Baby-Friendly e-Newsletter : Infant & Young Child Feeding and Nutrition in Perspective (Jan 2021)

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Breastfeeding and Mental Wellbeing during the Early Postnatal Period

Ms. Theresa T. T. NG (Clinical Psychologist)

Ms. Iris H. H. CHAN (Clinical Psychologist)

Ms. Annie C. S. SHEH (Clinical Psychologist)

Ms. Miranda H. S. LEUNG (Clinical Psychologist)

Given the well-documented benefits of breastfeeding on short- and long-term health, the majority of mothers nowadays intend to breastfeed their babies.¹  Nevertheless, there has been concern over the negative impact of breastfeeding on perinatal mental health in recent years. While breastfeeding difficulty may be a postnatal stressor, the latest evidence regarding its relationship with postnatal depression remains equivocal. This article aims to provide a brief summary of the latest research on the relationship between breastfeeding and postnatal mood problems and offer tips to healthcare professionals in supporting breastfeeding mothers presenting with mood problems.

Relationship between Breastfeeding and Postnatal Mood Problems 

It has been suggested that breastfeeding reduces stress and the risk of depression through the hormone oxytocin, which enhances maternal bonding and modulates the hypothalamic-pituitary-adrenal axis.²  Yet, it is challenging to expound the relationship between breastfeeding and postnatal depression.

The Agency for Healthcare Research and Quality (AHRQ) of the USA conducted its second review on Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries in 2018.³  The review on breastfeeding and postnatal depression included a systematic review of 48 cohort studies published in 2015 and 14 more recent cohort studies. The AHRQ review concluded an unclear association, in terms of both the magnitude and direction of effect, between breastfeeding and postnatal depression. It commented that the studies were heterogeneous in design and results were inconsistent.  

Notwithstanding the above, the systematic review⁴ included in the AHRQ review reported an association between breastfeeding and postnatal depression in most of the studies. In several longitudinal studies, breastfeeding difficulties predicted postnatal depression and vice versa. It also reported that antenatal depression and postnatal depression were associated with early cessation of breastfeeding. The latter might have mediated the association between antenatal and postnatal depression. Thus, the authors suggested a need to identify and support women with depressive symptoms in pregnancy or breastfeeding problems in early postnatal period to improve breastfeeding outcomes and maternal mood.

Psychological Features of Breastfeeding Mothers with Mood Problems 

It is not uncommon for healthcare professionals to come across mothers with mood issues while providing breastfeeding support. Emerging evidence suggests that supporting mothers through their breastfeeding difficulties is beneficial to the mental health of the mothers as well as health of their children.⁵  Meanwhile, working with mothers with postnatal mood issues may pose additional challenges which can probably be addressed with a better understanding of their clinical presentations.  

i) Repetitive Thinking Pattern

Ruminations and worries are very common in individuals with depression and anxiety. ^6,7  Mothers with depressive mood may repetitively and passively focus on negative thoughts and experiences, such as the discrepancy between expectations and realities of motherhood⁸, inadequacies as a mother, worries of inappropriate baby care, etc.

ii) Cognitive Biases and Difficulties

Research also shows that individuals with depressive mood tend to display cognitive biases to negative cues, e.g., having difficulties shifting attention away from negative scenes, tendency to appraise things negatively, enhanced recall of negative events, etc.⁹

As over-focusing on the negative aspects of one’s experiences likely hinders effective problem solving and sensitivity to the cues and needs of infants, mothers with mood issues are found to show reduced nurturing mother-infant interactions such as skin to skin contact (Bigelow et al., 2012, as cited in Brown et al., 2015).¹⁰

Apart from the abovementioned characteristics, these mothers may also experience ambivalence towards issues such as giving up breastfeeding, seeking professional help for their mood problems, etc. They thus may appear to be more resistant to health advices. To provide effective professional support to mothers with such struggles and possible mental characteristics, paying particular attention to the way we make conversations is essential.

What Healthcare Professionals Can Do

i) Communicate with empathy

Understanding and accepting the tendency for these mothers to ruminate and cope with their problems ineffectively could prepare us to listen to their difficulties non-judgmentally. They may appear non-attentive or even resistant to health advices due to their decreased ability to avoid unwanted thoughts and emotions. For example, mothers may want to keep on breastfeeding but seem overly anxious to continue after experiencing breast pain in the early days. Instead of directly challenging their beliefs or behaviours, try to validate their emotions and solicit more details of their concerns empathically, e.g., we may say, “On the one hand, you worry about experiencing the pain again; on the other hand, you really want to continue breastfeeding.  Breastfeeding the baby seems very important to you. Can you share a bit more with me?” (「你一方面擔心會再痛；另一方面你又好想繼續餵。餵母乳對你嚟講似乎好重要，可唔可以講多啲畀我聽？」) We can then affirm their efforts and normalise their struggles by saying “You are really tough to have kept trying to breastfeed! It is quite natural to worry that the pain may return. Mothers who have breast pain get similar worries as you do.” (「你繼續嘗試餵母乳真係好唔簡單！擔心啲痛會持續其實都係人之常情，其他試過乳頭疼痛嘅媽媽都有類似嘅擔心。」) Then ask for permission to offer information or suggestions that may address their concerns, e.g., we may ask, “Would you like to know more about using different breastfeeding positions and ways to manage the sore nipples?” (「你想唔想知多啲其他餵哺姿勢同埋處理乳頭疼痛嘅方法？」).

ii) Empower and Focus on the Positives

As one core feature of individuals with mood problems is their bias towards the negatives and tendency to overlook the positives, we may have to listen carefully to their narratives and look for positive aspects of their encounters. We can then gently reflect and affirm these positive experiences. For example, we may say, “Although breastfeeding is not easy, you have put in every effort in the past weeks.” (「雖然餵母乳並唔容易，但你喺呢幾個星期已經好努力咁嘗試。」) Besides, by listening actively and reflecting accurately on what the mothers value, the conversation may shift to positive aspects of breastfeeding or parenting as perceived by the mothers themselves, in turn empowering them to meet their goals, e.g., we may remark, “You feel great when you see him feeding well.” (「見到BB食得好，你就覺得一切都好值得。」).  As we build on this conversation and work out the actions that the mother may take to achieve what they value, we can instill a sense of hope, e.g., we may comment, “Even though you are having such a hard time, you will keep trying in order to offer the best to your baby” (「即使你好辛苦，你都會繼續嘗試，想將最好嘅畀BB。」) 

iii) Expand Perspectives

In view of their cognitive inflexibility, our goal in working with these mothers is to facilitate them to expand their perspectives. For example, instead of arguing with a worrisome mother whether she could exclusively breastfeed her infant, acknowledge this is a common concern among most mothers, gently explore with her whether she could try out some of our suggestions, and broaden her perspective to see that even if she could not breastfeed exclusively, her attempts have already attested to her love and commitment towards caring for her baby. After all, breastfeeding is but “one of the best” she could offer to her baby.

Apart from addressing breastfeeding issues, facilitate the mothers to understand the significance of responsive parenting in nurturing healthy development of the baby. As mothers with mood issues tend to miss or misinterpret babies’ cues, with their permission, coach and encourage them to respond contingently and interact more frequently with their baby. This would facilitate mother-infant bonding which, in turn, enhance their health and well-being. For example, we may say, “Responding to the baby’s needs is not easy, would it be helpful if I share a bit more about this with you?” (「唔少新手媽媽同你一樣，覺得要回應BB嘅需要好唔容易，如果我同你分享多啲呢方面嘅資訊，唔知可唔可以呢？」)

iv) Support Autonomy in Decision-Making

In cases where the mother expresses preference for other modes of feeding, we may facilitate her to make an informed choice on an agreeable infant feeding plan. Be aware that some ambivalent mothers may appear to be relying on us to make such decisions for them. However, when we try to give them any advices, they may opt for the opposite. Reflecting their ambivalence instead of giving advices or asking for permission before giving advices will help empower mothers and preserve their autonomy. In the decision-making process, offering information and emotional support in the context of a partnership is therapeutic.

Coping with Challenges of Working with Mothers with Mood Problems

It could be frustrating working with depressed or anxious mothers who seem preoccupied with their problems. Avoid attributing it negatively to the mothers’ motivation to change or our abilities to influence them. Seek peer support and employ healthy self-care practices after encounters that are more emotionally draining.

Despite the aforementioned challenges, any support healthcare professionals may render mothers in their breastfeeding journey could be invaluable to help them overcome difficulties in breastfeeding or cope with parenting and mental health issues.  While we do not invalidate the mother’s attempt to provide her baby with “the best” she could offer, healthcare professionals could help her recognise that breastfeeding is only a means to an end, which is the attainment of health. After all, “good enough” is enough.  

Being Aware of Postnatal Mood Problems

It is reported that up to 80% of postnatal women experience postnatal blues (or “baby blues”).¹¹  Such emotional disturbance usually subsides within a few days. If the distress persists or exacerbates, it may signal the onset of postnatal depression, a common mental illness estimated to affect 13% to 19% of postnatal women.¹¹  When postnatal depression is suspected, we should encourage mothers and significant others to seek help from the Maternal and Child Health Centre, family doctor, clinical psychologist or psychiatrist.

Key Messages:

• Latest research findings conclude that the association between breastfeeding and postnatal depression remains unclear, yet some evidence suggests their relationship may be bidirectional; identifying and supporting women with depressive symptoms in pregnancy or breastfeeding problems in early postnatal period is conducive to improving breastfeeding outcomes and maternal mood. 

根據最新的研究結果，母乳餵哺與產後抑鬱之間的關係尚不明確，但兩者或互相影響；及早識別和支援在妊娠期有抑鬱症狀或在產後早期有母乳餵哺問題的婦女，有助促進母乳餵哺和產婦情緒健康。

• Associated with their postnatal mood issues, mothers tend to over-focus on the negatives, may appear non-attentive or even resistant to health advices, and struggle to attune to their babies.

有產後情緒問題的媽媽傾向聚焦於負面事物和經歷，可能會顯得不專心，甚至會對健康建議顯得抗拒，也難於敏銳地回應孩子。

• When supporting mothers with mood issues to breastfeed, healthcare professionals should pay attention to the above features and communicate with them more tactfully.

為有情緒問題的媽媽提供母乳餵哺支援時，醫護人員應留意她們上述特質並有技巧地與她們溝通。

For the note of References, please refer to the PDF version.

Views expressed in this article are the author's and do not necessarily reflect the opinion or position of the BFHIHKA.

作者在本文章表達的見解，未必代表愛嬰醫院香港協會的意見或立場。

Editor-in-Chief: Dr Shirley Leung

All rights reserved by Baby Friendly Hospital Initiative Hong Kong Association.

愛嬰醫院香港協會，版權所有。