Is Maternal Depressive Symptomatology Effective on

BREASTFEEDING MEDICINE Volume 0, Number 0, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2012.0036

Original Article

Is Maternal Depressive Symptomatology Effective on Success of Exclusive Breastfeeding During Postpartum 6 Weeks? ¨ rs,4 and Fatih Kara 5 Ali Annagu¨r,1 Bilge Burçak Annagu¨r,2 Akkız Sxahin,3 Rahmi O

Abstract

Aim: The aim of this prospective study was to examine the relationship between success of exclusive breastfeeding and postpartum depressive symptomatology. Our hypothesis was that mothers with depressive symptoms initially fail exclusive breastfeeding. Subjects and Methods: One hundred ninety-seven mothers were enrolled in the study. The participants were interviewed twice. The first visit was within the first 48 hours after birth. The Edinburgh Postnatal Depression Scale (EPDS) was completed by the participants. The second interview was performed at 6 weeks. Participants answered questions regarding methods of breastfeeding for 6 weeks, any methodological problems, and nipple pain. The EPDS was again completed by the participants at 6 weeks. All newborns were term infants. Results: All the participants were divided into two groups: exclusive breastfeeding and mixed-feeding (partial breastfeeding and/or bottle feeding). Both groups were compared in terms of features, such as mode of delivery, parity, prevalence of depressive symptomatology (at 48 hours and 6 weeks), and delayed onset of lactation within the first 48 hours. Statistical significance was found for only three variables: delayed onset of lactation within the first 48 hours, gestational age, and the problems related to breastfeeding methods. Conclusions: Clinicians should pay special attention to any lactation difficulty during the first week postpartum. Early lactation difficulties are associated with greater risk of early termination of breastfeeding and lower breastfeeding success.

long-term health of both the mother and child.7,8 The World Health Organization in 2002 recommended that mothers breastfeed exclusively for the first 6 months and then continue to do so alongside complementary foods for up to 2 years and beyond.8 However, levels of breastfeeding worldwide are much below those recommended.9,10 Many factors may influence duration of breastfeeding, such as parity, mode of delivery, obstetric complications, gestational age, birth weight, Apgar scores, smoking, nipple pain, maternal physical disease, social support, maternal depressive symptoms, and PPD.11,12 There are many studies about the effect of infant feeding method on maternal mood. A few researchers have reported breastfeeding mothers were at higher risk of developing PPD.13,14 Other studies have found no relationship between these variables.15,16 Conversely, several have reported bottlefeeding mothers were at higher risk of developing depressive symptomatology.17,18 However, subsequent studies have suggested that maternal mood negatively influences breastfeeding outcomes, rather than the reverse.19–21 Dennis and McQueen22 have suggested that mothers with depressive

Introduction

M

ood changes are common in the early postpartum period. The prevalence of postpartum depression (PPD) ranges from 10% to 15% among women. However, depressive symptoms may occur more than a major depressive disorder in the postpartum period.1 PPD is one of the significant mental health problems that can have negative effects on mother–infant interactions. Researchers have shown that depressed mothers are more likely to express behaviors that have a negative impact on their children.2,3 Depressed mothers are also less sensitively attuned to their infant’s needs.4 Many authors have suggested a correlation between depressive symptoms and early termination of breastfeeding.5,6 Researchers have stated that women who were depressed prenatally were less likely to attempt to breastfeed and to persist in lactation. Breastfeeding has numerous benefits for both infant and maternal health. Besides the well-known nutritional, antiinfective, and immunologic properties, there is increased evidence that breastfeeding has a positive impact on the

Departments of 1Neonatology, 2Psychiatry, and 5Public Health, Selçuklu Medical School, Selçuk University, Konya, Turkey. Departments of 3Pediatrics and 4Neonatology, Meram Medical School, Konya University, Konya, Turkey.

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2 symptomatology may be more likely to discontinue breastfeeding earlier than nondepressed mothers. Our prospective study examines association between success of exclusive breastfeeding and postpartum depressive symptomatology. Our hypothesis was that mothers with depressive symptoms initially fail exclusive breastfeeding. Subjects and Methods Participants The study population comprised 197 mothers who delivered singleton neonates at Meram Faculty of Medicine of Selçuk University between October and December 2011 and whose infants had an uneventful prenatal, perinatal, and postnatal course. All the women were at least 18 years of age and able to understand Turkish. None of the mothers had any obstetric complications. Mothers with medical problems and smokers were excluded from the study. Newborns were term infants (‡ 37 weeks and ‡ 2,500 g). None of the newborns had any congenital anomaly and metabolic disease. Newborns admitted to the newborn clinic for delayed onset of lactation within the first 48 hours were included the study. Procedures The study was performed with the approval of the Selçuk University Medical Faculty’s Ethics Committee, and written informed consent, in accordance with the Declaration of Helsinki, was obtained from all participating mothers. The participants were interviewed twice. The first visit was within the first 48 hours after birth. Participants answered questions about sociodemographics, obstetric history, social support, education of breastfeeding, and their plan to breastfeed their baby. The Edinburgh Postnatal Depression Scale (EPDS) was completed by the participants. The following data were also collected for the babies: gestational age, birth weight, Apgar scores, and mode of delivery. The second interview performed at 6 weeks postpartum. Participants answered questions about methods of breastfeeding for the 6-week period, any methodological problems, and nipple pain. The EPDS was also completed by the participants at 6 weeks. Measures Depressive symptomatology. The EPDS was included in all postnatal questionnaires to measure depressive symptomatology. Although this 10-item self-report instrument does not diagnosis PPD, as this is possible only through a psychiatric interview, it is the most frequently used measure to assess postpartum depressive symptomatology and identify at-risk mothers. Using a cutoff score of >12, at 6 weeks postpartum the EPDS has a sensitivity of 68–95% and a specificity ranging from 78% to 96% compared with a diagnosis of major PPD established through a psychiatric interview.23 The Cronbach’s a for this sample was 0.87. The Turkish version of the EPDS has been validated by Aydın et al.24 The cutoff point is assumed as 12. Infant feeding outcomes. To promote consistency in the definition of breastfeeding and facilitate comparison of research results, two infant feeding methods are defined: 1 indicates exclusive breastfeeding (breastmilk only), whereas 2

indicates both partial breastfeeding (both breastmilk and formula) and bottle feeding (no breastmilk at all). Statistical analysis Data were analyzed with SPSS version 15 statistical software (SPSS, Inc., Chicago, IL). Mean values, SD frequencies, and percentages were calculated for descriptive data. The v2 test was used to compare categorical data. The differences between the two groups were compared with the Mann– Whitney U tests. A value of p < 0.05 was assumed to represent a statistically significant difference. Results Sample characteristics One hundred ninety-seven mothers were enrolled in the study. The mean age of the sample was 28.58 – 5.0 years, with a range from 18 to 44 years. All participants were married. Seventy-three percent of mothers had graduated primary school, 17% high school, and 10% university. In relation to monthly household income, 57% of women had an income of less than $750, 34% had incomes between $750 and $1,500, and 6% had incomes greater than $1,500. Thirty-four percent of the women were primiparous versus 66% multiparous, 15.2% delivered vaginally versus 84.8% by cesarean section, and 93.9% were discharged home within 48 hours of delivery. Twelve of the newborns (6.1%) were admitted to the newborn clinic for delayed onset of lactation within the first 48 hours. Causes of delayed onset of lactation in our study were particularly urgent cesarean section and flat or inverted nipples. Thirty-nine percent of the women had received training about breastfeeding, and the majority of the women (95.5%) planned to give exclusive breastfeeding. One-third of the women indicated that they had social support. The mean number of the delivery was 2.17 – 1.12 (range, 1–6). The mothers had a mean number of 2.12 – 1.09 children. The mean gestational age was 38.1 – 1.0 weeks. The mean Apgar scores at 1 minute and 5 minutes were 7.7 – 0.6 and 9.4 – 0.5, respectively. Depressive symptomatology The mean score on the EPDS was 6.4 – 5.4 at 48 hours. The mean score on the EPDS was 5.8 – 4.7 at 6 weeks. The prevalence of depressive symptomatology (EPDS score >12) at 48 hours and 6 weeks was 14.2% (n = 28) and 11.2% (n = 22), respectively. The prevalence of depressive symptomatology (EPDS score >12) in both measurements combined was 9.6% (n = 19). None of the participants was using an antidepressant. Infant feeding method outcomes Twenty-three percent of the women indicated that they had experienced a problem related to the breastfeeding method, and 41.4% of the women were experiencing several nipple pain. Infant feeding outcomes At 6 weeks postpartum, the majority of women (65.5%, n = 129) were exclusively breastfeeding, with 18.8% (n = 37) partial breastfeeding (both breastmilk and formula) and 15.7% (n = 31) bottle feeding.

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Table 1. Categorical Variables Compared for Exclusive Breastfeeding and Mixed-Feeding Groups

0.668

The participants were divided into two groups: exclusive breastfeeding and mixed-feeding (partial breastfeeding and/ or bottle feeding). Both groups were compared in terms of mode of delivery, parity, prevalence of depressive symptomatology (at 48 hours and 6 weeks), and delayed onset of lactation within the first 48 hours. Statistical significance was found for only two variables: delayed onset of lactation within the first 48 hours and gestational age. We found that any methodological problems and nipple pain negatively affect exclusive breastfeeding. Variables effective on exclusive breastfeeding are shown in Tables 1 and 2.

0.341

Discussion

% from total n = 197 (n) Exclusive breastfeeding

Variable Delivery Vaginal (n = 30) Cesarean (n = 167) Parity Primipara (n = 67) Multipara (n = 130) EPDS-1 > 12 (n = 28) £ 12 (n = 169) EPDS-2 > 12 (n = 22) £ 12 (n = 175) EPDS-3 > 12 (n = 19) £ 12 (n = 178) Delayed onset of lactation Yes No Methodological problems Yes No Nipple pain Yes No

Mixedfeeding

p value 0.406

17.1% (22) 11.8% (8) 82.9% (107) 88.2% (60) 0.347 36.4% (47) 63.6% (82)

Influence of depressive symptomatology at 48 hours and 6 weeks postpartum on infant feeding outcomes

29.4% (20) 70.6% (48)

13.2% (17) 16.2% (11) 86.8% (112) 83.8% (57) 9.3% (12) 14.7% (10) 90.7% (117) 85.3% (58) 0.217 7.8% (10) 13.2% (9) 92.2% (119) 86.8% (59) 1.6% (2) 14.7% (10) 98.4% (127) 85.3% (58) 4.7% (6) 58.8% (40) 95.3% (123) 41.2% (28) 26.4% (34) 73.6% (95)

0.001a 0.000a 0.000a

70.6% (48) 29.4% (20)

Categorical variables assessed were mode of delivery, parity, prevalence of depressive symptomatology (at 48 hours and 6 weeks), delayed onset of lactation within the first 48 hours, any problem related to breastfeeding methods, and experiencing several nipple pain. Mixed-feeding represents both partial breastfeeding (both breastmilk and formula) and bottle feeding (no breastmilk at all). a Statistically significant difference. EPDS-1, EPDS-2, and EPDS-3, scores on the Edinburgh Postnatal Depression Scale of depressive symptoms within 48 hours, at 6 weeks, and combined, respectively.

Table 2. Noncategorical Variables Compared for Exclusive Breastfeeding and Mixed-Feeding Groups Exclusive breastfeeding

Mixedfeeding

Mother’s age (years) 28.3 – 5.4 29.2 – 4.2 Number of deliveries 2.1 – 1.1 2.3 – 1.2 Number of children 2.0 – 1.0 2.3 – 1.2 Count of child 2.0 – 1.0 2.3 – 1.2 Gestational 38.2 – 0.9 38.0 – 1.1 age (weeks) Apgar score at 1 minute 7.8 – 0.6 7.7 – 0.6 5 minutes 9.4 – 0.5 9.3 – 0.5 Baby’s weight (g) 4,780.9 – 530.7 4,686.9 – 739.9 EPDS-1 6.0 – 5.03 7.1 – 6.2 EPDS-2 5.3 – 4.3 6.7 – 5.308

p value 0.131 0.140 0.116 0.092 0.036a 0.285 0.078 0.380 0.392 0.161

Mixed-feeding represents both partial breastfeeding (both breastmilk and formula) and bottle feeding (no breastmilk at all). a Statistically significant difference. EPDS-1 and EPDS-2, scores on the Edinburgh Postnatal Depression Scale of depressive symptoms within 48 hours and at 6 weeks, respectively.

The aim of this prospective study was to examine the relationship between success of exclusive breastfeeding and postpartum depressive symptomatology. Our hypothesis was that mothers with depressive symptoms initially fail exclusive breastfeeding. However, contrary to our expectation, an effect of higher maternal depressive symptomatology was not demonstrated on exclusive breastfeeding during 6 weeks after delivery. However, the important finding of this study that delayed onset of nutrition within the first 48 hours affects negatively exclusive breastfeeding during the 6 weeks after delivery. Furthermore, the success of breastfeeding was influenced by gestational age during the first 6 weeks. In addition, in mothers who experienced problems related to breastfeeding methods and nipple pain, exclusive breastfeeding as negatively affected. Many studies have examined the relationship between breastfeeding and the development of PPD. The results have been quite variable. Green et al.18 suggested that mothers who were bottle feeding at 12 week had significantly higher EPDS scores than mothers who were breastfeeding. In a similar study, Groer and Morgan25 suggested that depressed mothers were more likely to bottle feed than nondepressed mothers at 4–6 weeks. Green and Murray26 found that depressive symptomatology antenatally decreased breastfeeding initiation and duration. Other studies have found no association between breastfeeding and depressive symptomatology.15,16 Our finding is comparable with those of previous studies that found no association between breastfeeding and maternal mood. Furthermore, it should be noted that there was no effect of depressive symptomatology on breastfeeding initiation and duration within the 6 weeks immediately postpartum. Prolactin has a role in priming and triggering maternal behavior, and sustained high concentrations of prolactin during late pregnancy and puerperium are necessary for normal maternal behavior.27 Oxytocin also facilitates the onset of maternal behavior. In addition, relaxation and antistress effects will be induced in the mother.28 In animal experiments, lactating rats are less responsive to certain stressful stimuli than are nonlactating animals.28 Based on these data, it may be said that breastfeeding protects from depression. In our study, the majority of women (on average 85%) gave breastmilk to their babies. For this reason, the possible negative impact of depression on breastfeeding may be masked.

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4 Delayed onset of nutrition within the first 48 hours may be due to many reasons. Prematurity is the most important cause, related to the infant. Causes of delayed onset of milk production are as follows: primiparity, cesarean section delivery, stress during labor and delivery, maternal diabetes, and high maternal body mass index.30 There was no premature neonatal or complicated delivery in our study. The delayed onset of lactation group included particularly urgent cesarean section and flat or inverted nipples. Some reports have suggested that lactation difficulties during the first week postpartum are associated with greater risk of early termination of breastfeeding and lower breastfeeding success with subsequent children.31,32 Our finding is compatible with these studies indicating delayed onset of lactation and problems relation to breastfeeding methods are associated with failure of exclusive breastfeeding. Another factor that affects the success of exclusive breastfeeding during the immediate postpartum 6 weeks is gestational age. It was accepted that prematurity negatively affects the success of breastfeeding.30 Although we did not include premature infants in our study, we observed that gestational age affected the success of breastfeeding for the first 6 weeks. The critical issue is that a difference of a few days may influence the success of breastfeeding in mature infants also. Obviously, our study has certain methodological limitations. First, we used questionnaires to assess depressive symptomatology, not clinical interviews. Therefore, depression and other co-morbid psychiatric diagnoses were not included. Furthermore, some symptoms such as fatigue and sleep disorders, which can be expected in caring for a newborn, look like depressive symptomatology. Second, we evaluated only depressive symptomatology, although it is known that stress and anxiety are important factors for lactation performance.11 More specific results may be obtained when assessed with both anxiety and depression. Conclusions Early lactation difficulties were common even in women who were highly motivated to breastfeed. Clinicians especially should pay attention to lactation difficulty during the first week postpartum. So, early lactation difficulties are associated with greater risk of early termination of breastfeeding and lower breastfeeding success. Maternal mood states should be considered, and providing additional lactation guidance and psychological support during the first days postpartum could be beneficial for stimulating successful breastfeeding in more vulnerable women. Disclosure Statement No competing financial interests exist. References 1. Marcus SM, Heringhausen JE. Depression in childbearing women: When depression complicates pregnancy. Prim Care 2009;36:151–165. 2. Hart S, Field T, Nearing G. Depressed mothers’ neonates improve following the MABI and a Brazelton demonstration. J Pediatr Psychol 1998;23:351–356. 3. Weinberg MK, Tronick EZ. Emotional characteristics of infants associated with maternal depression and anxiety. Pediatrics 1998;102(5 Suppl E):1298–1304.

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Address correspondence to: Ali Annagu¨r, M.D. Neonatoloji AD Selçuklu Tıp Faku¨ltesi ¨ niversitesi Selçuk U Selçuklu-Konya, 42075, Turkey E-mail: [email protected]