The postpartum period is one of the most physically, mentally, and emotionally challenging times of a woman's life. There has been a dramatic rise in the number of mothers diagnosed with perinatal mental health problems in the U.S. in recent years. Postpartum mental health disorders include depression, anxiety, post-traumatic stress disorder, and psychosis. Up to 20% of all women develop depression or anxiety in the year after giving birth, and symptoms usually emerge in the first 4-6 weeks after delivery.
The relationship between breastfeeding and postpartum mental health is complicated. Breastfeeding that goes smoothly and without significant problems has a positive effect on mothers' mental health and well-being. These effects on maternal wellness are hormonally driven. Oxytocin, one of the main breastfeeding hormones, counteracts cortisol, lowers the stress response, and promotes mother-baby bonding. This leads to a decrease in anxiety, lower blood pressure, and relaxation. Prolactin, the other hormone involved in making breast milk, induces sleep (in both mothers and babies) and fosters mothering instincts. Oxytocin and prolactin also decrease depression-induced inflammation. Thus, breastfeeding not only helps prevent the emergence of mental health problems, but it can also ameliorate symptoms of depression and anxiety after they develop.
On the flip side, breastfeeding problems, including pain while nursing, sleep deprivation, and lactation failure, can be a trigger for mental health problems during the postpartum period. According to a recent study, women who experience persistent pain while breastfeeding are two times as likely to develop postpartum depression (PPD) than women who do not feel pain. Common causes of pain while breastfeeding include a shallow latch, tongue tie, skin abrasions, and infection. Hence, it is important that mothers who feel pain while breastfeeding get help from a lactation consultant as soon as possible.
Postpartum mental health disorders can also be exacerbated by sleep deprivation. Lack of sleep is a universal problem for new moms, but it can be especially problematic for those who are experiencing challenges with breastfeeding. Mothers who experience a low milk supply, are exclusively pumping, feeding multiples, and/or trying to establish a milk supply via pumping for a premature baby are at risk for significant sleep disruption and should be closely monitored for PPD. Per the Academy of Breastfeeding Medicine (ABM):
The demands of nighttime breastfeeding can be challenging for mothers for whom interruption of sleep is a major trigger for mood symptoms. In these cases, it may be helpful to arrange for another caregiver to feed the infant once at night, allowing the mother to receive 5–6 hours of uninterrupted sleep. A caregiver may also bring the infant to the mother to feed at the breast and then assume responsibility for settling the baby back to sleep, thereby minimizing maternal sleep disruption.
Breastfeeding problems and lactation failure can trigger PPD if mothers feel significant inadequacy and shame.
Mothers who are unable to breastfeed and/or experience problems with feeding may blame themselves and feel like they are "bad" mothers if breastfeeding does not go as planned.
It's important that mothers' feelings and emotions in these settings get addressed and that a priority is placed on helping new moms to enjoy their newborns.
These sentiments are mirrored in a recent publication by the ABM:
Breastfeeding difficulties and perinatal depression symptoms often present together, and management of depression should include a discussion of the mother's experience of breastfeeding. Some mothers with depression find that breastfeeding enhances bonding and improves their mood, whereas others find breastfeeding to be difficult. For dyads struggling with milk production and latch issues, efforts should be undertaken to simplify feeding plans to ensure that mother and infant have time to enjoy one another.
Mothers who are being treated for depression and anxiety are often concerned about taking prescription medications while breastfeeding. Fortunately, all of the commonly prescribed medications for anxiety and depression are safe for mothers to take while nursing. The first line medications for PPD are called selective serotonin reuptake inhibitors (SSRIs), of which sertraline (Zoloft) is the first line. Other commonly prescribed SSRIs are Prozac (fluoxetine) and Celexa (citalopram). Two excellent and easily accessible resources about the safety of medications while breastfeeding are the Infant Risk Center and the Drugs and Lactation Database (LactMed via the National Library of Medicine). Both of these resources can also be downloaded as apps for use on phones and tablets as well.
It's not unusual for new moms who are experiencing mental health symptoms to get conflicting advice. Some moms are counseled to continue to breastfeed around the clock, others are advised to breastfeed during the day and formula feed at night, and others are told to immediately stop breastfeeding and switch to formula. As mentioned earlier, breastfeeding can help to both prevent and treat depression by releasing hormones that decrease inflammation and promote relaxation and mother-infant bonding. It's important for new moms with PPD and anxiety to continue to breastfeed if they desire, but to know that they are "good" mothers no matter what feeding choice they ultimately make.
Self-care is essential for mothers struggling with postpartum mental health issues. This may include enlisting help at night to get extra pockets of sleep, reaching out to friends and family for help with cooking, cleaning, and housework, or making time to exercise. The majority of mothers who experience perinatal mood disorders go on to have successful breastfeeding relationships with their babies.
The keys to successful breastfeeding in the setting of a postpartum mental disorder is to reframe goals and expectations; to recognize that breastfeeding is not an "all or nothing" process; and to focus on self-care, rest, nourishment, and enlisting help. It's important to remember that adequate support during the "fourth trimester" is the key to preventing the development of both breastfeeding problems and mental health problems.
Brown, A., Rance, J., Bennett, J. Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. J Adv Nurs. 2016. 72(2): 273–282.
WRITTEN BYDr. Jessica Madden