Obstetrics & Gynecology:
August 2011 - Volume 118 - Issue 2, Part 1- pp 214-221
Early Breastfeeding Experiences and Postpartum
W atkins, Stephanie MSPH, MSPT; Meltzer-Brody, Samantha MD,
MPH; Zolnoun, Denniz MD, MPH; Stuebe, Alison MD, MSc
From Gillings School of Global Public Health and the Departments of Psychiatry and
Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill,
Corresponding author: Stephanie Watkins, MSPH, MSPT, UNC School of Global Public
Health, Department of Epidemiology, 2101McGavran-Greenberg Hall CB#7435, Chapel
Hill, NC 27599-7435; e-mail: email@example.com.
Financial Disclosure The authors did not report any potential conflicts of interest.
BACKGROUND: The first weeks after childbirth are a critical period for mother and
newborn. Women may present with lactation failure and postpartum depression. It is
unclear how a woman's early breastfeeding experiences relate topostpartum depression.
OBJ ECTIVE: We estimated the association between early breastfeeding experiences and
postpartum depression at 2 months.
METHODS: We modeled this association with logistic regression in a secondary analysis
of data from the Infant Feeding Practices Study II. We assessed postpartum depression
status with the Edinburgh Postnatal Depression Scale.
RESULTS: In the neonatal period, 2,586 women reported ever breastfeeding, among
whom 223 (8.6%) met criteria for major depression (Edinburgh Postnatal Depression
Scale 13 or greater) at 2 months postpartum. Women who disliked breastfeeding in the
first week were more likely to experience postpartum depression at 2 months (odds
ratio [OR] 1.42, 95% confidence interval [CI] 1.04–1.93) adjusting for maternal age,
parity, education, ethnicity, and postnatal WIC participation. Women with severe
breastfeeding pain in the first day (adjusted OR 1.96, 95% CI 1.17–3.29), the first week
(adjusted OR 2.13, 95% CI 0.74–6.15 compared with no pain), and the second week
(adjusted OR 2.24, 95% CI 1.18–4.26 compared with no pain) were more likely to be
depressed. Breastfeeding help appeared protective among women with moderate
(adjusted OR 0.22, 95% CI 0.05–0.94) or severe (adjusted OR 0.17, 95% CI 0.04–0.75)
pain with nursing.
CONCLUSION: Women with negative early breastfeeding experiences were more likely
tohave depressive symptoms at 2 months postpartum. Women with breastfeeding
difficulties should be screened for depressive symptoms.
LEVEL OF EVIDENCE: II
For infant feeding, breastfeeding is the physiologic norm. Infants who are not breastfed are
more likely to develop otitis media and nonspecific gastroenteritis. Among mothers, not
breastfeeding is associated with an increased risk of type 2 diabetes mellitus and breast and
ovarian cancer.1Based on these data, all major medical organizations recommend 6 months of
exclusive breastfeeding followed by continued breastfeeding for at least 1 year.2–4However,
although 75% of women in the United States now initiate breastfeeding, continuation rates at
6 and 12 months drop dramatically (43% and 23%, respectively). These rates fall far short of
the Healthy People 2020 goals of 61% at 6 months and 34% at 1 year.5,6
A history of short breastfeeding or not breastfeeding is associated with postpartum
depression.1This condition affects approximately 7–15% of women in the first 3 months after
birth and may result in maternal anxiety, depressed mood, poor concentration, and
hyperawareness of pain. These psychologic impairments may create difficulties with mother-
child bonding,7,8and they may alsoaffect breastfeeding.9–14The underlying neuroendocrine
mechanism linking breastfeeding difficulties with maternal mood has not been studied.
However, neurotransmitters in the brain are thought to contribute to both pain and
depression. Thus, stress or pain, which may be associated with breastfeeding, may result in a
decrease in serotonin levels with resultant anxiety and depression.15Early identification of
at-risk women is important to both decrease the negative sequelae of postpartum depression
and, potentially, to increase breastfeeding success.
No studies have evaluated the role of specific neonatal breastfeeding experiences and
postpartum depression.9We therefore estimated the association between early breastfeeding
experiences and postpartum depression in a longitudinal sample of women who initiated
breastfeeding. We hypothesized that negative early breastfeeding experiences are associated
with postpartum depression.
MAT ERIALS AND MET HODS
This study used data from the Infant Feeding and Practices Study II, a publically available
longitudinal data set sponsored by the Centers for Disease Control and Prevention, designed
to understand infant feeding patterns, infant health, mother's health, and mother's diet.
Approximately 4,902 women in the Infant Feeding and Practices Study II were recruited
between May 2005 and J une 2007 and followed from the seventh month of pregnancy
through the child's first year of life. Participants were identified from a nationally
representative consumer panel of more than 500,000 households in the United States.16
Compared with a nationally representative sample, participants in the Infant Feeding and
Practices Study II were more likely to be white, middle class, and employed women. Details
of the study design have been published elsewhere.16
From participating mothers in the Infant Feeding and Practices Study II cohort, we identified
women who initiated breastfeeding after delivery. To participate in the Infant Feeding and
Practices Study II, women had to be healthy and had given birth to either a full-term or
nearly full-term healthy neonate weighing at least 5 pounds at birth. The parent study
collected information on infant feeding and health, breastfeeding cessation, infant formula,
sleeping arrangements, child care, employment, and health over the child's first year of life.
With the exception of a telephone interview that was conducted at the time of the neonate's
birth, all data were collected by mailed self-report questionnaires. Questionnaires were sent
toparticipating mothers approximately 3 weeks postpartum, monthly between 2 months and
7 months postpartum, and then every 7 weeks between 7 and 12 months postpartum.
The original cohort included 4,902 healthy pregnant women whoagreed to participate in the
study. Three thousand four hundred fifty-two women delivered a singleton full term or
nearly full-term live birth of at least 5 pounds and met inclusion criteria for the study. Among
these women, 87.6% (n=3,033) completed the 2-month postnatal questionnaire. Maternal
mood was assessed on the 2-month questionnaire. Of the 3,033 women who completed the
neonatal questionnaire, 2,552 qualified and responded. Women in this sample had a higher
level of education, were older, were more likely to be employed, were more likely to be white,
and were less likely to smoke compared with a nationally representative sample from the
National Survey of Family Growth (1998–2000). Our cohort included 2,586 women who
initiated breastfeeding and completed the neonatal questionnaire.
Early breastfeeding experiences were obtained from a neonatal questionnaire completed by
the mother approximately 3 weeks after birth. We assessed several types of early
breastfeeding experiences among women who initiated breastfeeding after delivery, including
the level of pain involved with breastfeeding, the mother's overall feelings about
breastfeeding, the amount of breastfeeding support received, and the amount of time it took
for a mother's breast milk to come in after delivery. Women were asked how they felt about
breastfeeding during the first week after birth on a 5-point Likert scale ranging from
“disliked very much” to “liked very much.” This variable was coded as a dichotomous
variable with a Likert score of 1–3 indicating “disliked breastfeeding” and a Likert score of 4–
5 indicating “liked breastfeeding.” Women alsoreported their level of pain with breastfeeding
the first day, the first week, and the second week after delivery on a 10-point Likert scale.
Pain with breastfeeding was modeled as a four-level categorical variable: no pain, mild pain
(Likert level 1–2), moderate pain (Likert level 3–4), and severe pain (Likert level 5–10).
This variable was not coded using quartiles because the distribution of the variable was
strongly right-skewed. We also assessed whether women received help or advice with
breastfeeding while in the hospital or information about breastfeeding support groups and
services before a mother was discharged. Information on time until a mother's milk came in
was alsoascertained from the neonatal questionnaire.
The 2-month Infant Feeding and Practices Study II questionnaire included the Edinburgh
Postnatal Depression Scale. This screening tool is a 10-item instrument than can be
administered in 5 minutes and is widely used in the mental health profession. The instrument
was validated by Cox and colleagues in 1987.17A cut point of 9–10 was recommended as a
threshold for mild depression, and a score of 12–13 was recommended as a cut point for
major depression.18The sensitivity and specificity of the instrument as a screening tool for
major depression has been reported as 75% and 84%, respectively, for a cutoff score of 13.18
For this analysis, we categorized women with an Edinburgh Postnatal Depression Scale score
of 13 or greater as having major depression. Women with a score below 13 were considered
not tobe depressed.
Baseline covariate information was collected from the demographic questionnaire that was
administered to the national opinion panel from which the sample was drawn. If the mother
was not the panelist in the national opinion panel survey, a separate questionnaire was sent
to the mother to collect the demographic information. The following covariates were
considered in this analysis: household size modeled as a categorical variable (categories),
marital status (categories), race and ethnicity (categories), maternal age modeled as a
categorical variable (categories), parity (categories), education (categories), employment
status (categories), maternal occupation (categories), and postnatal WIC participation. All
sociodemographic covariates were ascertained from the national opinion panel data with the
exception of educational level and marital status, which were ascertained from the prenatal
We described the frequency distribution of all covariates by depression status. We modeled
the association between early breastfeeding experiences and postpartum depression as a
complete case analysis using logistic regression in SAS 9.1. Separate logistic models were
generated for each type of breastfeeding experience including pain with breastfeeding, time
until a woman's milk came in, breastfeeding support, and general feelings with breastfeeding.
We generated odds ratios (ORs) and 95% confidence intervals (CIs) for both crude and
multivariable adjusted models. We evaluated the assumption of linearity imposed by the logit
model by plotting the log odds of postpartum depression by levels of our ordinal variables. All
ordinal variables displayed a linear relationship. The following covariates were considered to
affect both a mother's early breastfeeding experiences and the risk of developing postpartum
depression: maternal age, parity, education, ethnicity, and postnatal WIC participation. These
covariates were included as confounders in the multivariable logistic regression models.
We also used multiple imputation to evaluate the sensitivity of the estimates obtained from
the complete case analysis. Data were imputed in SAS 9.1 using proc IVeware across five
imputations. Effect estimates across the five imputations were averaged and standard errors
were calculated accountingfor both within-imputation and between-imputation
Todetermine whether parity, feelings about breastfeeding, or breast pain modified the effect
of breastfeeding support on postpartum depression, we tested for interactions using a cross-
RESUL T S
Our cohort included 2,586 women who completed the 2-month Edinburgh Postnatal
Depression Scale and reported ever trying to breastfeed their infant in the hospital or birth
center or after the mother and child returned home. The mean age of women was 28.8 years.
Women in the cohort were predominantly white (83.5%) and married (80.2%) (Table 1). Two
months after delivery, 74.3% of women with available breastfeeding data (n=2,185)
continued to breastfeed.
Based on a positive Edinburgh Postnatal Depression Scale screen at 2 months, two hundred
twenty-three (8.62%) mothers who initiated breastfeeding met criteria for postpartum
depression. Women with postpartum depression were more likely to participate in postnatal
WIC (postpartum depression: 44.4% compared with no postpartum depression: 35.3%) and
were twice as likely to have less than a high school education (postpartum depression: 4.5%
compared with no postpartum depression: 2.0%) (Table 1). The mean age of the mother
when her child was born was similar between depressed and nondepressed women
(postpartum depression: 28.0 years compared with no postpartum depression: 29.1years).
At 2 months postpartum, mothers with postpartum depression were less likely to still be
breastfeeding (68.6%) compared with mothers without (74.9%) depressive symptoms
In multivariable logistic regression analyses, we found that negative early breastfeeding
experiences were associated with depressive symptoms at 2 months postpartum. Severe
breastfeeding pain in the neonatal period was associated with a twofold increase in odds of
postpartum depression. Specifically the odds of postpartum depression at 2 months among
women who reported severe pain with breastfeeding on day 1 was 1.96 (95% CI 1.17–3.29)
times that of women who reported no pain with breastfeeding on day 1. We similarly found an
increased odds (OR 2.24, 95% CI 1.18–4.26) of postpartum depression among women with
severe breast pain 2 weeks after delivery (Table 2). Thus, on average, 13.87 and 14.57
additional postpartum women would have to experience severe breastfeeding pain on day 1
and week 1, respectively, for one additional mother to experience postpartum depression at
two months.21Women who experienced moderate pain with breastfeeding were 22–85%
more likely to experience postpartum depression 2 months after delivery; however, these
effect estimates were not statistically significant at conventional levels (P=.05). Effect
estimates approximating the crude association between breastfeeding pain and the odds of
postpartum depression 2 weeks after delivery were similar tothe adjusted estimates.
A mother's feelings about breastfeeding in the first week after birth were alsoassociated with
increased odds of postpartum depression at 2 months. Women who disliked breastfeeding
were 1.42 (95% CI 1.04–1.93) times as likely to have postpartum depression 2 months after
delivery compared with women who reported “liking breastfeeding.” On average, 32.04
mothers would have to dislike breastfeeding for one additional postpartum woman to
experience postpartum depression. There was no association between timing of when a
mother's milk came in and odds of postpartum depression. Receiving information regarding
breastfeeding support groups at hospital discharge showed a small (OR 0.87, 95% CI 0.63–
1.20), although a nonsignificant, protective effect (Table 3). Overall, help with breastfeeding
in the hospital was not associated with depressive symptomatology.
The strength of the association between early breastfeeding experience and postpartum
depression was similar in magnitude when comparing the complete case with the multiple
imputation analyses. Both severe pain with breastfeeding and “disliking breastfeeding”
continued to be statistically significant in the imputed analysis.
Breastfeeding support, specifically help with breastfeeding in the hospital, did not appear to
have a beneficial effect among mothers regardless of parity. Moreover, the associations
among feelings about breastfeeding, receipt of support group information, and postpartum
depression at 2 months did not differ significantly by parity (all cross-product P>.15).
However, there was a small but statistically significant protective effect with receiving help
with breastfeeding in the hospital among women with moderate tosevere breast pain during
nursing on day 1 (moderate: OR 0.22, 95% CI 0.05–0.94, P=.04; severe: OR 0.17, 95% CI
0.04–0.75, P=.02). However, the 95% CIs were quite wide. Within the subset of women who
disliked breastfeeding in the neonatal period (n=1,264), breastfeeding help in the hospital was
not significantly associated with postpartum depression at 2 months (OR 0.83, 95% CI 0.49–
In a large sample of U.S. women, we found that negative early breastfeeding experiences
were associated with increased odds of depressive symptoms at 2 months postpartum. These
results suggest that early breastfeeding difficulties may indicate an increased risk for
postpartum depression. Targeting these women for early screening of postpartum depression
may identify women at risk and allow clinicians to reduce the morbidity associated with both
postpartum depression and curtailed breastfeeding.
Our study confirms and extends earlier work evaluating the association between curtailed
breastfeeding and postpartum depression. Specifically, limited breastfeeding duration, low
breastfeeding self-efficacy, and concerns over breastfeeding were associated with depressive
symptomatology.9–12,14In our large sample, women who were depressed were also less
likely to continue breastfeeding at 2 months compared with those women without depressive
symptoms. Moreover, our results support previous work that concerns about breastfeeding
and poor self-efficacy were associated with depressive symptomatology. More specifically,
compared with women with no early neonatal signs of breastfeeding difficulty, we found that
women who had negative feelings about breastfeeding and reported severe pain while
nursing soon after birth were more likely to experience postpartum depression at 2 months.
The receipt of breastfeeding help and information about support groups did not, in general,
offer a protective effect. However, we found that help with breastfeeding in the hospital did
offer a small beneficial effect for those mothers with moderate tosevere pain with nursing.
The mechanisms underlying our results remain to be elucidated. However, previous work
shows that feelings of pain and depression share the same descending pathways in the central
nervous system.15Neurochemical imbalances in key neurotransmitters such as serotonin
may contribute tofeelings of pain as well as depression. Specific to pregnancy, these findings
are consistent with earlier work linking childbirth-associated pain and catastrophizing with
subsequent depressive symptoms.22–24The association between pain and depression is
complex and may be mediated, in part, by differences in central nociception pathways. Such
differences have been identified in functional magnetic resonance imaging studies of patients
Ifsevere early breastfeeding-associated
catastrophizing, then aberrations in central nociception pathways may lead to both curtailed
breastfeeding and perinatal depression.
pain reflects pain
Our study has several strengths. This is the first study tomeasure the association between a
woman's early breastfeeding experiences and prevalence of postpartum depression 2 months
after delivery. We used data from a prospective cohort in which information on infant feeding
patterns was collected at frequent intervals throughout the child's first year of life. This most
likely limited poor recall of feeding practices that may occur if women are asked detailed
information about infant feeding later in her child's life. The Infant Feeding and Practices
information about infant feeding later in her child's life. The Infant Feeding and Practices
Study II collected extremely detailed information on breastfeeding from the prenatal period
through 12 months postpartum, which is unique to this cohort. In the analysis, we considered
multiple covariates that may confound the association between early breastfeeding
experience and postpartum depression based on the published literature and included these
covariates in our multivariable logistic regression models.
However, these data were also subject to several limitations. Although the data are from a
longitudinal cohort, researchers did not obtain the mother's baseline depression status. Thus,
we were not able toassess the temporality of the relationship. For example, if a mother was
depressed at the time of birth, this may have led to breastfeeding difficulties. Regardless of
the temporality of the events, women who exhibit signs of breastfeeding difficulties should be
screened and offered breastfeeding support. According to the published literature, social and
peer support may have not only positive effects on breastfeeding outcomes, but also
The potential for residual confounding is a second limitation of these data. We included
relevant covariates in our regression models that may confound the relationship between
breastfeeding experiences and postpartum depression. However, there may be residual
confounding of the effect estimates as a result of unmeasured confounding.
Finally, to estimate the association between a woman's early breastfeeding experiences and
odds of postpartum depression, we considered only those observations with complete data.
Women who completed the Edinburgh Postnatal Depression Scale were less likely to
participate in postnatal WIC, to have a larger family size, to have less than a high school
education, tobe single, and tobe African American. However, we examined the sensitivity of
our findings to missing data by using multiple imputation. Effect estimates were of similar
magnitude, and both breast pain and feelings about breastfeeding remained statistically
significant predictors of postpartum depression at 2 months.
In a large sample of U.S. women, we found that negative early breastfeeding experiences
were associated with depressed mood at 2 months postpartum. Our study supports the
findings of Dennis and McQueen in 2007 who found that women with postpartum depression
were more likely to report problems with breastfeeding and to discontinue breastfeeding 4–8
weeks postpartum.28Extreme breast pain during breastfeeding as well as a general dislike of
breastfeeding may identify women whoare more likely to experience postpartum depression.
Our results suggest that women with breastfeeding difficulties should be screened for
postpartum depression, and women with depressive symptoms should be offered
breastfeeding support. Screening and treatment of women with early breastfeeding
difficulties may reduce the severity of postpartum depression and enable women to meet
their breastfeeding goals, thereby improving health outcomes across twogenerations.
1. Ip S, Chung M, Raman G, Trikalinos TA, Lau J . A summary of the Agency for Healthcare
Research and Quality's evidence report on breastfeeding in developed countries. Breastfeed
Med 2009;4(suppl 1):S17–30.
2. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics
3. American College of Obstetricians and Gynecologists (ACOG). Breastfeeding: Maternal and
Infant Aspects. Special report from ACOG. ACOG Clin Rev 2007;12:1–16S.
4. American Academy of Family Physicians. Breastfeeding (position paper); 2001. Available
Retrieved May 10, 2011.
5. Breastfeeding among US children born 1999–2007. CDC national immunization survey.
Atlanta (GA): Centers for Disease Control and Prevention. Available at:
http://www.cdc.gov/breastfeeding/data/NIS_ data/index.htm. Retrieved May 10, 2011.
6. Healthy People 2020. Washington, DC: U.S. Department of Health and Human Services.
Available at: http://www.healthypeople.gov/2020/default.aspx. Retrieved May 10, 2011.
7. Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, et al. Perinatal
depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol
Assess (Summ) 2005:1–8.
8. Meltzer-Brody S, Leserman J . Psychiatric comorbidity in women with chronic pelvic pain.
CNS Spectr 2011;Feb 1:pii: Meltzer-Brody [Epub ahead of print].
9. Dennis CL, McQueen K. The relationship between infant-feeding outcomes and
postpartum depression: a qualitative systematic review. Pediatrics 2009;123:e736–51.
10. Taveras EM, Capra AM, Braveman PA, J ensvold NG, Escobar GJ , Lieu TA. Clinician
support and psychosocial risk factors associated with breastfeeding discontinuation.
11. Papinczak TA, Turner CT. An analysis of personal and social factors influencing initiation
and duration of breastfeeding in a large Queensland maternity hospital. Breastfeed Rev
12. Chaudron LH, Klein MH, Remington P, Palta M, Allen C, Essex MJ . Predictors, prodromes
and incidence of postpartum depression. J Psychosom Obstet Gynaecol 2001;22:103–12.
13. Dennis CL. The breastfeeding self-efficacy scale: psychometric assessment of the short
form. J Obstet Gynecol Neonatal Nurs 2003;32:734–44.
14. Dai X, Dennis CL. Translation and validation of the Breastfeeding Self-Efficacy Scale into
Chinese. J Midwifery Womens Health 2003;48:350–6.
15. Bair MJ , Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a
literature review. Arch Intern Med 2003;163:2433–45.
16. Fein SB, Labiner-Wolfe J , Shealy KR, Li R, Chen J , Grummer-Strawn LM. Infant Feeding
Practices Study II: study methods. Pediatrics 2008;122:S28–35.
17. Cox J L, Holden J M, Sagovsky R. Detection of postnatal depression. Development of the
10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782–6.
18. Cox J L, Chapman G, Murray D, J ones P. Validation of the Edinburgh Postnatal
Depression Scale (EPDS) in non-postnatal women. J Affect Disord 1996;39:185–9.
19. Klebanoff MA, Cole SR. Use of multiple imputation in the epidemiologic literature. Am J
20. He Y. Missing data analysis using multiple imputation: getting to the heart of the matter. Download full-text
Circ Cardiovasc Qual Outcomes 2010;3:98–105.
21. Bender R, Blettner M. Calculating the ‘number needed tobe exposed’ with adjustment for
confounding variables in epidemiological studies. J Clin Epidemiol 2002;55:525–30.
22. Ferber SG, Granot M, Zimmer EZ. Catastrophizing labor pain compromises later
maternity adjustments. Am J Obstet Gynecol 2005;192:826–31.
23. Boudou M, Teissedre F, Walburg V, Chabrol H. Association between the intensity of
childbirth pain and the intensity of postpartum blues [in French]. Encephale 2007;33:805–
24. Flink IK, Mroczek MZ, Sullivan MJ , Linton SJ . Pain in childbirth and postpartum
recovery: the role of catastrophizing. Eur J Pain 2009;13:312–6.
25. Gracely RH, Geisser ME, Giesecke T, Grant MA, Petzke F, Williams DA, et al. Pain
catastrophizing and neural responses to pain among persons with fibromyalgia. Brain
26. Cohen S, Gottlieb B, Underwood L. Social relationships and health. In: Cohen S,
Underwood L, Gottlieb B, editors. Social Support Measurement and Intervention: A Guide
for Health and Social Scientists. Toronto (Ontario): Oxford University Press; 2000.
27. Dennis CL, Hodnett E, Kenton L, Weston J , Zupancic J , Stewart DE, et al. Effect of peer
support on prevention of postnatal depression among high risk women: multisite randomised
controlled trial. BMJ 2009;338:a3064.
28. Dennis CL, McQueen K. Does maternal postpartum depressive symptomatology influence
infant feeding outcomes? Acta Paediatr 2007;96:590–4.
Figure. Nocaption available.
© 2011 The American College of Obstetricians and Gynecologists