The Advantages and Disadvantages of Breastfeeding for Maternal Mental and Physical Health

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"This chapter presents the state of the evidence concerning the advantages and disadvantages of breastfeeding for mothers."
C17 10/25/2012 15:39:45 Page 414
Breastfeeding and Maternal Mental and
Physical Health
Expectant mothers are inundated with
information about the benets of breastfeed-
ing for their babies but are often poorly
informed about the consequences breast-
feeding has for their own mental and physi-
cal health. Women know about the
potential benets of breastfeeding for the
babys immune function and intellect
(Kramer et al., 2001; Kramer et al., 2008),
but mothers could also be asking themselves:
What about me? A deep desire to breastfeed
an infant is not shared by every mother. In
fact, even before the advent of bottles and
formula, many afuent women avoided
breastfeeding altogether by paying poorer
women to do it for them in an arrangement
called wet-nursing. As the anthologist Sarah
Hrdy (1992) noted, during the heyday of
wet-nursing at the end of the 18th century
. . . up to ninety percent of infants born in
urban centers such as Paris and Lyon were
nursed by women other than their biological
mother(p. 415).
Today, the World Health Organization
(2009) recommends exclusive breastfeeding
for the rst 6 months postpartum and the use
of breast milk as a supplementary form of
feeding for up to 2 years in order to confer
optimal health benets to the mother and
child. Despite these guidelines, recent esti-
mates are that while 70% of mothers initiate
breastfeeding after the birth of their child,
only 13.5% of infants in the United States are
exclusively breastfed for 6 months (Centers
for Disease Control and Prevention, 2011a).
Deciding how an infant will be fed is a
complex decision involving various social,
psychological, emotional, and environmen-
tal factors (Arora, McJunkin, Wehrer, &
Kuhn, 2000). In order of importance, the
top ve reasons women give for deciding to
breastfeed are (1) its benets for the infants
health, (2) that it is natural,(3) to
strengthen bonding with their infant,
(4) convenience, and (5) benets for their
own health (Arora et al., 2000). By contrast,
the top ve factors that discourage breast-
feeding are (1) opposition by the babys
father, (2) concerns that the baby is not
getting enough milk, (3) the need to return
to work, (4) discomfort while breastfeeding,
and (5) the misconception that breastfeeding
will adversely change the appearance of the
breasts (Arora et al., 2000). Given the level of
commitment that breastfeeding requires,
and the number of factors that mothers
take into account when making this com-
plex decision, it is important for mothers to
C17 10/25/2012 15:39:45 Page 415
have good information about what breast-
feeding can and cannot offer them in return.
This chapter presents the state of the
evidence concerning the advantages and
disadvantages of breastfeeding for mothers.
Questions addressed include: Does breast-
feeding really help mothers bond with their
infants? Are there health benets of breast-
feeding for mothers? Will breastfeeding
change the appearance of the breasts? We
use the term breastfeeding to refer to any
amount of breastfeeding, whether it is the
infants sole nutritional source or only a
supplemental form of feeding. We use exclu-
sive breastfeeding, by contrast, to refer to when
infants are only given breast milk and are not
given any other liquid, solid, or vitamins
(Labbok and Krasovec, 1990). This chapter
starts with an overview of the biology of
breastfeeding, which forms the basis of many
of the consequences of breastfeeding
The core of the chapter summarizes the
evidence suggesting that breastfeeding aids
mothers in weight loss and reduces their risk
for ovarian and breast cancers, along with a
discussion of the inuence of breastfeeding
on maternal stress, postpartum depression,
and maternal bonding. We approach many
of these topics using the lenses of anthropol-
ogy and comparative research, highlighting
the ways that breastfeeding mothers are
sometimes very similar and sometimes
very different from their mammalian coun-
terparts. The chapter also presents informa-
tion on the physical, economic, and social
costs associated with breastfeeding for moth-
ers. Finally, we conclude by discussing
options women have in navigating the
mineelds associated with choosing an infant
feeding method.
Background on the biology of breastfeeding
is important for understanding how breast-
feeding can have a widespread impact on
maternal psychology and health. Here, we
present a brief overview. For a more detailed
account of the biological underpinnings of
breastfeeding, see Riordan (2005).
The two most important hormones
associated with lactation are oxytocin and
prolactin (see Riordan, 2005). Oxytocin,
named after the Greek word for speedy
birth,acts in the body as a smooth muscle
contractor, facilitating contractions during
labor and the release of milk during lacta-
tion. Prolactin is the primary hormone
responsible for milk production. Prolactin
levels increase slowly during pregnancy,
triggering changes in the breast tissue that
stimulate milk production. Oxytocin also
increases during pregnancy, although more
rapidly, quadrupling in volume to stimulate
labor (Riordan, 2005). Before a breastfeed-
ing session begins, the mothers body releases
oxytocin into the blood stream to aid in milk
ejection (White-Traut et al., 2009). Mothers
separated from their infants before a feeding
session do not show this prefeeding oxytocin
release; therefore, it appears that infant cues
drive this effect (McNeilly, Robinson,
Houston, & Howie, 1983). During the feed-
ing session, when tactile stimulation is
received from the nipple, oxytocin and
prolactin are released in pulsating patterns,
controlled by nerve bers linked to the
hypothalamus (Gimpl & Fahrenholz,
The majority of studies on the impacts of breastfeed-
ing have been conducted in the United States; for this
reason, studies discussed in this review were U.S.-
based unless otherwise noted.
Breastfeeding and Maternal Mental and Physical Health 415
C17 10/25/2012 15:39:45 Page 416
2001). Prolactin levels are generally height-
ened in women who are breastfeeding as
compared to women who are not breast-
feeding, although prolactin levels are pro-
portionate to breastfeeding frequency and
the infants milk demands (Battin, Marrs,
Fleiss, & Mishell, 1985).
Estrogen and progesterone are also sup-
pressed during lactation, resulting in a period
of postpartum infertility, called lactational
amenorrhea. This natural form of birth con-
trol remains 98% effective throughout the
rst 6 months of exclusive breastfeeding, as
long as breast milk is given to the child from
the breast at least every 4 hours during the
day and every 6 hours during the night
(Peterson et al., 2000; Valdes, Labbok, Pugin,
& Perez, 2000). Lactational amenorrhea
becomes a less effective form of contracep-
tion (94.6%) if mothers use a breast pump or
are separated from their infant for long peri-
ods (Valdes et al., 2000). This amenorrheic
state has been observed to last years in
malnourished populations seemingly because
of elevated levels of prolactin (Lunn, Austin,
Prentice, & Whitehead, 1984).
Until recently, scientists thought that
the functions of oxytocin and prolactin
were limited to birth and lactation, but
they now recognize the impact these hor-
mones have on psychological states. Oxyto-
cin and prolactin circulate in the brain and
act on their own receptors distributed widely
across different brain regions (Freeman,
Kanyicska, Lerant, & Nagy, 2000; Gimpl
& Fahrenholz, 2001). Animal research has
implicated oxytocin and prolactin in critical
maternal behaviors such as grooming, pro-
tection, and sensitivity to infant cues
(Freeman et al., 2000; Gimpl & Fahrenholz,
2001). As we discuss later, studies in humans
have revealed that breastfeeding mothers
experience lower levels of stress and negative
mood than do mothers who do not breast-
feed, perhaps aiding in the transition to
A large research literature suggests that
women who breastfeed experience an array
of health benets (Bernier, Plu-Bureau,
Bossard, Ayzac, & Thalabard, 2000; Rea,
2004). In the short term, breastfeeding helps
mothers lose weight gained during preg-
nancy (Garza & Rasmussen, 2000; Kramer
& Kakuma, 2004) and helps the uterus
contract after pregnancy (Negishi et al.,
1999). Over the long term, breastfeeding
is associated with reduced risk of reproduc-
tive cancers (Bernier et al., 2000), metabolic
syndrome (Ford, Giles, & Dietz, 2002;
Kramer & Kakuma, 2004), type 2 diabetes
(Stuebe & Rich-Edwards, 2009), and
cardiovascular disease (Schwarz et al.,
2009). The literature linking breastfeeding
to improved health has been reviewed else-
where (Bernier et al., 2000; Rea, 2004).
Here, we provide a general overview.
Weight Loss and Metabolic Syndrome
Breastfeeding is calorically costly and is
therefore associated with weight loss after
pregnancy. Human mothers devote an esti-
mated 525 to 625 calories per day producing
the 750 mL of milk infants require daily over
the rst year of life (Garza & Ramussen,
2000). A caloric shortfall is experienced in
most breastfeeding women, who often do
not report more hunger than nonbreastfeed-
ing women (Heck & de Castro, 1993).
In a study that followed more than
20,000 Danish women from pregnancy to
C17 10/25/2012 15:39:45 Page 417
18 months postpartum, women who exclu-
sively breastfed for the recommended
6 months after birth lost an additional
2 kgs (4.4 pounds) of pregnancy-related
weight by 6 months postpartum than
women who breastfed for shorter durations
(Baker et al., 2008). In line with this result, a
systematic review of 20 studies showed that
exclusive feeding with breast milk for the
rst 6 months postpartum predicts signi-
cantly greater postpregnancy weight loss
than with mixed forms of breastfeeding
(breastfeeding while introducing other foods
or liquids) (Kramer & Kakuma, 2004).
Studies have also shown that women
with a history of breastfeeding have a
reduced risk of developing metabolic syn-
drome, a combination of medical disorders,
such as obesity, insulin resistance, and high
blood pressure, which increases the risk of
cardiovascular disease and diabetes (Ford et
al., 2002). A cross-sectional analysis of 2,516
midlife women found a 20% reduction in
the risk of developing metabolic syndrome
for every additional year of breastfeeding
women reported (Ram et al., 2008). The
authors noted that, although weight loss
associated with breastfeeding accounted for
a signicant portion of the reduced risk in
their sample, breastfeeding was associated
with reductions in metabolic syndrome
risk above and beyond weight loss, even
when health behaviors and sociodemo-
graphic variables were statistically con-
trolled. These additional benets could
owe to the observation that breastfeeding
primes the body to become more metaboli-
cally efcient. This idea, dubbed the reset
hypothesis,proposes that breastfeeding
reverses gestational increases in fat accumu-
lation, insulin resistance, and lipid and
tryglicerin levels more quickly and com-
pletely (Stuebe & Rich-Edwards, 2009).
According to the hypothesis, the reset pro-
cess causes long-term positive impacts
on womens health, reducing the risk for
metabolic syndrome, and, consequently,
reducing the risk of type 2 diabetes and
cardiovascular disease.
New research indicates that breastfeed-
ing may reduce the risk of developing both
type 2 diabetes and cardiovascular disease.
For example, Schwarz and colleagues (2009)
found that among 139,681 postmenopausal
women, those who reported a lifetime his-
tory of breastfeeding of more than 1 year
were less likely to develop postmenopausal
diabetes, hypertension, and cardiovascular
disease than women who never breastfed.
Likewise, another large study found that
women who breastfed over their lifetime
for 2 years or more were 23% less likely to
develop coronary heart disease than women
who never breastfed, even after controlling
for parental history, early adult adiposity, and
various lifestyle factors (Stuebe et al., 2009).
Interestingly, some evidence suggests that
longer durations of breastfeeding the same
child, rather than total time spent breastfeed-
ing over ones lifetime, has the greatest pro-
tective benet against coronary heart disease
(Stuebe, Rich-Edwards, Willett, Manson, &
Michels, 2005).
A study that investigated the relationship
between type 2 diabetes and breastfeeding in
two cohorts of more than 70,000 women
found that, although the total lifetime dura-
tion of breastfeeding was associated with
reduced risk of type 2 diabetes, it was longer
durations of breastfeeding involving the
same child, as opposed to the combined
duration of breastfeeding across multiple
children, that conferred the greatest protec-
tive benets (Stuebe et al., 2005). In this
sample, a year of continuously breastfeeding
one child was associated with a 44% decrease
Breastfeeding and Maternal Mental and Physical Health 417
C17 10/25/2012 15:39:45 Page 418
in risk of developing later diabetes, while a
year of breastfeeding spread across two chil-
dren was only associated with a 24%
decrease. Whether this nding can be attrib-
uted to the reset hypothesis is unclear,
although it seems possible that womens
bodies could require more than half a year
of breastfeeding after any given pregnancy to
completely reset metabolic action.
Breast and Ovarian Cancer
Breastfeeding may also protect against breast
and ovarian cancers by suppressing ovula-
tion, and thus limiting lifetime estrogen
exposure (Clemons & Goss, 2001; Key &
Pike, 1988). Theoretically, reductions in
total estrogen exposure may reduce the
risk of breast cancer, because estrogen
increases rates of breast cell proliferation
and differentiation, giving more opportuni-
ties for mutations to occur and, when they
do, fueling cancer growth (Clemons & Goss,
2001; Key & Pike, 1988). In support of this
model, a meta-analysis of 23 case-control
studies found a small protective effect of
breastfeeding on breast cancer: Any lifetime
history of breastfeeding, regardless of dura-
tion, yielded a benet, although this effect
was small compared to other known biolog-
ical risk factors (Bernier et al., 2000). This
effect was strongest in nonmenopausal
women and in women who had breastfed
for longer than 12 months.
Recent research has also begun to
examine the impact of breastfeeding on
women with hereditary predispositions to
develop breast cancers, with mixed results.
Jernstrom and colleagues (2004), for exam-
ple, evaluated the role of breastfeeding in
women who carried the genetic mutations
BRCA1 or BRCA2, which are known to
raise the lifetime risk of breast cancer by
approximately 80% (King, Marks, &
Mandell, 2003). In this study, 685 carriers
were compared to 965 women with no
history of ovarian or breast cancer. They
found that cumulative breastfeeding for
longer than a year reduced the risk of
hereditary breast cancer in women with
the BRCA1 mutation, but not the BRCA2
mutation. By contrast, neither Lee et al.
(2008) nor Andrieu et al. (2006) observed
an association between breastfeeding and
breast-cancer risk in women with BRCA1
or BRCA2.
Studies suggest that the risk of ovarian
cancer is reduced by breastfeeding behaviors
as well. A review by Shoham (1994) revealed
that 6 of 11 studies found that breastfeeding
was related to reduced risk of ovarian cancer.
More recently, researchers analyzed 391
cases of epithelial ovarian cancer among
149,693 women in the NursesHealth Study
(Danforth et al., 2007). They found that for
each month of additional breastfeeding, the
risk of epithelial ovarian cancer was reduced
by 2%. Another study documented a similar
1.4% reduction in ovarian cancer risk for
every additional month of breastfeeding
(Jordan, Siskind, Green, Whiteman, &
Webb, 2010), although the reduction in
risk did not continue to accrue beyond
the rst 12 months. Breastfeeding has
been found not only to reduce the risk of
developing ovarian cancer, but also to
improve the chances of surviving in women
who do develop it. One study found that
women diagnosed with ovarian cancer lived
longer if they had ever breastfed than if they
had never breastfed (Nagle, Bain, Green, &
Webb, 2008). In this same study, there was
no relationship between duration or fre-
quency of breastfeeding and improved ovar-
ian cancer outcomes.
C17 10/25/2012 15:39:45 Page 419
Evidence continues to accumulate dem-
onstrating an association between breast-
feeding and reduced risk of ovarian and
breast cancers, diabetes, and cardiovascular
disease. Breastfeeding is a biologically com-
plex phenomenon, involving changes in hor-
mone levels that act on receptors throughout
the brain and the body. Although the links to
maternal health arenot yet fully known,these
hormone dynamics may exert long-term
impacts on womens health. Reductions in
diseases related to metabolic syndrome
may owe, in part, to weight loss and
improved metabolic function associated
with breastfeeding. Breastfeeding also reduces
lifetime estrogen exposure, potentially
accounting for reduced risk of reproductive
cancers among women with a history breast-
feeding. Some studies nd dose-response
relationships between increased total dura-
tion of lifetime breastfeeding and better
health outcomes.
Stress Regulation
Being a new parent is as stressful as it is
rewarding. Sources of maternal stressors
range from worries about being a good
mother (Mercer, 1986) to physical stressors,
such as sleep deprivation, body changes, and
sexual dysfunction (Gjerdingen, Froberg,
Chaloner, & McGovern, 1993). New moth-
ers struggle to nd time for their baby while
trying to meet the needs of partners, other
children, and themselves (Gruis, 1977). The
vigilance required to be a good parent is also
a stressor for new mothers (Hahn-Holbrook,
Holbrook, & Haselton, 2011). Given all the
stressful demands and challenges parenthood
brings, it is perhaps unsurprising that approx-
imately one in ve women self-report depres-
sive symptoms within the rst year after birth
(Gavin et al., 2005). However, nature may
also have provided mothers with a stress-
buffer: breastfeeding (Carter & Altemus,
1997; Groer, Davis, & Hemphill, 2002).
Only recently have scientists begun to
recognize the ways that lactation alters a
mothers stress responses (Groer et al.,
2002; Lonstein, 2007; Mezzacappa, 2004).
The earliest studies done on rodents revealed
that lactating dams were remarkably resistant
to stress. Lactating rodents exposed to stress-
ors, such as electric shocks, erce predators,
or complex mazes, displayed fewer hormo-
nal and cardiovascular signs of anxiety than
their nonlactating female counterparts (see
Neumann, 2001, for a review).
Corresponding research in humans has
shown a similar association between breast-
feeding and reduced stress. The rst study
conducted in humans showed that breast-
feeding women had signicantly lower hor-
monal stress responses (as evidence by lower
cortisol and ACTH) during exercise stress
than nonbreastfeeding mothers or women
without children (Altemus, Deuster, Gal-
liven, Carter, & Gold, 1995). Several fol-
low-up studies have since examined
womens cardiovascular and hormonal stress
responses to the classic Treir Social Stress
Task, which involves giving a public speech
and doing difcult mental arithmetic in front
of a critical audience. Although these studies
tend not to nd evidence of lower stress
reactivity using hormonal markers of stress,
such as cortisol, they consistently nd that
breastfeeding women have lower cardiovas-
cular markers of stress than do formula-
feeding women.
For example, one study detected lower
cardiovascular markers of stress (as evidence
Breastfeeding and Maternal Mental and Physical Health 419
C17 10/25/2012 15:39:45 Page 420
by lower basal systolic blood pressures,
higher levels of cardiac parasympathetic con-
trol, and modulation of heart rate reactivity)
during the task in breastfeeders compared
with nonbreastfeeding mothers and women
without children (Altemus et al., 2001).
Another study found similar cardiovascular
patterns for breastfeeding mothers during
the anticipation of the public-speaking
stressor (Light et al., 2000). It is possible
that any stress-buffering effects of breastfeed-
ing are more potent directly after the act.
Mothers randomly assigned to breastfeed
before this public-speaking stressor have
blunted cortisol responses when compared
to breastfeeding women who were
instructed to hold their infants (Heinrichs
et al., 2001).
The stress-reducing effects of breast-
feeding may extend to other stressors as
well. Mezzacappa, Kelsey, and Katkin
(2005), for example, compared the cardio-
vascular responses to difcult mental arith-
metic (verbal serial subtractions) and
immersion of ones hand into ice water in
four groups of womenthose exclusively
breastfeeding, exclusively formula-feeding,
mixed feeding (breast and formula), and
women without children. In response to
the challenging mental arithmetic, mothers
who breastfed exclusively displayed attenu-
ated heart-rate reactivity and shortened pre-
ejection period (PEP; an indicator of the
reduced cardiac stress related to the sympa-
thetic nervous system) compared to all other
groups. Moreover, this study found a dose-
response relationship between breastfeeding
frequency and stress reduction. Women
who breastfed more times per day had lower
heart rates in reaction to doing the difcult
mental arithmetic and reduced sympathetic
reactivity to the cold water task than women
who breastfed less frequently. In this study,
the stress buffering effects of breastfeeding
appeared to fade as children grew older.
Breastfeeding mothers with very young
infants derived greater stress-buffering
from breastfeeding than women who had
1-year-old children.
Preliminary research suggests links
between breastfeeding and reduced stress
in womens daily lives outside of the labora-
tory. Breastfeeding mothers are more likely
to report positive mood states, less anxiety,
and increased calm as compared to formula-
feeding mothers (Altshuler, Hendrick, &
Cohen, 2000; Carter & Altemus, 1997;
Fleming, Ruble, Flett, & Van Wagner,
1990; Ford et al., 2002; Heinrichs et al.,
2001). These differences between breast-
feeding and formula-feeding mothers
remain after controls for possible confounds,
including maternal age, work status, income,
and health behaviors (Mezzacappa, Gueth-
lein, & Katkin, 2002; Mezzacappa, Gueth-
lein, Vaz, & Bagiella, 2000; Mezzacappa &
Katlin, 2002).
While studies in rodents indicate that
the stress reduction associated with lactation
is mediated by the hormones oxytocin
(Neumann, Torner, & Wigger, 2000;
Windle, Shanks, Lightman, & Ingram,
1997) and prolactin (Bole-Feysot, Gofn,
Edery, Binart, & Kelly, 1998; Freeman
et al., 2000), data in humans are more
limited. We do know that women with
higher plasma oxytocin and prolactin in
the early postpartum period report less anxi-
ety than do women with lower levels of
these hormones (Nissen, Gustavsson, Wid-
strom, & Uvnas-Moberg, 1998; Uvnas-
Moberg, Widstrom, Werner, Matthiesen,
& Winberg, 1990). Furthermore, breast-
feeding women who release more oxytocin
during infant suckling have lower levels of
cortisol than women who release less
C17 10/25/2012 15:39:46 Page 421
oxytocin during infant feedings (Chiodera et
al., 1991). In addition, breastfeeding women
with higher oxytocin show reduced markers
of stress while preparing for a public-speak-
ing stressor relative to those with lower
oxytocin (Light et al., 2000).
Research in humans and other species
has shown that physiological responses to
stressors are reduced among lactating relative
to nonlactating females. In studies with
human mothers, the stress-buffering effects
of breastfeeding appear to be stronger in the
early postpartum period and soon after a
feeding session. Cardiovascular measures of
stress, which tap into sympathetic and para-
sympathetic nervous system activity, are
more likely to reveal differences in stress
reactivity between breast- and formula-
feeding women than hypothalamic-pitui-
tary-adrenal (HPA) axis hormones like cor-
tisol. Breastfeeding mothers also report less
perceived stress in their daily lives than
formula-feeding mothers. The stress-buffer-
ing effect of lactation appears to result from
the hormones oxytocin and prolactin in
nonhumans, although direct evidence in
humans in lacking. Collectively, nonhuman
and human evidence strongly suggests that
breastfeeding is an important regulator of
maternal stress in the postpartum period.
Postpartum Depression
Although the birth of a child typically con-
jures images of joy and fulllment, many
women experience feelings of hopelessness
and despair instead. Postpartum depression is
a devastating mental illness affecting approx-
imately 13% of women worldwide within
the rst 12 weeks after giving birth (OHara
& Swain, 1996), and roughly one in ve
women within the rst postpartum year
(Gaynes et al., 2005). Postpartum depression
is distinct from other postpartum mood dis-
orders like the common and transient post-
partum blues,which affects 50% to 80% of
mothers worldwide (Pitt, 1973; Yalom,
Lunde, Moos, & Hamburg, 1968), or the
very serious, although rare, occurrence of
postpartum psychosis (Herzog & Detre,
1976). The effects of postpartum depression
are insidious because they can disrupt
parenting behaviors (Field, 2010), resulting
in long-term negative consequences on the
cognitive, emotional, and behavioral devel-
opment of children (Grace, Evindar, &
Stewart, 2003). Because of the serious nega-
tive consequences of this disorder, there has
been much research identifying predictors of
postpartum depression.
A recent systematic review identied 12
studies that reported that breastfeeding
women had lower rates of postpartum
depression in comparison to formula-feed-
ing women (Dennis & McQueen, 2009).
However, there is an important question
that few studies explicitly address: Does
less breastfeeding lead to more depression,
or does more depression lead to less breast-
feeding? The vast majority of research on
this topic to date has focused solely on the
ways that depression can lead to less
It is easy to imagine why depression
might interfere with breastfeeding. Symp-
toms of depression commonly include
decreased motivation, increased anxiety,
and, for new mothers, avoidance of the
infant (Beck, 1992). Breastfeeding is an inti-
mate behavior demanding sustained periods
of direct motherinfant contact, which
many depressed mothers may nd difcult.
Formula-feeding then might seem the more
attractive option for depressed mothers,
because it can be performed by other care-
givers. Furthermore, anxiety associated with
Breastfeeding and Maternal Mental and Physical Health 421
C17 10/25/2012 15:39:46 Page 422
depression can interfere with the maternal
milk supply (Riordan, 2005), leading depre-
ssed mothers to feel that they have insufcient
milk and need to switch to formula to ensure
that their infant receives adequate nutrition.
Finally, many antidepressant medications are
not recommendedfor breastfeeding mothers,
because the active ingredients can be trans-
ferred to the baby through breast milk and
could have adverse impacts on infant devel-
opment (Riordan, 2005). It is not surprising,
then, that studies nd depressed mother are
less likely to breastfeed.
Depressed mothers commonly report
more difculties with breastfeeding (Edh-
borg, Friberg, Lundh, & Widstrom, 2005;
Tamminen, 1988), lower levels of breast-
feeding self-efcacy (Dai & Dennis, 2003),
and more failed breastfeeding attempts
(Fergerson, Jamieson, & Lindsay, 2002).
One study found that depressive symptoms
seven weeks after delivery predicted higher
rates of weaning by 24 weeks postpartum
(Galler et al., 1999). Similarly, another study
found that women who were depressed at
2 weeks postpartum were more likely to
wean before 2 months postpartum than
women who were not depressed at 2 weeks
postpartum (Taveras et al., 2003).
Researchers have found that women who
experience depression in pregnancy are less
likely to initiate breastfeeding (Seimyr,
Edhborg, Lundh, & Sjogren, 2004). These
studies show that decreased breastfeeding
behavior follows depression during preg-
nancy and in the early postpartum period.
However, the existence of this relationship
does not preclude the possibility that breast-
feeding may also exert protective effects
against postpartum depressive symptoms.
There are reasons to think that breast-
feeding could protect mothers against
depression. The act of breastfeeding releases
oxytocin, which has been found in lower
levels in depressed mothers than in nonde-
pressed mothers (Skrundz, Bolten, Nast,
Hellhammer, & Meinlschmidt, 2011).
Women currently using both breastfeeding
and formula-feeding methods report lower
levels of negative mood if they are randomly
assigned to breastfeed their infant in the
laboratory than if they are randomly assigned
to formula-feed (Mezzacappa & Katlin,
2002), perhaps from the oxytocin released
by breastfeeding. Breastfeeding is also asso-
ciated with reduced stress (Mezzacappa,
2004), and because stress is one of the stron-
gest risk factors in the development of
depression (Hammen, 2005), breastfeeding
could buffer women against depression.
Breastfed infants tend to have easier temper-
aments (Jones, McFall, & Diego, 2004) and
fewer health problems over the long term
(Ip et al., 2007), which could also have
positive downstream consequences for
maternal mental health. Taken together,
these ndings suggest that breastfeeding
could confer protective benets against
Very few studies have investigated the
possibility that breastfeeding might be pro-
tective against postpartum depression. Two
studies found that never having breastfed
versus having breastfed was associated with
subsequent postpartum depression (Chau-
dron et al., 2001; Hannah, Adams, Lee,
Glover, & Sandler, 1992), and one study
found that discontinuing breastfeeding ver-
sus continuing to breastfeed was also associ-
ated with subsequent depression (Nishioka
et al., 2011). Critically, however, none of
these studies controlled for baseline levels of
depression during pregnancy, leaving open
the possibility that women who engaged in
breastfeeding were simply less depressed
from the outset.
C17 10/25/2012 15:39:46 Page 423
Only one published study was identied
that explicitly set out to test the hypothesis
that breastfeeding is protective against the
development of postpartum depression
(Dennis & McQueen, 2007). This study
found that women who exclusively
breastfed at one week postpartum were
equivalently likely to become depressed at
4 or 8 weeks postpartum as women who
exclusively formula-fed (Dennis &
McQueen, 2007), suggesting that there is
no protective benet of exclusive breast-
feeding at one week against the develop-
ment of depressive symptoms at 4 and 8
weeks postpartum. Importantly, however,
this study may have been limited in its ability
to detect the mental health benets of
breastfeeding, because the mothers in the
sample had only been breastfeeding for a
very short time. Furthermore, the time
frame within which depression was assessed
(between 1 and 8 weeks postpartum) may
have been too narrow to detect the down-
stream effects of breastfeeding on depression.
Breastfeeding is clearly related to post-
partum depression; however, the nature of
that relationship remains somewhat unclear.
On the one hand, much research has shown
that depression predicts lower rates of breast-
feeding initiation and shorter durations of
breastfeeding. These effects likely result
from the increased problems depressed
women encounter while breastfeeding.
On the other hand, very little research has
assessed the possibility that breastfeeding
might also be protective against postpartum
depression. Given the theoretical reasons to
think that breastfeeding might be protective
against depression, further research using
longitudinal or experimental designs is
clearly needed before conclusions can be
drawn about whether the relationship
between depression and breastfeeding is
bidirectional (depression leading to less
breastfeeding and less breastfeeding leading
to depression) or simply unidirectional
(depression leading to less breastfeeding).
Maternal Bonding
Conventional wisdom holds that breastfeed-
ing helps mothers bond with their babies. In
fact, one of the most common reasons given
by women for wanting to breastfeed is the
opportunity to bond with their children
(Arora et al., 2000). In the scientic literature
as well, breastfeeding is often assumed to aid
in maternalinfant attachment, without nec-
essarily giving reference to direct evidence
(for examples, see Jansen, Weerth, &
Riksen-Walraven, 2008). Given this, it is
surprising that only a few studies have actu-
ally tested this hypothesis in humans, and
even fewer have found signicant results.
Here, we review the small literature on the
impact of breastfeeding on the motherchild
bond (for a more in-depth review, see Jansen
et al., 2008). Although the motherinfant
relationship is bidirectionalin that the
mother can bond with the infant and the
infant can bond with the motherour pri-
mary focus is maternal bonding. Briey,
however, we found no studies with evi-
dence that breastfed infants are more
securely attached to their mothers than for-
mula-fed infants (see Jansen et al., 2008, for a
review). Like the data linking lactation and
stress, most of what we have learned about
breastfeeding and bonding comes from ani-
mal studies.
Lactation is critical for inciting maternal
behaviors in many mammalian species,
because it releases the hormones oxytocin
and prolactin, which facilitate maternal
behavior (see Kendrick, 2000, for a review).
For example, female rats will suddenly
Breastfeeding and Maternal Mental and Physical Health 423
C17 10/25/2012 15:39:46 Page 424
display maternal behaviors if oxytocin
(Pedersen, Caldwell, Peterson, Walker, &
Mason, 1992) or prolactin (Bridges, DiBiase,
Loundes, & Doherty, 1985) is injected into
their brains. If a chemical that blocks the
actions of oxytocin or prolactin is injected
into the brain of a rat shortly after birth, a
rodents mothering behavior is signicantly
impaired (Bridges, Rigero, Byrnes, Yang, &
Walker, 2001; van Leengoed, Kerker, &
Swanson, 1987). In nonhuman primates,
however, hormonal changes linked to lacta-
tion play a smaller role in the onset of
maternal behaviors, with early learning
and social experience making up the differ-
ence (Pedersen, 2004). For example, admin-
istration of an oxytocin antagonist into the
brain of a female rhesus monkey reduces
certain caregiving behaviors, while leaving
others fully intact (Boccia, Goursaud,
Bachevalier, Anderson, & Pedersen, 2007).
Years of observations by primatologists also
tell us that maternal behaviors routinely
emerge in female primates without the
inuence of lactation. For example, female
primates who do not have offspring of their
own often seek out caregiving opportuni-
ties, such as carrying and grooming infants
(Hrdy, 1999).
Breastfeeding is certainly not necessary
for parental bonding to occur in humans, as
adoptive mothers, formula-feeding mothers,
and fathers can attest. However, might
breastfeeding give mothers, especially if
they are reluctant or are experiencing moth-
ering challenges, extra incentives to care for
their infant?
Recent studies in humans suggest that
oxytocin is important for maternal bonding.
For instance, plasma oxytocin levels during
pregnancy and the postpartum period pre-
dict more maternal bonding behaviors, such
as eye gaze, vocalizations, positive affect, and
affectionate touch, and more attachment-
related thoughts (Feldman, Weller,
Zagoory-Sharon, & Levine, 2007). Also,
mothers who provide high levels of affec-
tionate touch during a play session with their
children have higher levels of oxytocin after
the encounter than mothers who provide
low levels of affectionate touch (Feldman,
Gordon, Schneiderman, Weisman, &
Zagoory-Sharon, 2010). Given this evi-
dence, one might predict breastfeeding,
which gives women extra bursts of oxytocin,
would lead to greater levels of maternal
Three out of four studies investigating
whether breastfeeding promotes maternal
bonding have found supportive evidence
(see Martone & Nash, 1988, for the null
result). In the largest study on the topic,
motherinfant interactions were observed
at 4 and 12 months postpartum in women
who had either breastfed for at least a week
(n¼439) versus women who had not initi-
ated breastfeeding (n¼94) (Else-Quest,
Hyde, & Clark, 2003). The researchers
found that mothers who had breastfed for
at least 1 week showed higher-quality inter-
actions with their babies at 12 months, but
not at 4 months postpartum. In another
study of 405 women, mothers who were
supplying over half of their infants diet
though breastfeeding at 5 months postpar-
tum reported that they were more emotion-
ally bonded to their infant at that time than
women who were supplying less than half of
their infants diet through breast milk or
were not breastfeeding at all (Nishioka
et al., 2011).
Similarly, Britton, Britton, and Gron-
waldt (2006) found that mothers who were
breastfeeding at 3 months reported that they
felt they were more sensitive to their childs
needs than women who were not currently
C17 10/25/2012 15:39:46 Page 425
breastfeeding. The ndings of the previous
two studies should be interpreted with cau-
tion, however, because maternal behavior
was not rated by objective observers. In fact,
Britton, Britton, and Gronwaldt (2006)
found women who intended to breastfeed
in pregnancy also reported higher sensitivity
toward their infants at 3 months, suggesting
that women who choose to breastfeed may
just be more sensitive (or report being more
sensitive) from the outset. In fact, other
studies suggest that the quality of the mater-
nalinfant bond predicts a mothers willing-
ness to breastfeed. A study found that better
bonding behavior 48 hours after birth pre-
dicted higher rates of exclusive breastfeeding
at 6 months in a sample of more than 500
women (Cernadas, Noceda, Barrera, Marti-
nez, & Garsd, 2003).
At this early stage of the research, it is
too soon to tell whether breastfeeding
increases bonding between mothers and
infants as compared to other forms of feed-
ing. This topic deserves additional research
attention with prospective or experimental
designs and objective measures of bonding,
especially given that many women worry
that not breastfeeding will interfere with
their ability to bond with their babies.
One important observation in the largest
of the studies noted (Else-Quest et al.,
2003) was that women who had never
breastfed at all exhibited maternal sensitivity
well within the normal range dened by
clinicians. Oxytocin could still facilitate
maternal bonding for mothers who do not
breastfeed. For example, direct skin-to-skin
contact with the infant and affectionate
touch likely increases maternal oxytocin
levels (Uvnas-Moberg, 1998). These alter-
native mechanisms may be partly responsible
for bonding in mothers of adopted infants,
fathers, and other caretakers.
Breastfeeding has many possible benets for
mothers, but it can also clash with other
goals for women, such as having a full-time
career. Some of the costs associated with
breastfeeding are probably overstated, like
sagging breasts, whereas others are likely
understated, for example, the social stigma
associated with breastfeeding in some socie-
ties. Breastfeeding can also be problematic
for women with certain physical or health
conditions. Furthermore, many women nd
breastfeeding very difcult because of work
constraints or physical pain. Here, we review
the potential physical, economic, and social
costs associated with breastfeeding for
Physical Costs
Breastfeeding does have some physical costs
for women. Most mothers will have some
nipple discomfort during the rst 10 days of
breastfeeding (Riordan, 2005). If pain is
prolonged, a medical assessment by a lacta-
tion consultant or nurse is usually required to
identify the source of the problem. The most
common causes of severe nipple pain are
nonideal positioning of the infant at the
breast or poor suckling technique on the
part of the infant (Morland-Schultz & Hill,
2005). Both of these can usually be identied
and remedied by a trained lactation consul-
tant or nurse (Riordan, 2005). Severe nipple
pain can sometimes be a sign of a more
serious breastfeeding-related infection.
Common infections include mastitis, a usu-
ally benign infection that is easily treatable
by increasing breast milk expression and
antibiotics, and candidiasis (or thrush), a
yeast infection transferred from the babys
Breastfeeding and Maternal Mental and Physical Health 425
C17 10/25/2012 15:39:46 Page 426
mouth into the nipple that is treatable with
antifungal medications (Riordan, 2005).
Women can reduce their risk for these
and other breastfeeding-related infections
by employing good positioning and latching
techniques, and by massaging their breasts to
facilitate milk ow (Riordan, 2005).
Beyond the potential for discomfort,
breastfeeding restricts the types of medica-
tions a mother can take. A Scandinavian
study found that up to 25% of women
took some form of medication while they
were breastfeeding, and uncertainty regard-
ing the drugs safety was a major reason for
the discontinuation of breastfeeding (Math-
eson, Kristensen, & Lunde, 1990). There are
often alternative forms of a drug within the
same drug class (e.g., antibiotics, selective
serotonin reuptake inhibitors, oral contra-
ceptives) that are safe for breastfeeding
women. For example, a women who
requires medication to treat depression but
who also wants to breastfeed could talk to her
doctor about taking Paxil (paroxetine)
instead of Prozac (uoxetine) or Trilafon
(perphenazine) instead of Nardil (phenel-
zine), both of which are considered safe for
breastfed infants (Riordan, 2005). Mothers
and healthcare professionals can nd advice
about the safety of medications for breast-
feeding mothers online at LactMed (http://
LACT), the U.S. National Library of Medi-
cines drugs and breastfeeding database (U.S.
National Library of Medicine, 2001).
Nutrients to synthesize breast milk are
often mobilized from maternal stores at the
mothers expense (Dewey, 1997). To offset
these costs, the body generally has mecha-
nisms in place that help the mother rebound
from the nutritional stores used during
breastfeeding. For example, by producing
600 to 1,000 mL of breast milk per day, a
mother loses 200 mg of calcium daily (Rea,
2004); however, calcium absorption
becomes more efcient during pregnancy
and after weaning often resulting in net
calcium gains over the long term (Riordan,
2005). However, in women who are mal-
nourished or immunologically compro-
mised, the nutrients required for
breastfeeding can overwhelm the mothers
body and lead to health problems. For
example, a randomized clinical trial found
that breastfeeding among HIV-infected
women increased maternal death by three-
fold at a 2-year follow-up as compared to
formula feeding (Nduati et al., 2001). The
investigators postulated that the nutritional
demands posed by breastfeeding may be too
great for HIV-infected women. With the
exception of malnourished women or
women with HIV, the nutritional costs of
breastfeeding can usually be met by simply
increasing caloric intake of nutrient-rich
foods by 200 to 700 calories per day,
depending on the frequency of breastfeeding
(Riordan, 2005). Mothers are often advised
to take a multivitamin with 100 mg of iron,
along with a calcium and omega-3 fatty
acid supplement, to ensure proper nutrition
for the mother and breastfed infant
(Riordan, 2005).
A common reason that women give for
not breastfeeding is the belief that it will
adversely affect the appearance of the breasts
(Arora et al., 2000). Fathers also commonly
worry that breastfeeding will have these
effects, leading some men to discourage their
partners from breastfeeding (Bar-Yam &
Darby, 1997). These concerns, however,
are not supported by empirical evidence.
For example, a study of 93 women who
were seeking plastic surgery to improve the
shape of their breasts found no signicant
relationship between objective ratings of
C17 10/25/2012 15:39:46 Page 427
breast ptosis (drooping or sagging) and
breastfeeding initiation or duration (Rinker,
Veneracion, & Walsh, 2008). The notion
that breastfeeding makes breasts sag likely
stems from the fact that pregnancy does lead
to changes in breast tissue. This same study
found that number of pregnancies, along
with age, body mass index, larger prepreg-
nancy bra cup size, and smoking history
were positively related to breast ptosis. Sim-
ilarly, a prospective Italian study found that
mothers frequently reported that the size and
the shape of their breasts had changed after
childbirth, but these changes were not dif-
ferent as a function of infant feeding behav-
iors (Pisacane & Continisio, 2004).
Breastfeeding appears to have some clear
physical costs for mothers, although these are
usually transitory, and most can be amelio-
rated by proper breastfeeding techniques and
nutrition during breastfeeding. With the
exception of women with HIV or severely
malnourished women, there is little evi-
dence for any long-term physical costs asso-
ciated with breastfeeding.
Labor and Economic Costs
Breastfeeding can place a burden on wom-
ens time and freedom from childcare
responsibilities. A woman providing breast
milk exclusively to her child has to breast-
feed her child or express milk approximately
8 to 12 times per day during the rst 6
months of exclusive breastfeeding (U.S.
Department of Health and Human Services
Ofce on Womens Health [OWH], 2011).
Each breastfeeding or expression session
takes approximately 15 to 20 minutes,
meaning that women will spend an esti-
mated 2 to 4 hours per day breastfeeding
(OWH, 2011). Actual time spent feeding is
lessened by formula-feeding because the
infant drinks milk from a bottle more
quickly and formula is digested more slowly;
therefore, feedings can be performed faster
and less frequently. In addition, because
feeding responsibilities can be shared by
other caregivers, feeding with formula
may also give the mother more freedom.
The time commitment associated with
breastfeeding can place a burden on women
in the workplace. A breastfeeding mother
needs to allocate approximately 45 to 75
minutes per workday to express breast milk
(Mohler, 2011). In addition, breastfeeding
women need a private place to express milk,
a place to store breast milk, and the ability to
take several breaks per day. It is also possible
that women who need to make these
arrangements are perceived as less serious
about their jobs, or are stigmatized by co-
workers who are uncomfortable with breast-
feeding (Smith, Hawkinson, & Paull, 2011).
Given the burden that pumping breast milk
at work places on women, it is not surprising
that women who return to work within 12
weeks after birth wean sooner than those
who do not return to work within 12 weeks
(Callen & Pinelli, 2004).
In a cross-cultural comparison, the
United States was found to have the lowest
breastfeeding initiation rates compared to
other industrialized nations such as Canada,
Sweden, and Australia (Callen & Pinelli,
2004), a fact that may be related to American
maternity leave policies (Guendelman et al.,
2009). In the United States, the Family and
Medical Leave Act allows mothers only 12
weeks of unpaid maternity leave. Compare
this to Sweden, where parents are entitled to
approximately 16 months of paid leave after
the birth of a child (Galtry, 2003). As a result
of this, approximately one-third of Ameri-
can women return to work within 3 months
of giving birth, as compared to in Sweden,
Breastfeeding and Maternal Mental and Physical Health 427
C17 10/25/2012 15:39:46 Page 428
where only about 5% return to work within
3 months (Klerman & Leibowitz, 1999). It
should not be surprising that breastfeeding
initiation is nearly universal in Sweden (97%
of mothers), with approximately 40% of
infants still breastfeeding exclusively at 6
months (Galtry, 2003). The possible link
between breastfeeding rates and maternity
leave policies highlights the role of structural
factors in shaping infant feeding decisions,
which are normally thought to simply reect
personal choices.
Recently, the U.S. government has
taken steps that might increase rates of
breastfeeding initiation and its duration. In
2010, President Obama signed the Patient
Protection and Affordable Care Act, which
includes a provision requiring employers to
provide a place other than the bathroom and
reasonable break time for female employees
to express breast milk for the rst year after a
childs birth. Some employers are exempted,
however, because they have fewer than 60
employees or because allowing breaks
would cause an unreasonable burden for
the business.
Although breastfeeding does require
substantial time commitments for the
mother, which may reduce the time availa-
ble for work, there may be some economic
benets of breastfeeding. The increased cost
of formula as compared with breastfeeding is
between $1,000 and $4,000 per year per
baby (Mohler, 2011). Additional indirect
cost savings include the possibility that there
will be fewer medical bills related to infant
illness and fewer absences from paid work
time for doctor visits with sick infants (Moh-
ler, 2011). Because there are possible health
benets of breastfeeding, such as reduced
risk of type 2 diabetes in mothers (Stuebe
& Rich-Edwards, 2009) or reduced risk of
gastrointestinal infection in infants (Kramer
et al., 2001), breastfeeding is associated with
reductions in medical costs (Mohler, 2011).
Breastfeeding also does not require environ-
mental waste from formula production and
packaging. Furthermore, breastfeeding
women may save some time that would
otherwise be spent preparing formula and
sterilizing bottles.
Breastfeeding poses signicant burdens
on womens time and freedom during the
postpartum period. Feeding with formula
allows mothers more freedom, because
other caregivers can care for the infant
more readily. Pumping breast milk for feed-
ings when the mother is absent is also not
feasible for many women who do not have
access to adequate support. These costs,
however, may be offset to some extent by
the fact that breastfeeding is less expensive
than formula-feeding, and may lead to con-
siderable reductions in healthcare costs and
time taken from work because of child and
maternal illness over the long term. Future
research might address whether women gain
equivalent health benets from breast
pumping and breastfeeding, given that this
question has important implications for
women who are in the workforce and
need to pump regularly.
Social Costs
Breastfeeding can have some social costs for
women. For example, women often feel
embarrassed about breastfeeding in public,
although it is legal in 45 states in the United
States. A study found that low-income preg-
nant women in Missouri felt that discreetly
breastfeeding in ones home in front of
visitors was acceptable, but that it was less
acceptable to breastfeed in public, especially
if people were embarrassed by it or if the
breastfeeding was not discrete (Libbus &
C17 10/25/2012 15:39:46 Page 429
Kolostov, 1994). Similarly, women often
reported feeling vulnerablewhile breast-
feeding in public and expect to receive
negative attention for it (Sheeshka et al.,
2001). These feelings can lead women to
remain housebound or restrict their move-
ments during exclusive breastfeeding to
avoid the social stigma of breastfeeding in
public (Sheeshka et al., 2001).
In cultures where breastfeeding is widely
accepted, women often have more freedom
to breastfeed in public places. For example,
Dettwyler (1995b) asserts that in places such
as Mali or Nepal, women are able to breast-
feed their infants in public freely and with-
out stigmatization. Dettwyler (1995b) argues
that the sexualization of the breast in many
Western cultures accounts for much of the
taboo surrounding breastfeeding in public,
noting that in Mali and Nepal, where breast-
feeding in public is completely socially
acceptable, breasts do not have the same
sexual connotation for men or women
that they do elsewhere in the world. In
cultures where the primary function of the
breast is thought to be sexual, the sight of a
women breastfeeding is often considered
pervertedor obscene.For example,
the popular social networking website, Face-
book, ofcially banned pictures of women
breastfeeding their infants, claiming that these
photos violated their decency code by show-
ing an exposed breast (Worthman, 2009).
Women who breastfeed in cultures where
breastfeeding is taboo often face continual
pressure from friends and family to use for-
mula, have low breastfeeding condence, feel
intense stigma around breastfeeding in public,
and have very little access to breastfeeding
information outside of medical professionals
(Scott & Mostyn, 2003).
The social acceptability of breastfeeding
varies by culture and ethnicity, which has
implications for breastfeeding rates (see
Kelley, Watt, and Nazoo, 2006, for a
review). Women who immigrate to the
United States from cultures where breast-
feeding is more common have higher rates
of breastfeeding than the U.S. population.
For example, Black women who immigrate
to the United States from West Indian Coun-
tieswhere breastfeeding is the normare
more likely to intend to breastfeed exclu-
sively after birth than are African American
women (Bonuck, Freeman, & Trombley,
2005). Among Puerto Rican women, length
of residence in the continental United States
is inversely associated with breastfeeding ini-
tiation (Perez-Escamilla et al., 1998), indicat-
ing that living in a culture like the United
States where breastfeeding is less common
than in Puerto Rico can alter breastfeeding
There is also variation across cultures in
beliefs about the appropriate age to wean a
child. Women who violate their local norms
can face social stigma. Although the average
duration of breastfeeding in traditional soci-
eties is approximately 2.5 years (Dettwyler,
1995a), many women in the United States
report that they receive negative reactions
from others if they breastfeed past the rst
few months postpartum (Kendall-Tackett &
Sugarman, 1995). In a survey conducted in
the United States, the percentage of mothers
citing social stigmaas a negative aspect of
breastfeeding was strongly related to the age
of the child: 29% of women breastfeeding
past 6 months and 61% of women breast-
feeding past 24 months reported feeling
stigma as a result of breastfeeding
(Kendall-Tackett & Sugarman, 1995).
Recent research also suggests that
breastfeeding women face social stigma in
the United States regardless of where or how
long they choose to feed their infants. In a
Breastfeeding and Maternal Mental and Physical Health 429
C17 10/25/2012 15:39:46 Page 430
series of studies conducted with college
students, breastfeeding mothers were rated
as less competent and less likely to be hired
for a hypothetical job compared to mothers
who were not breastfeeding or women
without children (Smith et al., 2011). In
this research, the negative effects of breast-
feeding were comparable, in terms of the
negative perceptions evoked in the minds of
both male and female students, to a womans
decision to purposefully sexualize her breasts
(Smith et al., 2011). These results suggest
that although breastfeeding may have many
benets for the mother, mothers who choose
to breastfeed may also suffer social costs.
Moving into the private realm, mothers
may also be concerned that breastfeeding
will have negative consequences for their
social relationships. Breastfeeding is an inti-
mate experience between a mother and her
child that can sometimes lead the other
parent to feel left out. Fathers sometimes
report that breastfeeding interrupts their
ability to form a relationship with the new
infant (Bar-Yam & Darby, 1997). Even
when fathers are supportive of their partners
breastfeeding, many also admit to feelings of
jealousy at their inability to contribute dur-
ing the feeding process (Rempel & Rempel,
2011). In-depth interviews with fathers sug-
gest that these feelings can lead fathers to
postpone the forming of a relationship with
the child until after the infant is weaned or to
compensate by becoming more involved in
other aspects of caring for the infant (i.e.,
baths, diapers) (Gamble & Morse, 1993).
Presumably, the feeling of being left out
of the parenting process can also extend to
families in which two women co-parent, but
only one breastfeeds the baby.
Families can sometimes alleviate these
negative feelings in co-parents by framing
breastfeeding as a team effort, discussing with
co-parents the benets of breastfeeding for
their child, involving co-parents in breast-
feeding decisions, and having co-parents
provide instrumental support (like helping
with chores or entertaining company)
(Gamble & Morse, 1993). Additionally,
co-parents may participate in infant feeding
directly if breastfeeding mothers use a breast-
pump to express milk that can be fed to the
infant in a bottle.
Another factor that can lead partners to
have negative attitudes toward breastfeeding
is its impact on womens sexuality (Rempel
& Rempel, 2011). Breastfeeding lowers
womens estrogen levels in the early post-
partum period (Battin et al., 1985), which
can lead to decreases in sexual desire and
cause vaginal dryness for a subset of women,
making sex painful (Brown & McDaniel,
2008). For example, breastfeeding women
report more vaginal pain during intercourse
at 3 months postpartum than formula-feed-
ing women, although there was no differ-
ence at 6 months postpartum (Connolly,
Thorp, & Pahel, 2005). Another study found
that breastfeeding at 3 months (but not 6
months) was related to reduced frequency of
sex, sexual desire, and sexual satisfaction as
compared to women who were not breast-
feeding (Judicibus & McCabe, 2002). Over-
all, women perceive that breastfeeding has a
slightly negative impact on the physiological
aspects of sexuality; however, most report
that it does not greatly affect the sexual
relationship with their partner (Avery,
Duckett, & Frantzich, 2000). In one study,
the majority of women (60.3%) perceived
that the babys father thought breastfeeding
made them neither more nor less sexually
desirable than before pregnancy, while
12.7% thought it made them less sexually
attractive, and 27% thought it made them
more attractive to their partner.
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Although there are social costs associated
with breastfeeding for mothers, there can
also be social costs associated with not breast-
feeding (Hauck & Irurita, 2003). Because of
the widespread beliefs about the positive
effects of breastfeeding on a child, women
sometimes feel extensive social pressure to
breastfeed. Although most mothers (approx-
imately 96%; Simopoulos & Grave, 1984)
are physically capable of breastfeeding, other
barriersjust as realcan make breastfeed-
ing nearly impossible. If women do not have
access to accurate information regarding
proper breastfeeding techniques, they may
not produce enough milk to support the
needs of their infant or may develop physical
problems that make breastfeeding painful.
Furthermore, many mothers must work to
nancially support the needs of their chil-
dren and are not allowed convenient or
exible breaks to breast pump, nor are
they given the space necessary to pump
and store their breast milk.
Whatever the reasons behind the deci-
sion not to breastfeed, many women feel
that this decision will lead to the perception
that they are bad mothers(Ladd-Taylor &
Umansky, 1998). As one mother recounts,
I was feeling very guilty [for stopping
breastfeeding] and I didnt know what to
do(Hauck & Irurita, 2003, p. 70). There
have even been select reports of medical
professionals pushing the breast is best
message, regardless of the mothers circum-
stances and choices, leading some mothers to
report they are breastfeeding just to keep
the nurses happy(Bauer, 2000, p. 15).
These overt instances of pressure from health
professionals are likely extreme, rare exam-
ples. For many years, physicians, breastfeed-
ing consultants, nurses, and clinical experts
have been aware that encouraging mothers
to breastfeed by supporting them is helpful,
but that pressuring them or creating guilt for
lack of success is not (Dillaway & Douma,
2004). Nonetheless, even when healthcare
professionals are sensitive in their approach,
family, friends, and even strangers share their
advice about best practices for breastfeeding
initiation, duration, and weaning. Interviews
with new mothers have revealed that when
the expectations of others do not match the
choices of the mother, mothers can often
feel guilt (Hauck & Irurita, 2003).
Breastfeeding is associated with some
social costs. Mothers can become socially
restricted by breastfeeding because they do
not feel comfortable breastfeeding in public
places. Furthermore, breastfeeding mothers
are stigmatized and perceived as less compe-
tent than nonbreastfeeding mothers, a fact
that could have negative consequences for
women in the workplace or for women who
breastfeed for periods beyond the cultural
norm. Finally, some women nd that breast-
feeding reduces their sex drive for a time or
makes their partners feel left out of the
childcare experience. There are, however,
also social costs associated with not breast-
feeding, such as being branded a bad
motheror being made to feel guilty.
This chapter reviewed the scientic research
on the benets and costs associated with
breastfeeding for mothers. Many studies
point out that breastfeeding is associated
with many health benets for mothers,
including reduced risk for metabolic syn-
drome and certain reproductive cancers.
Furthermore, evidence suggests that breast-
feeding could buffer women against biolog-
ical and psychosocial stressors during the
postpartum period. Little evidence is
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available examining whether breastfeeding
reduces the risk of postpartum depression
or increases maternal bonding to the infant.
More research isneeded in each of these areas.
Although research has often focused on
the benets of breastfeeding for mothers,
there is also evidence of substantial costs
associated with breastfeeding. Mothers
must devote several hours per day to breast-
feeding if it is the sole feeding method, and
some mothers feel conned to their homes
because they are uncomfortable breastfeed-
ing in public. Breastfeeding mothers also
face signicant logistical and professional
challenges in the workplace. Finally, the
majority of women will experience some
discomfort during breastfeeding, particularly
early in the postpartum period, which can
sometimes develop into painful conditions
requiring medical attention.
More studies are needed to evaluate
these many trade-offs in the benets and
costs of breastfeeding at both the population
and individual level. Even if studies demon-
strate that the benets of breastfeeding out-
weigh the costs for women as a group,
decisions for individual mothers need to
be made based on their personal circum-
stances, which will vary in the many com-
plex and multifaceted trade-offs described in
this chapter. Because of the growing evi-
dence of the health benets of breastfeeding
for infants and their mothers, it makes sense
for social policies to attempt to reduce bar-
riers to breastfeeding. Policy makers and
healthcare professionals have made strides
in breastfeeding promotion in recent years
(Centers for Disease Control and Preven-
tion, 2011b). Educating mothers, partners,
families, and communities about the health
benets of breastfeeding, along with how to
overcome the challenges, have proven to be
particularly effective (Centers for Disease
Control and Prevention, 2011b). However,
policy makers and medical professionals
should also realize that variation in mothers
circumstancesboth personal and struc-
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best choice for a particular woman and
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