many studies found that depression was associated with less exclusive breastfeeding at some time points (Dennis & McQueen, 2007); Gaffney, Kitsantas, Brito, & Swamidoss, 2014; Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn, 2013; Hatton et al., 2005; Henderson et al., 2003; Watkins et al., 2011). Some studies found no association between exclusivity and depression (Bogen et al., 2010).

There are many confounding variables, including the time of measurement, with the influence of depression being significant in early breastfeeding (4 to 6 weeks), but not later (8 to 12 weeks) (Dennis & McQueen, 2007); Hatton et al., 2005), or whether a mother was experiencing breastfeeding problems or pain in the early postpartum period (Watkins et al., 2011), in addition to psychosocial variables, such as the strength of the intention to breastfeed (Bogen et al., 2010) or confidence (Bogen et al., 2010; Field, Hernandez-Reif, & Fiejo, 2002).

The temporality of the relationship between PPD and breastfeeding is unclear, particularly since many of the studies are cross-sectional. Longitudinal studies have noted that depression precedes weaning (Dennis & McQueen, 2007), while others found breastfeeding to be protective (Hahn-Holbrook et al., 2013). Results varied depending on the time measured (Hatton et al., 2005), and on demographic factors (McKee et al., 2004), such as race/ethnicity and socioeconomic status.

Research is currently underway in a sample of women recruited from the maternity unit of a New Hampshire hospital, testing the effectiveness of an educational intervention on the reduction of postpartum depression symptoms. As part of this larger study, breastfeeding outcomes were measured. In this sample, prenatal anxiety and prenatal depression had a significant negative effect on the intent to breastfeed exclusively. A history of depression prior to pregnancy and current symptoms of postpartum depression, both appear to have a negative effect on exclusive breastfeeding as well as earlier weaning compared to those without depression. Further results will be available when data collection is complete.

Look at both together

The importance of addressing breastfeeding and maternal mental health simultaneously concerns many professional disciplines, including mental health, obstetrics, pediatrics, and lactation. In the prenatal period, current and previous history of mood disorders, as well as infant feeding intent should be considered together. Anticipatory guidance about expectations, management of breastfeeding problems, and fatigue should be provided, as well as referrals to mental health services. Medication management of depression either prenatally or postpartum must take into consideration a woman’s breastfeeding goals, and the potential emotional impact on her ability to meet those goals, or manage the process of loss if she is unable to do so. Depression is likely to be influenced by the value of breastfeeding to the mother, requiring consideration of motivation, confidence, feelings of guilt, and cultural influences on feeding choice.

Lactation consultants and other obstetrical health providers must be alert to the potential co-morbidity of breastfeeding problems and postpartum depression. Management of each must involve consideration of the other, in the context of the individual family’s needs, goals, and resources. Assessment for postpartum depression symptoms may be a skill needed by lactation consultants and pediatric providers, just as lactation expertise is an essential resource for pediatric and obstetric providers. Mental health providers who are aware of the meaning of breastfeeding to mothers, as well as the health benefits of and challenges inherent in the experience will be able to provide treatment and recommendations which more holistically meet the needs of breastfeeding women and babies. It is clear that there is no single recommendation for all mothers/families. Management of both breastfeeding and depression is significant to the health and well-being of mothers, newborns, and families. Research, education, and practice must reflect knowledge of the interaction between maternal mood disorders and lactation in order to provide appropriate, compassionate, and evidence-based care.

References

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Bogen, D. L., Hanusa, B. H., Moses-Kolko, E., & Wisner, K. L. (2010). Are maternal depression or symptom severity associated with breastfeeding intention or outcomes? The Journal of Clinical Psychiatry, 71(08), 1069–1078. doi:10.4088/jcp.09m05383blu
Dennis, C.-L., & McQueen, K. (2007). Does maternal postpartum depressive symptomatology influence infant feeding outcomes? Acta Paediatrica, 96(4), 590–594. doi:10.1111/j.1651-2227.2007.00184.x
Dennis, C.-L., & McQueen, K. (2009). The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics, 123(4), e736–e751. doi:10.1542/peds.2008-1629
Dunn, S., Davies, B., McCleary, L., Edwards, N., & Gaboury, I. (2006). The relationship between vulnerability factors and breastfeeding outcome. Journal of Obstetric, Gynecologic & Neonatal Nursing, 35(1), 87–97. doi:10.1111/j.1552-6909.2006.00005.x
Fairlie, T. G., Gillman, M. W., & Rich-Edwards, J. (2009). High pregnancy-related anxiety and prenatal depressive symptoms as predictors of intention to breastfeed and breastfeeding initiation. Journal of Women’s Health, 18(7), 945–953. doi:10.1089/jwh.2008.0998

Birth_Birth Trauma: Psychological Trauma of Childbirth in Our Time
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Field, T., Hernandez-Reif, M., & Feijo, L. (2002). Breastfeeding in depressed mother-infant dyads. Early Child Development and Care, 172(6), 539–545. doi:10.1080/03004430215105
Figueiredo, B., Canário, C., & Field, T. (2013). Breastfeeding is negatively affected by prenatal depression and reduces postpartum depression. Psychological Medicine, 44(05), 927–936. doi:10.1017/s0033291713001530
Gaffney, K. F., Kitsantas, P., Brito, A., & Swamidoss, C. S. S. (2014). Postpartum depression, infant feeding practices, and infant weight gain at six months of age. Journal of Pediatric Health Care, 28(1), 43–50. doi:10.1016/j.pedhc.2012.10.005
Hahn-Holbrook, J., Haselton, M. G., Dunkel Schetter, C., & Glynn, L. M. (2013). Does breastfeeding offer protection against maternal depressive symptomatology? Archives of Women’s Mental Health, 16(5), 411–422. doi:10.1007/s00737-013-0348-9
Hamdan, A., & Tamim, H. (2012). The relationship between postpartum depression and breastfeeding. The International Journal of Psychiatry in Medicine, 43(3), 243–259. doi:10.2190/pm.43.3.d

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Hatton, D. C., Harrison-Hohner, J., Coste, S., Dorato, V., Curet, L. B., & McCarron, D. A. (2005). Symptoms of postpartum depression and breastfeeding. Journal of Human Lactation, 21(4), 444–449. doi:10.1177/0890334405280947
Henderson, J. J., Evans, S. F., Straton, J. A. Y., Priest, S. R., & Hagan, R. (2003). Impact of postnatal depression on breastfeeding duration. Birth, 30(3), 175–180. doi:10.1046/j.1523-536x.2003.00242.x
McKee, M. D., Zayas, L. H., & Jankowski, K. R. B. (2004). Breastfeeding intention and practice in an urban minority population: relationship to maternal depressive symptoms and mother–infant closeness. Journal of Reproductive and Infant Psychology, 22(3), 167–181. doi:10.1080/02646830410001723751
Pippins, J. R., Brawarsky, P., Jackson, R. A., Fuentes-Afflick, E., & Haas, J. S. (2006). Association of breastfeeding with maternal depressive symptoms. Journal of Women’s Health, 15(6), 754–762. doi:10.1089/jwh.2006.15.754
Watkins, S., Meltzer-Brody, S., Zolnoun, D., & Stuebe, A. (2011). Early Breastfeeding Experiences and Postpartum Depression. Obstetrics & Gynecology, 118(2, Part 1), 214–221. doi:10.1097/aog.0b013e3182260a2d

deborahmccarter_bioDeborah McCarter-Spaulding, PhD, RN, is an Associate Professor of Nursing at Saint Anselm College and International Board Certified Lactation Consultant (IBCLC). Her current research is addressing an educational intervention provided by postpartum nurses and its effect on postpartum depression symptoms. She is also looking at the relationship between postpartum depression and breastfeeding. Her previous research work has also been related to breastfeeding, particularly breastfeeding confidence (self-efficacy). She is also interested in women’s health, gender issues, and global health, particularly in interdisciplinary context.

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