Breastfeeding & Post-Partum Depression

By Maggie Sullivan Moderator | 06 Aug, 2013

Thank you to our colleagues at GANM for initiating a discussion regarding the link between breast feeding and post-partum depression. The author poses a few questions at the end of her comment and I've included some of the replies.

Initial post by Jennifer Hahn-Holbrook, PhD:
"I wanted to share my recently published paper on the link between breastfeeding and postpartum depression, in the hopes that it might spark a discussion.

Numerous studies show that breastfeeding women are less likely to be depressed postpartum than formula feeding women. However, many questions remain.
 
Are women who struggle with depression in pregnancy or the postpartum less likely to breastfeed? In other words, is depression causing early weaning? Or, instead, is breastfeeding somehow protecting women against postpartum depression? Our research team sought to answer these questions using a data set of 200 women from Los Angeles who were asked to fill out a self-report depression questionnaire at 5 times during their pregnancy, and to report on their infant feeding behaviors and depressive symptoms at 3, 6, 12 and 24 months after delivery.
 
What we found was surprising; the relationship between breastfeeding and postpartum depression seemed to “go both ways” (e.g., it was bi-directional). Women who were depressed during pregnancy weaned their infants an average of 2 months sooner than women who were not depressed during pregnancy, suggesting that, somewhere along the line, depression was interfering with these women’s motivation, ability, or access to support services for breastfeeding. On the flip side, women who were breastfeeding frequently at 3 months postpartum were more likely to have experienced a resolution of their symptoms by 12 & 24 months postpartum than women who were not breastfeeding at 3 months, or who were only breastfeeding a token amount. In other words, breastfeeding seemed to be protective against depression, too.
 
The idea that breastfeeding might serve as protection against depressive symptoms raises interesting questions. For instance, rates of postpartum depression vary dramatically from nation to nation and from culture to culture. In some countries, like Singapore, Malta, Malaysia, Austria, and Denmark, there are very few reports of postpartum depression, whereas in countries like Brazil, Guyana, Costa Rica, Italy, Chile, South Africa, Taiwan, and Korea, reports of postpartum depression are very prevalent (Halbreich & Karkun, 2006). Obviously, numerous, social, cultural, measurement and economic factors contribute to these differences, but could cross-national differences in breastfeeding be one of them?
 
I would love to hear your thoughts on the questions posed here. Have any of you seen incidences in your communities where breastfeeding and depression seemed to be intertwined? Also, because there is clear evidence that depression predicts poor breastfeeding outcomes, what steps might we take to help depressed women meet their breastfeeding goals?
 
Sincerely,
Jennifer Hahn-Holbrook, PhD
Assistant Professor of Psychology
Chapman University

PS. Here is the Halbreich & Karkun citation, if you are interested in cross-cultural rates of postpartum depression:
 
Halbreich, U., & Karkun, S. (2006). Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. Journal of Affective Disorders, 91, ­97-111."

REPLY: Sabah O. Jebreen
Thank you for sharing a very valuable document and raising a crucial Maternal/neonatal health issue. Currently I work in a national project mainly to achieve MDG 4 &5 by decreasing the maternal and neonatal mortality 2/3 by the year 2015. One of the most challenging health issues we keep facing is absence of short-term breastfeeding period. Even with a well-established breastfeeding program at the public sector level, we are facing two sabotaging counteracts, the formula producing companies, and the cultural misconception of breastfeeding.
Yes we all agree that breastfeeding is the ultimate physiological process for nurturing newborns, yet physicians, nurses/ midwives, and mothers share the practice of early bottle feeding without second thoughts. I find myself standing on the other side struggling for maintaining breastfeeding practice.
Breastfeeding practice is a multifactorial, and we try to keep these factors under control, yet not always we succeed.

Sabah O. Jebreen RN/ HD Edu
NNC Task Manager
Health Systems Strengthening II
Abt Associates Inc.
Amman, Jordan

REPLY: Michele Sare
Great discussion! In some beginning research in rural Haiti, we have found other caveats to this 'chicken-and-egg' discussion and those are education and mother's nutrition (linked to economy). Under educated women who lack understanding of 'principles' of breastfeeding and nutrition also lacked enough money to purchase or grow sufficient protein and other nutrient rich foods necessary for adequate milk production. While it wasn't our focus, we did note that these were the women who presented with S/S of depression or ineffective coping mechanisms. Just a quick review of the countries that you've identified as 'depressive' and 'not' - I'd guess that what is missing here is the view from the Social Determinates of Health - most
especially education and economy.

 - Michele Sare at Nurses for Nurses International

REPLY: Sabrina Escher
Very interesting topic indeed. I totally agree with the study , but I wonder why science has to proove something innate as healthy. Breastfeeding is the fisiological part of raising an infant. Obviously it is the best for mother and child. That women stop breastfeeding when depressed sounds logical too.

To me it would be interesting to know why a woman gets postpartum depression. Dont think it has to do with breastfeeding directly. I'm more inclined to think it is linked to suppressed negative perceptions combined with hormonal changes. A traumatic birth experience or not being able to experience all the fisiological processes would enhance chances of falling into a depression but doesnt have to be the only cause.

I think cultural and personal perceptions on birthing and partnership have an influence on how we experience the entire birthing process. In all my births I felt this depressive moment during the first week, but I just didnt go there, because I had so many more ups that pulled me away from the whole.

There are many interesting things women experience that aren't mentioned by science. For instance in the first month after birth, having visions of the baby being in danger. When living in the city, by cars, people...in the jungle by snakes, spiders etc. Many women have that but never mention it, because they think its embarrassing. It's part of keeping the mother alert of possible dangers. But what happens to that process when women are in real danger?

- Sabrina Escher

REPLY: Rachel Breman
What a timely discussion for World Breastfeeding Week! Check out http://worldbreastfeedingweek.org/ for more information on what is going on globally. Please share with the GANM your thoughts and experiences in your clinical practice with depression and breastfeeding.

One clinical experience I have seen with numerous patients is having women who are uncomfortable with breastfeeding and then having a vicious cycle of self-doubt combined with a screaming newborn and the need to feed the baby. Women seem to get defeated, or possibly depressed. In these circumstances breastfeeding becomes more challenging. Often times formula is introduced, the baby takes the bottle and the woman’s self-doubt seems to get stronger. There was an article that was published in the journal Pediatrics, "Effect of Early Limited Formula on Duration and Exclusivity of Breastfeeding in At-Risk Infants: An Randomized Controlled Trial"
· Valerie J. Flaherman, Janelle Aby, Anthony E. Burgos, Kathryn A. Lee, Michael D. Cabana, and Thomas B. Newman Pediatrics 2013; 131:6 1059-1065; published ahead of print May 13, 2013, doi:10.1542/peds.2012-2809. The researchers found that some formula in at risk babies was ok for breastfeeding long term, but they used very small amounts of formula, which is not necessarily what happens in real, clinical situations.

Again, please share with us your clinical experiences with breastfeeding and depression.

Thank you,
 - Rachel Breman, MSN, MPH, RN

Attached resources:

Replies

 

Linda Murray Replied at 8:08 AM, 7 Aug 2013

Hi there,

Thanks very much for this discussion thread! I just finished my PhD on postnatal depression in central Vietnam. Like many of you have alluded to, the literature generally shows mothers who are depressed will breastfeed less, or for a shorter duration. However, my research found that this wasn't the case in the Vietnamese context. This requires further investigation, but it is possible it was because the rates of mixed feeding (breastfeeding and artificial milk) are very high to begin with, whether mothers are experiencing depression or not. Another poster in this threat spoke about the fact there can still be strong influences on new mothers to use artificial milk in some contexts despite evidence of the benefits of breastfeeding. I think the pressures on women to use substances other than breast milk in low-and-middle income countries is very relevant to consider in this discussion.

There was recently an excellent systematic review by Fisher et al., (2012) that suggests there are many common associations with poor maternal mental health in low-and-middle income countries such as poverty, experiences of violence and previous psychiatric illness. However obviously these may vary according to cultural context. This article is available here:
http://www.who.int/bulletin/volumes/90/2/11-091850/en/

Maggie Sullivan Moderator Replied at 10:40 AM, 7 Aug 2013

Linda-thank you for your comment and for the new resource. I've attached the link here and included the introduction for folks. The discussion at the end of the article is quite good. Thanks again, Linda, for the suggestion.

Bulletin of the World Health Organization 2012;90:139-149H. doi: 10.2471/BLT.11.091850

Introduction
The nature, prevalence and determinants of mental health problems in women during pregnancy and in the year after giving birth have been thoroughly investigated in high-income countries.1 Systematic reviews have shown that in these settings, about 10% of pregnant women and 13% of those who have given birth2 experience some type of mental disorder, most commonly depression or anxiety.3 Social, psychological and biological etiological factors interact, but their relative importance is debated.

The perinatal mental health of women living in low- and lower-middle-income countries has only recently become the subject of research,1 in part because greater priority has been assigned to preventing pregnancy-related deaths. In addition, some have argued that in resource-constrained countries women are protected from experiencing perinatal mental problems through the influence of social and traditional cultural practices during pregnancy and in the postpartum period.4,5

This systematic review was performed with the objective of summarizing the evidence surrounding the nature, prevalence and determinants of non-psychotic common perinatal mental disorders (CPMDs) among women living in low- and lower-middle-income countries.

Attached resource:

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