Shiri, a 34-year-old first time mom in Westchester, NY, had always planned to breastfeed. Not only because it was the healthiest choice for her baby, but also because she liked that she would lose those extra pounds faster and save money on formula. But Shiri's plan fell through soon after delivery when her daughter had trouble sucking and getting enough milk. Breastfeeding also caused her excruciating nipple pain.
"I felt like everybody else got to hold her and enjoy her, but I had to suffer through this one thing," Shiri says about her now 22-month-old daughter. Shiri (who asked that we not use her last name) spent three months breastfeeding and pumping before she accepted that she was not making enough milk and trying to only made her feel worse. She switched to formula.
Shiri is hardly alone in her decision to stop breastfeeding sooner than she had originally planned. Although 80 percent of pregnant women in the United States intend to breastfeed, only about 40 percent continue as long as they intended, according to the American Academy of Pediatrics. Some of the main reasons for stopping early are a poor latch or ineffective suck reflex. Other reasons include nipple pain and concerns about not making enough milk.
A recent study published in the Maternal and Child Health Journal suggests that women with unmet expectations about breastfeeding may be at higher risk for postpartum depression (PPD).
Researchers in the UK and Spain followed nearly 14,000 pregnant women in the Bristol area of England. They asked women in their third trimester if they planned to breastfeed, and then followed up in the postpartum period about whether and how much they had been breastfeeding. The researchers also assessed the women's risk of depression during pregnancy and after giving birth.
The researchers found that 65 percent of the women in the study planned to breastfeed for at least the first four weeks after giving birth. However, only 80 percent of those women actually started breastfeeding, and 56 percent breastfed for the entire four weeks. Just 43 percent breastfed exclusively for those first four weeks.
Although researchers found that the risk of PPD was highest among the women who did not breastfeed, the increase was affected by whether the women had planned to breastfeed. Four weeks after giving birth, the women who were not breastfeeding despite wanting to during pregnancy had a fourfold increase in PPD risk compared with breastfeeding women. Mothers who were not breastfeeding but who had never planned to had double the risk of the breastfeeding women.
"Breastfeeding is good for so many things and that's not new [information],” says Maria Iacovou, PhD, a sociologist at the University of Cambridge in England and an author of the current study. But according to Iacovou, what is new – and urgent from a public health perspective – is the finding that there is increased PPD risk among women who plan to breastfeed and then are not able to. "Health providers really need to think about ways of supporting these women and helping them," she says.
Does breastfeeding reduce PPD risk?
Several studies have suggested that breastfeeding could help protect women against PPD. Breastfeeding has been associated with getting more sleep – possibly because it is faster than preparing a bottle in the middle of the night – and having lower levels of stress hormones during anxiety-provoking situations, both of which could improve mood and reduce the risk of depressive symptoms.
Kathleen Kendall-Tackett, PhD, a clinical associate professor of pediatrics at Texas Tech University School of Medicine and international board certified lactation consultant, researches the connection between breastfeeding and PPD. She thinks that women who do not breastfeed could miss out on these stress and sleep benefits. Some research, including Kendall-Tackett's, suggests that women may have to breastfeed exclusively, not combine it with formula feeding, to gain these benefits.
This new study suggests that women who wanted to breastfeed and did not may be in the most vulnerable position, possibly because they feel disappointment and guilt in addition to not getting the physiological benefits of breastfeeding.
Other experts claim that women stop breastfeeding because they have PPD, not the other way around. A 2007 study done in Canada found that women who were at risk of PPD one week after giving birth were more likely to be disappointed in how breastfeeding was going. They were also more likely to stop breastfeeding by two months after giving birth. On the other hand, women who had difficulty breastfeeding, but who were not experiencing depressive symptoms one week after giving birth, were not at higher risk of developing PPD over the subsequent two months.
Cindy-Lee Dennis, PhD, a professor of nursing and medicine at the University of Toronto, and an author of the 2007 study, says their findings suggest that depressive symptoms can bring on breastfeeding difficulties. "Postpartum depression can distort the way a mom feels about childcare [and] make her feel like the baby is not settled or gaining enough weight," she says. Dennis recommends doctors screen women who are having a lot of trouble breastfeeding for depressive symptoms.
The importance of breastfeeding education and support
Even if difficulty with breastfeeding does not increase the risk of PPD, experts agree that it is still important to support women in their breastfeeding goals. "If moms who are depressed fail at breastfeeding, that is another strike against their perceptions of being a good mom," Dennis says.
Before they give birth, "women should find out about the resources in their communities," says Kendall-Tackett. New mothers can get tips from prenatal classes and from lactation consultants, which many hospitals offer before discharge. Insurance companies also sometimes reimburse for home visits from lactation consultants.
And it can help to find a hospital or birth setting that supports breastfeeding initiatives right after delivery, such as encouraging mothers and their babies to stay in the same room, says Diana Cassar-Uhl, MPH, an international board certified lactation consultant based in Hudson Valley, NY.
Breastfeeding support resources
La Leche League International is a nonprofit organization that runs group meetings across the country to help women breastfeed.
Baby Café is another nonprofit organization that offers drop-in centers to help moms in certain areas of the United States.
MOBI: Motherhood International has online support groups.
The Women, Infants, and Children (WIC) Program also provides breastfeeding help to women who are below a certain income threshold.
The importance of supporting all mothers
Shiri wishes she had known that breastfeeding does not always come automatically and adjustments can be made to make it easier and more comfortable. But after she was having difficulty breastfeeding, the idea of going to a lactation support group was too intimidating. "I was worried it would be all women who were breastfeeding, and maybe having some trouble but not to the extent that I was," she says.
There are support groups for mothers that do not pass judgment based on infant feeding choice, says Cassar-Uhl. The Fearless Formula Feeder group on Facebook shares information, articles, and events for both formula and breastfeeding parents. (Fearless Formula Feeder is run by Suzanne Barston, who writes for Seleni.org.) Support for Bottle Feeding Mothers is another Facebook group that supports women who are either unable or choose not to breastfeed was created by a woman who was unable to breastfeed for medical reasons.
"I think it would help a lot of women who have trouble breastfeeding if formula didn't have such a bad rap," Shiri says. At story time at her local library, she felt self-conscious when all the other mothers were breastfeeding, and she was bottle-feeding. "I felt like there was a stigma around formula, and I might as well be giving her Coke in her bottle," Shiri says.
Kendall-Tackett urges people not to question or admonish women who are bottle-feeding. "We jump in and judge and assume, and we don't know," she says. "Keep your unsolicited advice to yourself. We have to respect the choice not to breastfeed," says Kendall-Tackett.