Satisfaction with Breastfeeding and Not Frequency of Feeding is Associated with a Reduction of Postpartum Depressive Symptoms

Abstract

Purpose:

Postpartum depression (PPD) resembles a major depression in the postpartum period and affects 10–15% of all women after giving birth. Several studies suggest an association between a lower risk of PPD and breastfeeding. The highly stressful period of the COVID-19 pandemic has led to an increase in the incidence of mental illness in general and PPD in particular. Our aim was to investigate the relationship between breastfeeding behavior and PPD in more detail.

Methods:

In this context, 291 women who gave birth between April 2020 and September 2021 were surveyed up to 6 months postpartum on depressive symptoms, breastfeeding behavior, and anxieties.

Results:

In particular, the fact that the women stated after 6 months that their expectations of breastfeeding had been met appeared to lead to a significantly lower risk of PPD. Therefore, not breastfeeding frequency but satisfaction with breastfeeding behavior was decisive for the risk of PPD development. Significant correlations were found between different anxieties and breastfeeding behavior. Higher anxieties led to a shorter desired time of breastfeeding in months, less frequent breastfeeding per day, and less satisfaction with breastfeeding behavior.

Conclusion:

Our results suggest that improving the breastfeeding experience as well as reducing prepartum anxieties or treating postpartum anxieties could be a primary prevention for PPD.

Introduction

The postpartum period represents a demanding time for numerous women, marked by hormonal fluctuations and challenges of motherhood.¹ Approximately 50–80% of new mothers experience the “baby blues” within the initial hours or days following childbirth.² “Baby blues” is characterized by mild depressive symptoms and mood instability, typically resolving swiftly.^3,4 It is crucial to distinguish this transient condition from postpartum depression (PPD), a more severe depressive disorder affecting 10–15% of postpartum women.⁵ PPD typically emerges within 4 weeks postpartum, with a duration extending up to 12 months, peaking in severity between the second and sixth months after delivery.³ Symptoms of PPD include depressed mood, fatigue, feelings of worthlessness and guilt, and even suicidal thoughts.⁶ A PPD diagnosis requires the presence of at least five symptoms persisting for over 2 weeks.⁵ The treatment approach of PPD is multimodal and includes psychotherapy and antidepressants. Unrecognized or untreated PPD can have profound consequences for mothers and their offspring, with associated difficulties in bonding, behavioral problems, and disruptions in emotional and cognitive development.⁵

Numerous risk constellations for PPD are known, including a history of depression, severe prepartum anxiety, interpersonal conflicts, traumatic birth experiences, inadequate social support, and high self-expectation.^4,7

The role of breastfeeding in the context of PPD remains a subject of debate, but several studies suggest an association between lower PPD risk and breastfeeding. Breastfeeding offers benefits to both mother and child, including a lower risk of cancer and reduced blood pressure. Furthermore, breastfeeding contributes to enhanced mother–child bonding and psychological well-being.^8,9

In recent years, the COVID-19 pandemic has significantly impacted the health experiences leading to increased risk for mental illness with elevated rates of anxiety and depression.^10,11 Women giving birth during COVID-19 showed higher rates of PPD.¹² The experiences during the COVID-19 pandemic highlighted the main problems regarding PPD: the complexity of diagnosis and treatment of the disease.

Therefore, the aim of our study was to analyze the association between PPD and breastfeeding behaviors to eventually find hints toward preventive opportunities.

Methods

Study design

A prospective cohort study was performed by following 291 pregnant women during their perinatal period. Longitudinal analyses were carried out using self-reported questionnaires prepartum, and at 3 days, 1, 2, and 6 months postpartum (Fig. 1). Breastfeeding questionnaires were administered peripartum and at 1, 2, and 6 months postpartum.

FIG. 1.

Graphical representation of all questionnaires at the different survey dates.

Study population

The study was conducted with 291 pregnant women who were under obstetric care at the LMU Perinatal Center Großhadern of the university hospital in Munich between April 2020 and September 2021, thus, during the COVID-19 pandemic.

Due to dropout, 39 women were excluded from the study, leaving a total of 252 women. The demographic and clinical data apart from maternal age (22–38 years; mean 33.97 ± 4.417) are shown in Supplementary Table S1.

All participants gave their written consent for participation and completed the questionnaires in printed form.

Questionnaires

Depressive symptoms

The Edinburgh Postnatal Depression Scale (EPDS) was developed in 1987 as a screening instrument for PPD and translated and adapted to German.^13–15 It consists of 10 items, scored with a 4-point Likert scale (0 to 3). An EPDS value of 10 or higher has a middle (10–12) to high (≥13) probability for depression.¹⁶ Patients were asked to answer how they felt in the last 7 days. The EPDS was queried prepartum, and at 1 (1M), 2 (2M), and 6 months (6M) postpartum.

Berlin Mood Questionnaire

The Berlin Mood Questionnaire (BSF) is a self-reported instrument to assess depressive affects. Unlike the EPDS, the BSF is not specifically designed for the postpartum episode. The BSF consists of 30 items—each scored on a 4-point Likert scale—in the categories “elevated mood,” “engagement,” “anger,” “anxiety,” “fatigue,” and “apathy.”¹⁷ To adapt the BSF to the postpartum situation, the shortened version of the test including 14 items was used.¹⁸

The BSF was queried prepartum, and at 3 days (3D), 1 (1M), 2 (2M), and 6 months (6M) postpartum.

Anxieties

One of the main factors influencing the development of PPD is anxiety. For this reason, we also focused on assessing anxieties using various questionnaires. Because our study took place during the COVID-19 pandemic, the majority of the questions focused on COVID-19-related fears. Even if COVID-19-related fears are currently no longer specifically relevant, most of the surveyed fears can be transferred to the general postpartum period (for example, the fear of an illness of the child or the restriction of leisure activities after childbirth). Because COVID-19 is categorized as a respiratory disease, COVID-19-related fears can be attributed to similar infections such as influenza or the respiratory syncytial virus.

For the statistical analysis, the anxieties were grouped into: general prepartum anxiety (only queried prepartum), anxiety regarding childbirth (queried prepartum, 3 days (3D), and 6 months (6M) postpartum), COVID-19-related anxiety (queried prepartum, 3 days (3D), 1 (1M), 2 (2M), 2–6 (2–6M), and 6 months (6M) postpartum), and anxiety as a category of BSF.

The specific anxieties queried are listed in the Supplementary Data.

Breastfeeding behavior

Regarding the breastfeeding behavior, the desired time to breastfeed in months (desired breastfeeding length) and the frequency of breastfeeding per day (breastfeeding frequency) were assessed. In addition to the desired breastfeeding length, 6 months postpartum, questions regarding the fulfillment of breastfeeding expectations were included.

In further analysis, data were also examined for differences depending on whether expectations of breastfeeding have been fulfilled (satisfied or not satisfied). The demographic data were compared in the two groups satisfied with the breastfeeding experience and not satisfied with the breastfeeding experience, with no significant difference of maternal age (p = 0.321). The chi-squared test was used for the other demographic data showing no significant difference in the distributions of demographic and additional clinical data.

Statistical analysis

Software SPSS Statistics 29 (IBM in New York, USA) was used to perform statistical analyses. Data are presented accordingly as mean (±standard deviation). For statistical examination the Mann–Whitney U test, the Kruskal–Wallis test, and the Friedman’s ANOVA, as well as the chi-squared test for categorical variables, were used. The Spearman Rho correlation was used for correlation analysis. Distribution analysis was Bonferroni-corrected. p Values ≤ 0.05 were rated as statistically significant.

Results

Risk of PPD in respective collective

Mean EPDS values showed an overall decreasing trend over time (Mean_prepartum = 7.59 ± 4.74, Mean_1M = 7.31 ± 4.49, Mean_2M = 7.23 ± 4.95, Mean_6M = 7.03 ± 4.74; p = 0.005; Supplementary Figure S1), with a significant difference between EPDS prepartum and 6 months postpartum (p = 0.011). Using the Friedman’s ANOVA, a significant difference of EPDS values across different time points was observed (p = 0.005).

Similar results emerged regarding the BSF categories (mean values in Supplementary Table S2). The categories “engagement” and “elevated mood” showed a significant positive correlation with time (r_engagement = 0.079, p_engagement = 0.018; r_elevatedmood = 0.197, p_elevatedmood < 0.001), while “engagement” showed no significant differences between the different survey time points (p = 0.052). “Elevated mood” showed significant differences over time (p < 0.001) with significant differences in post-hoc analysis, especially regarding the prepartum values (p_{prepartumvs1M} < 0.001, p_{prepartumvs2M} = 0.001, p_{prepartumvs6M} < 0.001). In addition, the category “anxiety” revealed a significant improvement over time (r = −0.153, p < 0.001) with significant differences between the survey time points (p < 0.001).

Regarding the category “fatigue,” no significant correlations with time but significant differences between the survey time points appeared (p < 0.001) with significant lower values in the later postpartum time (p_3Dvs1M = 0.044, p_3Dvs2M = 0.008, p_3Dvs6M = 0.015).

Interestingly the category “apathy” seems to only change slightly over the postpartum time but without any correlations (p = 0.003), whereas the category “anger” shows a significant increase over time (r = 0.109, p = 0.001) with significant differences over the different survey time points (p = 0.016).

Anxieties in the respective collective over time

The general anxiety regarding childbirth and the BSF category “anxiety” showed similar results. The anxiety regarding childbirth was significantly lower over time (r = −0.103, p = 0.007) with significant differences between the survey time points (Mean_prepartum = 2.50 ± 0.86, Mean_3D = 2.45 ± 1.08, Mean_6M = 2.28 ± 1.04; p = 0.014).

Regarding COVID-19-related anxieties, no clear trend emerged postpartum, but the general COVID-19-related anxiety postpartum was much lower than prepartum (Mean_prepartum = 29.99 ± 7.85, Mean_3D = 16.79 ± 6.26, Mean_1M = 14.02 ± 5.23, Mean_2M = 13.71 ± 5.11, Mean_2-6M = 15.98 ± 4.85, Mean_6M = 18.78 ± 5.24; p < 0.001) with significant differences between all survey time points in the post-hoc analysis.

Breastfeeding behavior

Regarding breastfeeding mode, the questionnaires at the different survey timepoints concentrated on the breastfeeding frequency and the desired breastfeeding length in months. While at 3 days postpartum, 95.6% of all patients breastfed (breastfeeding frequency per day: 8.1 ± 4.21, desired breastfeeding length in months: 7.0 ± 3.56), this proportion decreased to 93.3% at 1 month (breastfeeding frequency per day: 7.9 ± 3.82, desired breastfeeding length in months: 7.3 ± 4.59) and 90.1% at 2 months postpartum (breastfeeding frequency per day: 6.7 ± 4.09, desired breastfeeding length in months: 6.9 ± 5.31). At the endpoint of our study, 6 months postpartum, around 63.1% of all patients were still breastfeeding (desired breastfeeding length in months: 10.8 ± 6.71).

A more detailed examination of the breastfeeding mode (fully, mostly, partially, and not breastfed) was conducted between the 9th and 16th week postpartum (Fig. 2). The categories non breastfed and breastfed (including the subgroups fully, mostly, and partially breastfed) were compared. The proportion of nonbreastfeeding women increased significantly from 9.1% at week 9 postpartum to 15.5% at 16 weeks postpartum (p < 0.001), while breastfeeding remained predominant at week 16 postpartum.

FIG. 2.

Feeding mode in percentage from the 9th to the 16th week postpartum.

Friedman’s ANOVA showed significant differences of desired breastfeeding length between the survey time points (p < 0.001) with higher desired breastfeeding length at 6 months postpartum. This increase of desired breastfeeding length in the postpartum period is also reflected in the significant positive correlation (r = 0.227, p < 0.001).

Moreover, breastfeeding frequency exhibited significant changes over the postpartum period (Friedman’s ANOVA, p < 0.001), with a significant decrease in breastfeeding frequency over time (r = −0.112, p = 0.004).

In addition, the study of breastfeeding behavior showed that 6 months after birth, the breastfeeding experience was in line with expectations (satisfied) in 62.3% of all cases, whereas in 30.2%, expectations were not met (not satisfied).

Breastfeeding habits as a function of breastfeeding-expectations

When comparing patients who fulfilled their breastfeeding expectations with patients who did not, the chi-squared test revealed significant differences in breastfeeding behavior at all time points and in breastfeeding behavior between the 9th and 16th week postpartum (p < 0.001). At all time points of the survey, there were significantly more women who were not breastfeeding when breastfeeding expectations were not met. To examine the connections between breastfeeding behavior and expectations, the data were analyzed using the Mann–Whitney U test. Higher rates of fulfilled breastfeeding expectations showed higher desired breastfeeding length (p_1M < 0.001, p_2M < 0.001, p_6M < 0.001; p_3D = 0.384) and higher breastfeeding frequency (p_3D = 0.003, p_1M < 0.001, p_2M < 0.001).

Breastfeeding behavior over time was then analyzed using the Spearman correlation after the study cohort was divided according to whether breastfeeding expectations were fulfilled or not fulfilled (Fig. 3).

FIG. 3.

Feeding mode between the 9th and 16th weeks postpartum regarding breastfeeding expectations (grey = satisfied, black = not satisfied).

When analyzing the desired breastfeeding length, the group with satisfied breastfeeding expectations showed a significant positive correlation of the desired breastfeeding length and increasing time postpartum (r = 0.366, p < 0.001), whereas the group of not satisfied expectations showed no significant correlation (p = 0.296).

The breastfeeding frequency showed significant negative correlations with time regardless of the breastfeeding expectations (r_satisfied = −0.120, p_satisfied = 0.016; r_{not-satisfied} = −0.193, p_{not-satisfied} = 0.007).

Influence of breastfeeding on the likelihood of PPD

The chi-squared test was used to assess differences in breastfeeding experiences across EPDS categories, showing a significantly lower risk of PPD in the group with satisfied breastfeeding expectations (p_{EPDSprepartum} = 0.416, p_EPDS1M < 0.001, p_EPDS2M = 0.022, p_EPDS6M = 0.009). A more detailed analysis of the EPDS using the Mann–Whitney U test (Fig. 4) showed significantly reduced EPDS values in the same group compared with the group without fulfilled breastfeeding expectations only 1 (p < 0.001) and 2 months after birth (p = 0.025). The significant negative correlation between EPDS values in the whole collective 1 (r = 0.241, p = 0.001) and 2 months (r = 0.148, p = 0.024) after birth and breastfeeding expectations after 6 months, emphasizes the connection between EPDS and breastfeeding expectancy.

FIG. 4.

Boxplots of EPDS values over time, regarding breastfeeding expectations (grey = satisfied, black = not satisfied, circles = mild outliers [>1.5 interquartile range]).

Subsequently, breastfeeding habits in the various EPDS categories were compared using the Kruskal–Wallis test. No significant difference was found in the desired duration or frequency of breastfeeding in the various EPDS categories at any time during the survey (Supplementary Table S3), nor were there any significant correlations between the desired duration or frequency of breastfeeding and the various EPDS categories (Supplementary Table S4).

Considering the probability of PPD in relation to whether the women breastfed or not, the Mann–Whitney U test was used. The results revealed a significant higher EPDS value 1 month postpartum, when women were not breastfeeding peripartum (p = 0.029). Additional analysis of the EPDS over time—using Friedman’s ANOVA—was conducted depending on whether the woman was breastfeeding. The EPDS values over time differed significantly for women breastfeeding at the specific survey timepoints (p_3D = 0.002, p_1M = 0.010, p_2M = 0.011, p_6M = 0.047, p_9th = 0.018, p_10th = 0.034, p_11th = 0.030, p_12th = 0.030, p_13th = 0.047), with decreasing EPDS values over time. However, for women who were not breastfeeding at the respective times, the EPDS value only differed significantly 10 weeks after birth (p = 0.048), with the EPDS value also decreasing over time.

Influence of breastfeeding on symptoms of PPD represented by the BSF

Considering the influence of breastfeeding on the BSF categories, nearly no significant difference was found in the scores depending on whether the child was breastfed or not. The only exceptions were the category “anger” 6 months postpartum regarding breastfeeding 1 month postpartum (p_anger1M = 0.043, Mean_{breastfeeding} = 2.62 ± 1.04, Mean_{notbreastfeeding} = 3.42 ± 1.56) and the category “engagement” 6 months postpartum regarding breastfeeding 6 months postpartum (p_engagement6M = 0.043, Mean_{breastfeeding} = 6.29 ± 1.81, Mean_{notbreastfeeding} = 6.94 ± 1.78).

Examining breastfeeding between the 9th and 16th week postpartum revealed that the only significant differences depending on breastfeeding appeared in the BSF categories “fatigue” prepartum with higher levels of “fatigue” for women not breastfeeding (p_9th = 0.040, p_13th = 0.030, p_15th = 0.040, p_16th = 0.040) and “elevated mood” 3 days postpartum (p_14th = 0.034, p_16th = 0.033) with higher values of “elevated mood” for women breastfeeding.

In addition to the mere differences of the BSF categories between breastfeeding and nonbreastfeeding women, the variation of BSF categories over time as a function of breastfeeding was also examined. For the BSF categories “fatigue,” “engagement,” and “apathy,” significant differences over time only appeared for breastfeeding women, while for the categories “anxiety” and “elevated mood,” significant differences over time for breastfeeding and nonbreastfeeding women were observed (p values in Supplementary Table S5). The BSF category “anger” showed no significant differences over time depending on whether women were breastfeeding or not.

The correlation analysis to determine the relationship between desired breastfeeding length or breastfeeding frequency and the individual BSF categories also showed no clear relationship with only a few significant correlations with no clear trend over the different survey time points (p values in Supplementary Table S6).

However, if we consider the values of the BSF depending on women with fulfilled breastfeeding expectations, the results are similar to those of the EPDS. Significant differences occure in the categories “fatigue” (p_prepartum = 0.003, p_3D = 0.033, p_1M = 0.038, p_2M = 0.021), “engagement” (p_prepartum = 0.001), “anxiety” (p_prepartum = 0.003, p_1M = 0.009, p_2M = 0.017, p_6M = 0.007) “elevated mood” (p_prepartum = 0.026, p_3D = 0.029, p_2M = 0.014) and “apathy” (p_3D = 0.026), with significantly better values for women with fulfilled breastfeeding expectations (higher engagement and elevated mood, lower fatigue, anxiety, and apathy; values in Supplementary Table S7).

Association of anxieties with breastfeeding experience

For the statistical analysis of anxieties, these were first grouped into prepartum anxieties, fear of childbirth, and COVID-19-related anxieties, as well as the BSF category “anxiety.”

When analyzing the anxieties in relation to whether the women were breastfeeding or not, no significant differences appeared.

Nearly no significant correlations were observed between the different anxieties and breastfeeding behavior, with the only exception being COVID-19-related anxieties correlating with breastfeeding frequency (r_frequency3D__{COVIDanxiety3D} = −0.150, p_{frequency3D_COVIDanxiety3D} = 0.030; r_{frequency1M_COVIDanxiety1M} = −0.151, p_{frequency1M_COVIDanxiety1M} = 0.029) and the desired breastfeeding length 6 months postpartum (r_{COVIDanxiety1M} = −0.166, p_{COVIDanxiety1M} = 0.024; r_{COVIDanxiety2M} = −0.187, p_{COVIDanxiety2M} = 0.010).

When examining the anxieties in relation to whether breastfeeding expectations were met, prepartum anxieties (p = 0.013), the fear of giving birth (p = 0.027), as well as COVID-19-related anxieties (p_prepartum = 0.040, p_3D = 0.004, p_1M = 0.001, p_2M = 0.001) showed significant differences with lower levels of anxiety in women with fulfilled breastfeeding expectations (mean values in Supplementary Table S8), suggesting less fears, leading to a better breastfeeding experience.

Considering the feeding mode of the newborn between the 9th and 16th week postpartum in association with anxieties, women with higher levels of prepartum- and COVID-19-related anxieties tended to breastfeed less (Supplementary Table S9).

Prepartum anxieties and breastfeeding experience

For a more detailed analysis, the individual prepartum anxieties were also examined. Significant negative correlation was observed between breastfeeding frequency at 3 days and 1 month postpartum and prepartum anxiety for sexual impairment postpartum (r_3D = −0.140, p_3D = 0.042; r_1M = −0.163, p_1M = 0.019) and prepartum anxiety of not getting visited by relatives (r_3D = −0.169, p_3D = 0.014). In addition, the desired length of breastfeeding 3 days and 1 month postpartum correlated significantly positively with the fear of having an emergency c-section (r_3D = 0.166, p_3D = 0.023; r_1M = 0.201, p_1M = 0.007), the fear of episiotomies (r_3D = 0.161, p_3D = 0.027) and the fear of health impairments (r_1M = 0.157, p_1M = 0.037).

Discussion

In this study, we investigated breastfeeding habits during the COVID-19 pandemic concerning the association between breastfeeding and general anxieties as well as COVID-19-related anxieties, and between breastfeeding and the EPDS.

The observed significant difference in EPDS values and values of the BSF categories over the postpartum period suggests a decreasing risk of PPD over time and is consistent with the existing literature reporting dynamic changes in PPD symptoms during different postpartum periods.²

The increasing desired breastfeeding length is consistent with literature emphasizing the beneficial impact of prolonged breastfeeding on maternal mental well-being.⁹ In addition, the decreasing breastfeeding frequency over time postpartum could probably be explained due to a decrease of exclusively breastfeeding women and an increase in complementary foods of the infant. In addition, the current study shows that fulfilled breastfeeding expectations lead to longer and more frequent breastfeeding, with a higher likelihood of fully breastfeeding their newborns.

Previous studies suggest a positive correlation between favorable breastfeeding experiences and maternal mental health.¹⁹ This is consistent with our finding showing lower EPDS values for women with fulfilled breastfeeding expectations. Our results are also consistent with other studies having been performed during the COVID-19 pandemic where lower rates of PPD were found when breastfeeding intention and practices were coherent.²⁰

Furthermore, the EPDS differed descriptively over time depending on the breastfeeding mode, most notably, a lower risk of PPD associated with full breastfeeding until postpartum week 16, supporting the existing literature suggesting a positive association between PPD risk and the duration of breastfeeding.^9,19

In addition, prepartum anxieties were observed, showing significant influences on breastfeeding habits. The current study showed that several anxieties regarding pregnancy and birth lead to a reduction in breastfeeding, while a reduction of prepartum anxieties also seems to support fulfilling breastfeeding expectations. The association between prepartum anxieties and breastfeeding habits presents a novel contribution, suggesting that reducing prepartum anxieties could positively influence breastfeeding practices and therefore potentially be beneficial for lowering the risk of PPD.

A bidirectional influence was observed, suggesting a complex relationship, needing further exploration. Higher anxieties seem to lead to less willingness to breastfeed, fewer breastfeeding, and a lower rate of fulfilled breastfeeding expectations. On the contrary, less breastfeeding and unfulfilled breastfeeding expectations also seem to lead to increased anxieties.

Breastfeeding offers benefits for the mental and physical health of mother and child. Besides lowering risks of PPD, beneficial effects on the risk of breast and ovarian cancer, high blood pressure, and sleep quality are known.^8,9,21,22 In addition, a potential protective effect of breastfeeding against severe COVID-19 infections for mother and child was discussed,²⁰ which could have been a potential influencing factor in our study. However, breastfeeding also has beneficial effects on the children. Children that were breastfed show fewer infectious diseases, lower rates of obesity and diabetes, a decreased blood pressure, lower risks for allergic conditions, superior cognitive and motoric skills, and a reduced incidence of leukemia and sudden infant death syndrome.^8,9,21,22

Because reduced levels of anxiety appear to be linked not only to a better breastfeeding experience but also to longer and more frequent breastfeeding, it can be postulated that a reduction in anxieties could improve breastfeeding overall and therefore contribute severely to the overall health of child and mother.

While our study has provided valuable insights, it is not without limitations. The focus on breastfeeding habits was not the primary objective, resulting in limited data collection on breastfeeding behavior. The use of self-reported questionnaires and the absence of behavioral observations are notable constraints. In addition, details on whether women received breastfeeding counseling or required varying levels of breastfeeding support were not included. The high rate of excluded women due to dropouts or incomplete questionnaires further warrants consideration.

To further validate our findings, additional research is essential. A comparison of the same questionnaires with women post-COVID-19 pandemic could offer insights into the lasting impact of breastfeeding on anxieties. Exploring the effects of reducing prepartum anxieties and enhancing peripartum health status on breastfeeding habits and PPD risk would be informative. Furthermore, investigating the potential benefits of breastfeeding support for women at high risk or already experiencing PPD could contribute to developing targeted interventions. Finally, our results provide important evidence that improving the breastfeeding experience could also be a primary prophylaxis for the development of PPD and the reduction of anxiety. To prove this thesis, we are currently planning a follow-up study, where we plan on testing whether lactation counseling—and an improvement of the breastfeeding experience through intensified lactation counseling—could be used as primary prophylaxis for PPD.

Conclusion

In conclusion, our results suggest a clear association between breastfeeding, PPD, and anxieties. Breastfeeding, especially a satisfying breastfeeding experience, seems to have a positive influence on PPD.

High pre- and postpartum anxieties, on the contrary, appear to have both a negative influence on PPD and a negative influence on breastfeeding, which leads to a further worsening of PPD. Reducing prepartum anxieties or treating postpartum anxieties could be a primary prevention for PPD. In addition, improving the breastfeeding experience could also be an effective prevention.

Authors’ Contributions

Conceptualization: Sa.M. and L.H.; Methodology: Sa.M.; Formal analysis and investigation: L.H., M.T., and E.M.D.; Writing—original draft preparation: L.H. and Sa.M.; Writing—review and editing: S.B., L.E., F.G., and M.J.; Funding acquisition: Sa.M.; Resources: Sa.M.; Supervision: Sa.M., T.K., and Sv.M.

Ethics Approval and Consent to Participate

This study was performed in line with the principles of the Declaration of Helsinki and was approved by the local ethics committee of the Ludwig Maximilian University of Munich (reference number–Nr. 20-378).

Consent to Participate and to Publish

Informed consent was obtained from all individual participants included in the study. A specific consent to publish was not necessary as no individuals can be identified in this publication.

Disclosure Statement

Sv.M.: Research support, advisory board, honoraria and travel expenses from AbbVie, AstraZeneca, Clovis, Eisai, GlaxoSmithKline, Medac, MSD, Novartis, Olympus, PharmaMar, Pfizer, Roche, Sensor Kinesis, Teva, Tesaro; T.K.: holds stock of Roche, Biontech, Valneva, BayerAG, relative employed at BayerAG. The other authors declare that no conflict of interests.

Funding Information

Open Access funding enabled and organized by Projekt DEAL. Sa.M. was funded by DFG-funded Clinician Scientist Program PRIME, grant number 413635475.

Supplementary Material

Supplementary Data

Supplementary Figure S1

Supplementary Table S1

Supplementary Table S2

Supplementary Table S3

Supplementary Table S4

Supplementary Table S5

Supplementary Table S6

Supplementary Table S7

Supplementary Table S8

Supplementary Table S9

References

Stewart

, Vigod

. Postpartum depression: Pathophysiology, treatment, and emerging therapeutics. Annu Rev Med, 2019; 70:183–196.

O’Hara

, McCabe

. Postpartum depression: Current status and future directions. Annu Rev Clin Psychol, 2013; 9:379–407.

Pearlstein

, Howard

, Salisbury

, et al. Postpartum depression. Am J Obstet Gynecol, 2009; 200(4):357–364.

Dorsch

, Rohde

. Postpartale psychische Störungen—Update 2016. Frauenheilkunde up2date, 2016; 10(04):355–374.

Sonnenmoser

. Postpartale depression: Vom Tief nach der Geburt. Deutsches Ärzteblatt, 2007 02/2007 2/2007:2.

Payne

, Maguire

. Pathophysiological mechanisms implicated in postpartum depression. Front Neuroendocrinol, 2019; 52:165–180.

Vieira

, Caldeira

, Eugenio

, et al. Breastfeeding self-efficacy and postpartum depression: A cohort study. Rev Lat Am Enfermagem, 2018; 26:e3035.

Figueiredo

, Dias

, Brandao

, et al. Breastfeeding and postpartum depression: State of the art review. J Pediatr (Rio J), 2013; 89(4):332–338.

Dias

, Figueiredo

. Breastfeeding and depression: A systematic review of the literature. J Affect Disord, 2015; 171:142–154.

10.

Schelhorn

, Ecker

, Ludtke

, et al. Psychological burden during the COVID-19 pandemic in Germany. Front Psychol, 2021; 12:640518.

11.

Xiong

, Lipsitz

, Nasri

, et al. Impact of COVID-19 pandemic on mental health in the general population: A systematic review. J Affect Disord, 2020; 277:55–64.

12.

Chen

, Li

, Xiong

, et al. Prevalence and risk factors associated with postpartum depression during the COVID-19 pandemic: A literature review and meta-analysis. Int J Environ Res Public Health, 2022; 19(4).

13.

Bergant

, Nguyen

, Heim

, et al. [German language version and validation of the Edinburgh postnatal depression scale]. Dtsch Med Wochenschr, 1998; 123(3):35–40.

14.

Cox

, Holden

, Sagovsky

. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry, 1987; 150:782–786.

15.

Muzik

, Klier

, Rosenblum

, et al. Are commonly used self-report inventories suitable for screening postpartum depression and anxiety disorders? Acta Psychiatr Scand, 2000; 102(1):71–73.

16.

Levis

, Negeri

, Sun

, et al.; Group DESDE. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: Systematic review and meta-analysis of individual participant data. BMJ, 2020; 371:m4022.

17.

Hörhold

, Klapp

. Testungen der Invarianz und der Hierarchie eines mehrdimensionalen Stimmungsmodells auf der Basis von Zweizetpunkterhebungen an Patienten- und Studentenstichproben. Z med Psychol, 1993; 2:27–35.

18.

Rose

. Emperiegeleitete Reduktion der BSF-Items zur Verwendung bei der 24h-Protokollierung mit Hilfe des Psion-Taschencomputers. In: Cotta

. Psychophysiologische Reaktionen Unter Psychosomatischen Therapiebedingungen. 1998. Dissertation. Charité, Berlin. 1994.

19.

Dennis

, McQueen

. The relationship between infant-feeding outcomes and postpartum depression: A qualitative systematic review. Pediatrics, 2009; 123(4):e736–e751.

20.

Chang

, Li

KMC

, Chien

, et al. Associations between breastfeeding intention, breastfeeding practices and post-natal depression during the COVID-19 pandemic: A multi-country cross-sectional study. Matern Child Nutr, 2023; 19(1):e13450.

21.

Lara-Cinisomo

, McKenney

, Di Florio

, et al. Associations between postpartum depression, breastfeeding, and oxytocin levels in Latina mothers. Breastfeed Med, 2017; 12(7):436–442.

22.

Brown

, Jordan

. Impact of birth complications on breastfeeding duration: An internet survey. J Adv Nurs, 2013; 69(4):828–839.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.01 MB

0.02 MB

0.01 MB

0.02 MB

0.01 MB