Antenatal Depressive Symptoms and Breastfeeding: A Prospective Cohort Study

Abstract

Introduction:

Globally many women suffer from depression during pregnancy. This study investigated the impact of antenatal depressive symptoms on the duration of breastfeeding up to 6 months among women in Sabah, Malaysia.

Subjects and Methods:

A prospective cohort study of 2,072 women was conducted in Sabah during 2009–2010. Participants were recruited at 36–38 weeks of gestation and followed up at 1, 3, and 6 months postpartum. Depressive symptoms were assessed using the validated Malay version of the Edinburgh Postnatal Depression Scale (EPDS). Cox regression analyses were performed to determine the relationship between antenatal EPDS scores and cessation of breastfeeding before 6 months postpartum.

Results:

In total, 1,078 (52%) women with complete information on breastfeeding duration were included in the final sample. Approximately 99% of mothers were breastfeeding at discharge, and 87% of them continued to breastfeed at 6 months postpartum. Women with an antenatal EPDS score of 8 or above were twice more likely to stop breastfeeding before 6 months (adjusted hazards ratio=1.95; 95% confidence interval, 1.26, 3.01) than those who scored less than 4 on the EPDS.

Conclusions:

Depressive symptoms during pregnancy appeared to be associated with early breastfeeding cessation for mothers residing in Sabah.

Introduction

Depression has become the leading cause of disease burden for women of reproductive age.^1,2 It is estimated that between 9% and 24% of women worldwide experience a depressive disorder while pregnant.³ When left untreated, antenatal depression may lead to serious consequences for both the mother and the infant. Women struggling with depressive symptoms during pregnancy tend to receive poor prenatal care and have increased incidence of obstetric complications and preterm delivery,^4,5 and their infants may experience impaired physical, social, psychological, and cognitive development.⁶

After birth, breastfeeding plays an important role in preventing mortality and achieving optimal nutrition and health outcomes for the newborn.⁷ Studies from a variety of societies have examined factors that influence mothers at risk of a short breastfeeding duration.^8–10 Only a few have investigated the effects of antenatal depression on breastfeeding practices, but their findings remain inconclusive. For instance, a study of two maternal cohorts in Britain found no association between antenatal depression and early cessation of breastfeeding,¹¹ yet a recent longitudinal study of American primiparous mothers reported that those with fewer depressive symptoms during pregnancy breastfed for a longer period.¹²

In Malaysia, the available data suggested a range of 8.6–30.2% of mothers suffering from antenatal depression.^13–15 According to the most recent nationwide survey, the prevalence of “ever breastfeeding” was 94.7%, and about 37% of children were breastfed for at least 2 years.¹⁶ However, there has been no published report on the relationship between depression during pregnancy and infant feeding practices in Malaysia or South East Asia. The present study thus aimed to determine whether antenatal depressive symptoms could increase the risk of lactation cessation within 6 months postpartum in Sabah, Malaysia.

Subjects and Methods

Study design and participants

A prospective cohort study of maternal depression was undertaken at five maternal and child health clinics in the Kota Kinabalu and Penampang Districts of Sabah, Malaysia, between 2009 and 2010. Sabah, with a population of 3.5 million, is situated on the Island of Borneo in East Malaysia. Estimates from the Department of Statistics Malaysia showed that the Gross Domestic Product per capita in Sabah was 18,603 Ringgit (approximately 5,200 USD) in 2013, well below the national average of 32,984 Ringgit (approximately 9,100 USD).

Pregnant women who attended the clinics for their routine antenatal care at 36–38 weeks were approached and invited to participate in this study. Women were excluded if they had a multiple pregnancy, were illiterate, or were deemed unsuitable as advised by health professionals. A minimum sample size of 570 mothers at 6 months postpartum was required, calculated by assuming a prevalence of any breastfeeding between 82% and 88%.

In total, 2,072 eligible women consented to participate (response rate, 92.2%). They were asked to complete a self-administered questionnaire in a private space. Trained nurses were available for clarification if required. Information collected from the baseline questionnaire included demographic, socioeconomic, and health characteristics, as well as depressive symptoms during pregnancy. Mothers were then followed up at 1, 3, and 6 months postpartum when they returned to the clinics for immunization and routine examination of the infants. Detailed information on infant feeding methods was obtained at each follow-up. The content validity of the questionnaire was verified through a pilot study involving 50 pregnant women from the same catchment area. At the end of 6 months postpartum, 979 participants (47.2%) remained in the cohort.

Measurements

The presence of depressive symptoms was measured using the Edinburgh Postnatal Depression Scale (EPDS), which has been widely used in antenatal and postnatal depression research.¹⁷ The EPDS consists of 10 items rated on a 4-point scale (from 0 to 3). The total score thus ranges from 0 to 30, with higher scores indicating more severe depressive symptoms. The reliability and validity of the Malay version of the EPDS have been verified.¹⁸ In this study, “any breastfeeding” was defined as feeding with breastmilk (direct from the breast or expressed) with or without other drinks, formula, or other infant food.¹⁹

Statistical analysis

Descriptive statistics were first applied to profile the characteristics of participants. In addition to univariate statistics, a full Cox regression analysis was performed to ascertain the effects of antenatal depressive symptoms on discontinuation of “any breastfeeding” before 6 months. The antenatal EPDS score was categorized according to the tertiles of its distribution, with the lowest level being the reference group. Confounding variables considered in the regression model included maternal age (in years), ethnicity (indigenous; nonindigenous), education level (primary; secondary or above), monthly household income (<1,000 Ringgit; ≥1,000 Ringgit), occupation (not employed; employed), method of delivery (vaginal delivery; cesarean section), and the gender of infant. These variables were either established or plausible factors associated with breastfeeding duration from the literature and were applicable to Malaysian women. All analyses were undertaken using SPSS package version 21 software (IBM, Armonk, NY).

Ethical considerations

The study protocol was approved by the Sabah State Health Department and the Human Research Ethics Committee of Curtin University (approval number HR 169/2008). An information letter explaining the project was given to and read to each woman before obtaining her written consent. All participants were assured of confidentiality of the information provided and their right to withdraw at any time without prejudice.

Results

The final sample consisted of 1,078 (52%) participants with complete information on breastfeeding duration. Table 1 summarizes the characteristics of the cohort, whose average age was 27 (standard deviation=5.7) years with a median antenatal EPDS score of 5 (interquartile range=7). More than half of them were Muslim (64.8%) and housewives (72.6%) and came from families with a monthly household income of less than 1,000 Ringgit or 300 USD (68.8%). Nearly 80% of participants were indigenous people comprising all Sabah ethnic minority groups. The remainder were of Indonesian (10.6%), Filipino (4.7%), Chinese (3.5%), Malay (3.2%), or Indian (0.4%) origin. Approximately 53% of the infants were male, and most (87.9%) of the birth weights fell within the normal range. Compared with mothers included in the final sample, the excluded women tended to be employed with a higher household income, but otherwise no differences in maternal age, education level, religion, or ethnicity were apparent between the two groups.

Table 1.

Characteristics of the Participants (n= 1,078)

Variable	n (%)
Ethnicity
Indigenous	836 (77.6%)
Nonindigenous	242 (22.4%)
Religion
Islam	698 (64.8%)
Christian	354 (32.8%)
Buddhist	26 (2.4%)
Maternal education level^a
Primary	362 (34.7%)
Secondary or above	682 (65.3%)
Maternal occupation^a
Not employed	765 (72.6%)
Employed	288 (27.4%)
Monthly household income (Ringgit)^a
<1,000	729 (68.8%)
≥1,000	330 (31.2%)
Method of delivery^a
Vaginal delivery	972 (91.3%)
Cesarean section	93 (8.7%)
Infant's gender^a
Male	571 (53.1%)
Female	505 (46.9%)
Infant's birth weight (g)^a
<2,500	84 (9.0%)
2,500–3,900	823 (87.9%)
≥4,000	29 (3.1%)
Maternal age (years) [mean (SD)]	27.0 (5.7)
Antenatal EPDS score [median (IQR)]	5.0 (7.0)

Some responses were missing these data.

EPDS, Edinburgh Postnatal Depression Scale; IQR, interquartile range; SD, standard deviation.

For our cohort, almost every mother (98.8%) was breastfeeding at discharge, and 86.9% of them continued to breastfeed for at least 6 months. Table 2 shows the association between plausible predictors and “any breastfeeding” duration to 6 months postpartum. According to the univariate analysis, apparent increase in the risk of breastfeeding cessation was observed among mothers with high depression scores. The results of Cox regression analysis confirmed that women who reported an antenatal EPDS score above 7 were twice more likely to discontinue lactation by the end of 6 months after childbirth (adjusted hazards ratio=1.95; 95% confidence interval, 1.26, 3.01), compared with those with an EPDS score of 3 or lower. Maternal education level of secondary school or above (adjusted hazards ratio=1.69; 95% confidence interval, 1.05, 2.70) was also significantly associated with a shorter duration of “any breastfeeding,” whereas the effect of household income appeared to be marginal.

Table 2.

Crude and Adjusted Hazard Ratio (95% Confidence Interval) of Breastfeeding Cessation at 6 Months Postpartum (n=1,078)

		HR (95% CI)
Variable	n (%)	Crude	Adjusted	p
Antenatal EPDS score				0.004
0–3	387 (35.9%)	1.00	1.00
4–7	333 (30.9%)	1.32 (0.83, 2.12)	1.15 (0.71, 1.87)
8–30	358 (33.2%)	2.26 (1.49, 3.43)	1.95 (1.26, 3.01)
Maternal age (years)				0.323
<25	383 (35.5%)	1.00	1.00
≥25	695 (64.5%)	1.40 (0.97, 2.03)	1.22 (0.82, 1.82)
Ethnicity				0.593
Indigenous	836 (77.6%)	1.00	1.00
Nonindigenous	242 (22.4%)	0.99 (0.66, 1.48)	0.89 (0.58, 1.37)
Maternal education level				0.030
Primary	362 (34.7%)	1.00	1.00
Secondary or above	682 (65.3%)	2.07 (1.37, 3.15)	1.69 (1.05, 2.70)
Monthly household income (Ringgit)				0.042
<1,000	729 (68.8%)	1.00	1.00
≥1,000	330 (31.2%)	1.83 (1.30, 2.57)	1.52 (1.02, 2.29)
Maternal occupation				0.867
Not employed	765 (72.6%)	1.00	1.00
Employed	288 (27.4%)	1.58 (1.10, 2.25)	0.97 (0.64, 1.47)
Method of delivery				0.137
Vaginal delivery	972 (91.3%)	1.00	1.00
Cesarean section	93 (8.7%)	1.68 (1.02, 2.76)	1.48 (0.88, 2.48)
Infant's gender				0.397
Male	571 (53.1%)	1.00	1.00
Female	505 (46.9%)	0.85 (0.61, 1.20)	0.86 (0.60, 1.22)

CI, confidence interval; EPDS, Edinburgh Postnatal Depression Scale; HR, hazard ratio.

Discussion

This longitudinal study provides the first report on the effects of antenatal depressive symptoms on breastfeeding duration in Sabah, Malaysia. Our finding that more depressed women stopped breastfeeding earlier is consistent with the Norwegian Mother and Child Cohort Study (n=42,225), which suggested that symptoms of anxiety and depression at 30 weeks of gestation were associated with early cessation of breastfeeding before 6 months postpartum.²⁰ Another study of Canadian women similarly showed that antenatal depression predicted a shorter duration of breastfeeding within 8 months after childbirth.²¹

Although a comprehensive mechanism is lacking on the relationship between breastfeeding outcomes and depression, women suffering from antenatal depression were more likely to report insufficient milk supply,²² a typical reason given by mothers for terminating breastfeeding in different cultures.^23,24 In addition, prenatally depressed mothers, compared with their nondepressed peers, have more intention to formula feed during pregnancy²⁵ and less confidence to breastfeed in the postpartum period,²¹ both of which are linked to a shorter duration of breastfeeding.^26,27

Studies of women in Western countries have reported that being well educated is associated with longer breastfeeding duration.^28,29 This study, however, found that mothers who had completed secondary education or above were more likely to stop breastfeeding before 6 months. The finding is consistent with those in developing countries, where a higher educational level can lead to abandonment of traditional infant feeding practices and therefore less intention to breastfeed.³⁰

The main strength of this study is its prospective design, which minimized the recall errors on infant feeding methods and enabled the evaluation of a cause–effect relationship between antenatal depressive symptoms and breastfeeding outcomes. Nonetheless, several limitations should be considered. First, the results may not be generalized beyond the state of Sabah because of differences in culture among ethnic minority groups. Second, complete information on breastfeeding duration was only available for 52% of the participants recruited at baseline. Nevertheless, the final sample was still sufficient to allow for comparison of antenatal depression scores between breastfeeding groups. Third, similar to other observational studies, self-selection bias could not be avoided. All our participants were recruited from the community clinics at 36–38 weeks of gestation; therefore these local residents should be representative of the population of Sabah pregnant women. Finally, the present prospective cohort study was limited to 6 months postpartum because of resource and budget constraints. Further research with a longer follow-up period is recommended to ascertain the role of maternal mental health on breastfeeding duration.

Conclusions

Antenatal depressive symptoms appear to increase the risk of early breastfeeding cessation. Screening and intervention programs to reduce depression during pregnancy may help to further promote and protect long-term breastfeeding in Sabah, Malaysia.

Footnotes

Acknowledgments

The authors gratefully acknowledge the time and devotion of participants in this study. A.S.M.Y. and L.T. were supported, respectively, by a scholarship from the Ministry of Higher Education Malaysia and by an Endeavour Australia Cheung Kong Research Fellowship.

Disclosure Statement

No competing financial interests exist.

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