The Effects of Breastfeeding on Maternal Mental Health: A Systematic Review

Abstract

Background:

Breastfeeding has many positive effects on the health of infants and mothers, however, the effect of breastfeeding on maternal mental health is largely unknown. The goal of this systematic review was to (1) synthesize the existing literature on the effects of breastfeeding on maternal mental health, and (2) inform breastfeeding recommendations.

Materials and Methods:

A literature search was conducted in electronic databases using search terms related to breastfeeding (e.g., breastfeeding, infant feeding practices) and mental health conditions (e.g., mental illness, anxiety, depression), resulting in 1,110 records. After reviewing article titles and abstracts, 339 articles were advanced to full-text review. Fifty-five articles were included in the final analysis.

Results:

Thirty-six studies reported significant relationships between breastfeeding and maternal mental health outcomes, namely symptoms of postpartum depression and anxiety: 29 found that breastfeeding is associated with fewer mental health symptoms, one found it was associated with more, and six reported a mixed association between breastfeeding and mental health. Five studies found that breastfeeding challenges were associated with a higher risk of negative mental health symptoms.

Conclusions:

Overall, breastfeeding was associated with improved maternal mental health outcomes. However, with challenges or a discordance between breastfeeding expectations and actual experience, breastfeeding was associated with negative mental health outcomes. Breastfeeding recommendations should be individualized to take this into account. Further research, specifically examining the breastfeeding experiences of women who experienced mental health conditions, is warranted to help clinicians better personalize breastfeeding and mental health counseling.

Background

The World Health Organization (WHO) and numerous professional societies, governmental and nongovernmental organizations, recommend that infants should be breastfed for at least the first 6 months of life.^1

–5 Evidence supporting breastfeeding includes positive effects on infant immune systems,^{3,4,6

–16} reduced risk of sudden infant death syndrome,^4,6,17,18 protection against obesity and diabetes,^{4,6,9,19

–22} decreased risk of some pediatric cancers,^6,23,24 and positive effects on cognitive development.^6,25
–27 There are also benefits of breastfeeding to women, including postpregnancy weight loss,^6,28

–31 protection against type 2 diabetes, hypertension, and cardiovascular disease,^{3,4,6,31

–36} and lowered risk of breast and ovarian cancer.^{3,6,35,37
–39} In addition, breastfeeding can facilitate bonding between mother and baby.^40
–42

Given these benefits and the general cultural sentiment around the world that ‘breast is best,’ many new mothers feel pressured to breastfeed.^42,43 However, some individuals are unable to do so for a variety of reasons, including insufficient milk supply,^{3,6,41,44
–46} nipple or breast pain,^{3,6,42,44
–46} inadequate latching,^3,4,45,46 and employment needs or obligations, along with lack of accommodations.^9,45,46 Some may make the personal choice to not breastfeed.⁴⁶ Regardless of the reason, judgment, and stigma are often experienced by those who do not breastfeed^47,48; the judgment can come from others or oneself. If women are unable to breastfeed or choose not to, this can cause a great deal of stress and guilt, which may potentially contribute to a higher incidence of postpartum depression and anxiety.^{4,7,41
–43,47,49}

Even if women are not experiencing difficulties with feeding or stress from associated expectations, the challenges inherent to breastfeeding, such as lack of sleep, can trigger the onset or exacerbation of mental health conditions. As postpartum mental health conditions have significant negative consequences for mothers and their offspring, including stunted growth,⁵⁰ negative effect on children's cognitive and social development,^51,52 and psychological problems and temperament,^51,52 maternal mental health effects associated with the pressure to breastfeed may be more detrimental and outweigh the potential physical benefits of breastfeeding itself.

The goal of this review was to synthesize the existing literature and examine to what extent breastfeeding is associated with symptoms of mental health conditions for women within a year of delivery. We seek to provide information to best inform counseling for individuals experiencing breastfeeding challenges and mental health conditions.

Methods

Database search strategy

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.⁵³ In consultation with a health sciences librarian, we conducted searches in PubMed/Medline (NCBI), PsycINFO (Ovid/Wolters Kluwer), Scopus (Elsevier), CINAHL (EBSCOhost), and Google Scholar in June 2019. The search terms included words related to breastfeeding (e.g., breastfeeding, infant feeding practices, human milk, lactation, breast milk expression) and mental health conditions [e.g., psychosis, psychiatric, mental illness, posttraumatic stress disorder (PTSD), mood disorders, anxiety, depression, maternal mood]. The full search strategy can be found in the Supplementary Appendix SA1.

Inclusion and exclusion criteria

After duplicates were removed, articles of interest were those that reported on the effect of infant feeding method or duration on maternal mental health outcomes. Articles were included or excluded for further review as outlined in PRISMA diagram in Figure 1. Articles were included only if they were in English and were original research articles. The subjects of interest were human women over the age of 18 who were within 1 year postpartum. The mental health outcomes of interest included (1) depression, (2) anxiety, (3) PTSD, (4) obsessive–compulsive disorder, (5) bipolar disorder, (6) psychosis or other psychotic disorder, and (7) other mental health disorders, not including substance use disorders.

FIG. 1.

PRISMA diagram.

Articles were carefully reviewed for what was considered the exposure versus outcomes. Articles were included if infant feeding practices where the exposure and mental health symptoms were the outcome; those in which the exposure was mental health, and the outcome was infant feeding practice was excluded (Fig. 1), as we were not interested in the effect of mental health on breastfeeding in this analysis.

Screening phase 1

Reviewers 1 (O.M.) and 2 (M.Y.) reviewed 1,110 titles and abstracts independently on Rayyan⁵⁴ for initial eligibility criteria and were blinded to the other reviewer's responses. Articles for which inclusion seemed likely, or exclusion could not be determined based on title and abstract alone, were advanced to the second screening phase. Articles for which Reviewers 1 and 2 were discordant (N = 149) were rereviewed by Reviewers 3 (B.N.) and 4 (F.P., see acknowledgement) for the same determinations. In this phase, 339 of 1,110 articles (30.5%) were sent to screening phase 2 for review of the full text (Fig. 1).

Screening phase 2

Citations for full-text review were entered into Research Electronic Data Capture (REDCap), hosted at the University of Massachusetts Chan Medical School.⁵⁵

Reviewers 1 and 2 independently read each article. Reviews resulted in concordance for 246 of 339 articles (72.6%) being excluded and 53 of 339 (15.6%) being included by both reviewers. Forty articles, which had discordant decisions on independent review were unblinded and discussed by Reviewers 1 and 2 until consensus was reached and 27 of those (67.5%) were included (Fig. 1).

Data abstraction

The 80 included articles from screening phase 2 were each fully abstracted using a standard abstraction form by either Reviewers 1, 2, 3, or 5 (G.M.). Abstracted data included study aims, study design, population demographics (race, ethnicity, insurance, age, education), geographic location, time point at which infant feeding method was gathered and approach, time point at which mental health outcome was gathered and type, a summary of pertinent results, and study strengths and limitations.

At this stage, articles that did not explicitly report on the effect of infant feeding method on a specific maternal mental health outcome were excluded. Twenty-five articles were excluded at this stage. Articles that reported on the effect of infant feeding challenges, but not infant feeding method or duration were excluded. This left 55 articles included in final analyses (Table 1).

Table 1.

Characteristics of Included Studies, Breastfeeding, and Mental Health Outcomes

Authors	Country	Study type Sample size	Breastfeeding (BF) definition	BF data gathered	Mental health (MH) symptom(s)	MH assessment timing	Quality score
Abou-Saleh et al.⁸⁹	Dubai and UAE	1Prospective cohort 141	Any breastfeeding vs. no breastfeeding	Early postpartum, late postpartum	Depression (EPDS >12)	Early postpartum	9
Abou-Saleh et al.⁸⁹	Dubai and UAE	1Prospective cohort 141	Any breastfeeding vs. no breastfeeding	Early postpartum, late postpartum	Depression (Present State Examination)	Late postpartum	9
Ahn and Corwin⁹⁰	USA	Prospective cohort 84	Mostly breast milk vs. mostly formula	Early postpartum, late postpartum	Depression (EPDS >10)	Early postpartum, Late postpartum	11
Alder and Cox⁶¹	United Kingdom	Retrospective cohort 89	Exclusive breast milk vs. mixed	Late postpartum	Depression (Goldberg's Symptoms Ratings >2)	Late postpartum	9
Allen et al.⁷⁷	USA	Prospective cohort 46	Any current breastfeeding vs. Initiated breastfeeding vs. never initiated	Early postpartum, late postpartum	Depression (EPDS Trend)	Late postpartum	8
Assarian et al.¹¹¹	Iran	Prospective case–control 458	Exclusive breast milk vs. mixed vs. no breastfeeding	Early postpartum, late postpartum	Depression (clinical diagnosis)	Early postpartum, late postpartum	9
Assarian et al.¹¹¹	Iran	Prospective case–control 458	Exclusive breast milk vs. mixed vs. no breastfeeding	Early postpartum, late postpartum	Anxiety (clinical diagnosis)	Early postpartum, late postpartum	9
Bandelow et al.¹⁰⁵	Germany	Retrospective cohort 128	Any breastfeeding vs. no breastfeeding	Late postpartum	Panic disorder (Clinical diagnosis)	Late postpartum	15
Beck et al.⁶²	USA	Prospective cohort 903	Exclusive breastfeeding vs. mixed breastfeeding	Early postpartum	Depression (PHQ2)	Late postpartum	13
Beck et al.⁶²	USA	Prospective cohort 903	Exclusive breastfeeding vs. mixed breastfeeding	Early postpartum	Depression (PDSS-Short Form >14)	Early postpartum, late postpartum	13
Bergink et al.⁷¹	Netherlands	Prospective cohort 51	Any breastfeeding vs. no breastfeeding	Early postpartum	PTSD (PSS-SR >12)	Late postpartum	14
					Bipolar disorder (Young Mania Rating Scale >8)	Unknown
					Psychosis (Clinical diagnosis)	Early postpartum
					Other (Clinical global impressions - severity scale >3)	Unknown
Bonnin⁹¹	France	Prospective cohort 29	Any breastfeeding vs. no breastfeeding	Early postpartum	Depression (Zerssen Score = 4,5)	Early postpartum	8
Borra et al.⁸⁰	England	Prospective cohort 14451	Initiated breastfeeding vs. not initiated; exclusive breast milk vs. mixed vs. no breastfeeding	Early postpartum, late postpartum	Depression (EPDS >12)	Late postpartum	16
Carta et al.¹¹⁰	Italy	Efficacy trial 151	Exclusive breast milk vs. mixed vs. no breastfeeding	Hospital, early postpartum	Depression (EPDS >10)	Hospital, early postpartum	9
Chaudron et al.⁶⁵	USA	Prospective cohort 465	Any breastfeeding vs. no breastfeeding	Early postpartum, late postpartum	Depression (Diagnosis on NIMH diagnostic interview, CES-D >16, or receiving antidepressants)	Early postpartum, late postpartum	15
Chojenta et al.⁹²	Australia	Prospective cohort 5219	Any breastfeeding vs. no breastfeeding	Late postpartum	Depression (Self Report of Diagnosis)	Not reported	11
Chong et al.⁶⁷	USA	Prospective cohort 61	Any breastfeeding vs. no breastfeeding	Early postpartum, late postpartum	Depression (Mean CES-D)	Late postpartum	14
Cooke et al.⁶⁴	Australia	Prospective cohort 334	Any breastfeeding vs. no breastfeeding	Hospital, early postpartum, late postpartum	Depression (EPDS >12)	Early postpartum, late postpartum	9
Cooke et al.⁶⁴	Australia	Prospective cohort 334	Any breastfeeding vs. no breastfeeding	Hospital, early postpartum, late postpartum	Anxiety (STAI)	Early postpartum, late postpartum	9
Dagher et al.⁹³	USA	Prospective cohort 603	Any breastfeeding vs. no breastfeeding	Early postpartum, late postpartum	Depression (EPDS >12.5)	Early postpartum, late postpartum	13
de Jager et al.⁶³	Australia	Retrospective cohort 174	Exclusive breast milk vs. mixed	Hospital, early postpartum, late postpartum	Depression (mean DASS-21)	Late postpartum	11
de Jager et al.⁶³	Australia	Retrospective cohort 174	Exclusive breast milk vs. mixed	Hospital, early postpartum, late postpartum	Anxiety (mean DASS-21)	Late postpartum	11
Ding et al.⁷⁹	China	Prospective cohort 214	Exclusive breast milk vs. mixed vs. no breastfeeding	Early postpartum, late postpartum	Depression (EPDS >10)	Early postpartum	14
Eastwood et al.¹⁰²	Australia	Cross-sectional 25455	Any breastfeeding vs. no breastfeeding	Early postpartum, late postpartum,	Depression (EPDS >10)	Early postpartum, late postpartum	9
Eastwood et al.¹⁰²	Australia	Cross-sectional 25455	Any breastfeeding vs. no breastfeeding	Early postpartum, late postpartum,	Depression (EPDS >12)	Early postpartum, late postpartum	9
Falah-Hassani et al.⁶⁶	Canada	Prospective cohort 522	Any breastfeeding vs. no breastfeeding	Early postpartum	Depression (EPDS >10)	Early postpartum, late postpartum	11
Falah-Hassani et al.⁶⁶	Canada	Prospective cohort 522	Any breastfeeding vs. no breastfeeding	Early postpartum	Anxiety (STAI >40)	Early postpartum, late postpartum	11
Figueiredo et al.⁸²	Portugal	Prospective cohort 145	Exclusive breast milk vs. mixed or no breastfeeding	Hospital, late postpartum	Depression (Mean EPDS)	Hospital, late postpartum	10
Green et al.⁸³	UAE	Prospective cohort 125	Any breastfeeding vs. no breastfeeding	Hospital, late postpartum	Depression (EPDS >13)	Late postpartum	11
Haga et al.⁸⁴	Norway	Prospective cohort 1,396	Exclusive breast milk vs. mixed or no breastfeeding	Late postpartum	Depression (Mean EPDS)	Late postpartum	15
Hahn-Holbrook et al.⁸⁵	USA	Prospective cohort 205	Exclusive breast milk (at breast vs. pumping) vs. mixed vs. no breastfeeding	Late postpartum	Depression (EPDS >10)	Late postpartum	13
Hamdan and Tamim⁸⁶	UAE	Prospective cohort 137	Any breastfeeding vs. no breastfeeding	Late postpartum	Depression (EPDS >10)	Late postpartum	8
Hamdan and Tamim⁸⁶	UAE	Prospective cohort 137	Any breastfeeding vs. no breastfeeding	Late postpartum	Depression (Mini International Neuropsychiatric Index)	Late postpartum	8
Hamdan and Tamim⁸⁷	UAE	Prospective cohort 137	Any breastfeeding vs. no breastfeeding	Late postpartum	Depression (EPDS >10)	Late postpartum	12
Hamdan and Tamim⁸⁷	UAE	Prospective cohort 137	Any breastfeeding vs. no breastfeeding	Late postpartum	Depression (Mini International Neuropsychiatric Index)	Late postpartum	12
Heinrichs et al.¹⁰⁹	Germany	Randomized controlled trial 43	Exclusive breast milk	Late postpartum	Depression (Mean German Self-Rating Depression Scale)	Late postpartum	15
Heinrichs et al.¹⁰⁹	Germany	Randomized controlled trial 43	Exclusive breast milk	Late postpartum	Anxiety (Mean German STAI)	Late postpartum	15
Henshaw et al.⁶⁸	USA	Prospective cohort 204	Exclusive breast milk vs. mixed vs. breastfeeding for infant comfort vs. no breastfeeding	Hospital, early postpartum, late postpartum	Depression (mean EPDS)	Hospital, early postpartum, late postpartum	14
Henshaw et al.⁶⁸	USA	Prospective cohort 204		Hospital, early postpartum, late postpartum	Depression (mean PDPI-R)	Hospital, early postpartum, late postpartum	14
Imširagić et al.⁵⁹	Croatia	Prospective cohort 372	Initiated breastfeeding vs, did not initiate; exclusive breast milk vs. mixed vs. no breastfeeding	Hospital, late postpartum	Depression (EPDS >9)	Hospital, late postpartum	9
Imširagić et al.⁵⁹	Croatia	Prospective cohort 372		Hospital, late postpartum	PTSD (Impact of Events Scale)	Hospital, late postpartum	9
Jardri et al.⁸⁸	France	Prospective cohort 758	Any continued breastfeeding vs. discontinued BF	Hospital, early postpartum	Depression (EPDS >8)	Hospital	10
Jardri et al.⁸⁸	France	Prospective cohort 758	Any continued breastfeeding vs. discontinued BF	Hospital, early postpartum	Depression (Mini International Neuropsychiatric Index)	Late postpartum	10
Jobst et al.⁶⁰	Germany	Prospective cohort 100	Any breastfeeding vs. no breastfeeding	Late postpartum	Depression (MADRS >10)	Hospital, late postpartum	5
Kendell et al.⁷⁴	Scotland	Prospective cohort 81	Any breastfeeding vs. no breastfeeding	Early postpartum	Depression (Unknown Mood Scale)	Hospital, Early Postpartum	14
					Depression (Unknown Mood Scale)	Late postpartum
					Anxiety (Unknown Mood Scale)	Hospital, early postpartum
Khalifa et al.⁷⁰	Sudan	Prospective cohort 238	Exclusive breastfeeding vs. mixed or no breastfeeding	Late postpartum	Depression (EPDS >12)	Late postpartum	16
Koutra et al.⁵⁸	Greece	Prospective cohort 1,037	Any breastfeeding initiated vs. never initiated; additional details included when breastfeeding was initiated and duration of breastfeeding	Late postpartum	Depression (EPDS >13)	Late postpartum	17
Liu et al.¹⁰³	China	Retrospective cohort 882	Exclusive breast milk vs. mixed vs. no breastfeeding	Early postpartum	Depression (EPDS >10)	Early postpartum	17
Maimburg and Vaeth¹⁰⁸	Denmark	Randomized controlled trial 1,067	Exclusive breastfeeding vs. mixed breastfeeding	Early postpartum	Depression (EPDS >12)	Early postpartum	17
Maliszewska et al.⁹⁶	Poland	Cross-sectional 548	Any breastfeeding vs. no breastfeeding	Hospital	Depression (EPDS >12)	Hospital, early postpartum, late postpartum	16
Maliszewska et al.⁹⁶	Poland	Cross-sectional 548	Any breastfeeding vs. no breastfeeding	Hospital	Depression (PHQ9 > 9)	Hospital, early postpartum, late postpartum	16
Mancini et al.⁹⁵	USA	Cross-sectional 755	Exclusive breast milk vs. mixed vs. no breastfeeding	Early postpartum	Depression (Postpartum Depression Screening Scale >80)	Early postpartum	17
McCoy et al.¹⁰⁷	USA	Retrospective cohort 209	Any breastfeeding vs. no breastfeeding	Early postpartum	Depression (EPDS >12)	Early postpartum	12
Mosack and Shore⁹⁹	USA	Cross-sectional 79	Any breastfeeding vs. no breastfeeding	Early postpartum, late postpartum	Depression (EPDS >12)	Early postpartum, late postpartum	15
Mosack and Shore⁹⁹	USA	Cross-sectional 79	Any breastfeeding vs. no breastfeeding	Early postpartum, late postpartum	Depression (CES-D > 16)	Early postpartum, late postpartum	15
Nam et al.¹⁰⁴	Korea	Retrospective cohort 81,447	Prescribed breast milk suppression by 12 weeks vs. not prescribed	Late postpartum	Depression (Inpatient or Outpatient Clinical Diagnosis within 6 months Postpartum)	Late postpartum	17
O'Neill et al.⁷⁶	Ireland	Prospective cohort 56	Any breastfeeding vs. no breastfeeding	Late postpartum	Depression (EPDS >12/13)	Early postpartum	16
Otto et al.¹⁰⁶	Netherlands	Retrospective cohort 112	Any breastfeeding vs. no breastfeeding	Late postpartum	Depression (EPDS >10)	Late postpartum	16
Pope et al.¹⁰⁰	Canada	Cross-sectional 2,848	Exclusive breast milk vs. mixed vs. no breastfeeding	Late postpartum	Depression (EPDS >12)	Early postpartum, late postpartum	15
Reifsnider et al.⁷⁸	USA	Prospective cohort 150	Exclusive breast milk vs. mixed vs. no breastfeeding	Early postpartum, late postpartum	Depression (Mean EPDS)	Early postpartum, late postpartum	13
Roomruangwong et al.⁵⁷	Thailand	Retrospective case–control 313	Breastfeeding at breast vs. breastfeeding via pumping vs. formula	Early postpartum	Depression (EPDS >11)	Early postpartum	17
Shah and Lonergan⁹⁴	Pakistan	Cross-sectional 434	Exclusive breast milk vs. mixed vs. no breastfeeding	Early postpartum	Depression (EPDS >10)	Early postpartum	15
Sibolboro Mezzacappa and Endicott⁹⁸	USA	Cross-sectional 1,165	Any breastfeeding vs. no breastfeeding	Unknown	Depression (CES-D > 16)	Early postpartum, late postpartum	16
Sword et al.⁷²	Canada	Prospective cohort 2,560	Any breastfeeding initiated vs. never initiated	Hospital	Depression (EPDS >12)	Early postpartum	15
Warner et al.⁷⁵	Great Britain	Prospective cohort 2,375	Any breastfeeding vs. no breastfeeding	Early postpartum	Depression (EPDS >12)	Late postpartum	12
Wei et al.¹⁰¹	USA	Cross-sectional 586	Exclusive breast milk vs. mixed vs. no breastfeeding	Early postpartum	Depression (Beck–Gable PDSS; 60 = minor; 80 = major)	Early postpartum	13
Xu et al.⁷³	Australia	Prospective cohort 1,86,452	Breastfeeding at breast vs. breastfeeding through pumping vs. no breastfeeding	Hospital	Depression (Clinical Diagnosis: Hospital Admission)	Early postpartum, late postpartum	15
					Anxiety (Clinical Diagnosis: Hospital Admission)	Early postpartum, late postpartum
					Bipolar Disorder (Clinical Diagnosis: Hospital Admission	Early postpartum, late postpartum
					Psychosis (Clinical Diagnosis: Hospital Admission)	Early postpartum, late postpartum
					Adjustment Disorder (Clinical Diagnosis: Hospital Admission	Early postpartum, late postpartum
					Personality Disorder (Clinical Diagnosis: Hospital Admission)	Early postpartum, late postpartum
Ystrom⁸¹	Norway	Prospective cohort 42,225	Exclusive breast milk vs. mixed vs. no breastfeeding	Early postpartum, late postpartum	Depression (Mean SCL-8)	Late postpartum	12
Ystrom⁸¹	Norway	Prospective cohort 42,225	Exclusive breast milk vs. mixed vs. no breastfeeding	Early postpartum, late postpartum	Anxiety (Mean SCL-8)	Late postpartum	12
Yusuff et al.⁶⁹	Malaysia	Prospective cohort 2,072	Exclusive breastfeeding vs. mixed breastfeeding	Late postpartum	Depression (mean EPDS)	Early postpartum, Late postpartum	17
Zainal et al.⁹⁷	Malaysia	Cross-sectional 411	Exclusive breast milk vs. mixed or no breastfeeding	Late postpartum	Depression (Mini International Neuropsychiatric Index)	Late postpartum	14

Exclusive breastfeeding: breast milk was the main or only form of infant nutrition, whether or not method of delivery (e.g., at breast vs. pump/bottle) was reported by the authors; Mixed breastfeeding: combination of breast milk through any delivery method and formula or other liquids; Any breastfeeding: used when the authors did not separate exclusive breastfeeding and mixed breastfeeding; No breastfeeding: breast milk was not given as a form of infant nutrition.

Early postpartum: weeks 1 through 6 of the postpartum period; Late postpartum: week 7 through month 12 of the postpartum period.

EPDS, Edinburgh Postnatal Depression Scale; PHQ, patient health questionnaire; DSS, panic disorder severity scale; PSS-SR, posttraumatic symptom scale, self-report version; NIMH, National Institute of Mental Health; CES-D, center for epidemiologic studies depression scale; STAI, State-Trait Anxiety Inventory; DASS, depression anxiety stress scale; PDPI-R, postpartum depression predictors inventory – revised; PTSD, posttraumatic stress disorder; MADRS, Montgomery–Asberg depression rating scale; SCL, symptom checklist.

Each study included in the final analyses was given a quality score based on the revised Downs and Black Checklist.⁵⁶ Given the majority (54 of 55) of included articles were observational, the Downs and Black items 3, 4, 8, 9, 11, 14, 15, 19, 23, and 24 were removed, as they were not applicable.

Definitions of breastfeeding as exposure

Breastfeeding was broadly considered as human-made milk provided to an infant whether directly from the breast or expressed and provided through a bottle or similar receptacle. The abstracted articles had heterogeneous definitions of infant feeding, which were operationally categorized to facilitate comparisons. The categories were: (1) exclusive breast milk: breast milk was the main or only form of infant nutrition, whether or not method of delivery (e.g., at breast vs. pump/bottle) was reported; (2) mixed breastfeeding: combination of breast milk through any delivery method and formula or other liquids; (3) any breastfeeding: used when the authors did not separate exclusive breastfeeding and mixed breastfeeding; and (4) no breastfeeding.

Following the initial complete abstraction of data, reviewers identified that several studies reported results on the likely relationship between breastfeeding challenges and maternal mental health.^{57

–64} Breastfeeding challenges included poor latch, poor milk supply, painful nipples, breast infection, or negative feelings during breastfeeding, among others. As this was deemed likely highly relevant, each article included at this stage was rereviewed to abstract these data where they existed.

The majority of the authors of the included literature used the terms “woman,” “mother,” and “breastfeeding,” thus this is the language we use throughout the article. However, we acknowledge that not all childbearing or breastfeeding individuals identify as “woman” or “mother.” We recognize historical and contemporary efforts to advocate for reproductive and mental health justice and acknowledge and support these efforts to be more inclusive of perinatal individuals who do not identify as women.

Mental health outcomes

Mental health outcomes of interest included symptoms of depression, anxiety, PTSD, bipolar disorder, psychosis, or other mental health conditions (Table 1). Studies, which discussed only “maternal distress” or similar outcomes, but did not connect this to a mental health disorder, were excluded. For each article, we abstracted the method used by the researchers to determine a mental health outcome, noting that a variety of approaches were utilized. Many used validated screening tools such as the Edinburgh Postnatal Depression Scale (EPDS) for depression or the Panic Disorder Severity Scale (PDSS) for panic disorder. If a measurement tool was utilized, the name and the cutoff score applied by the authors of that article were abstracted. Rather than using screening tools, some articles reported on other mental health-related outcomes, such as admission to hospital for psychiatric illness.

Self-efficacy

A few articles discussed the role of self-efficacy,^63,65

–68 or a person's confidence in being able to breastfeed, in mediating the relationship between infant feeding method and maternal mental health outcomes. For those that discussed self-efficacy, we abstracted relevant results.

IRB statement

This study was reviewed by the Institutional Review Board (IRB) at the University of Massachusetts Chan Medical School and was determined to be a nonhuman subjects' research, and therefore exempt from full review.

Results

Overview of studies

Study characteristics are outlined in Table 1. Of the 55 studies included, there were 34 prospective cohort studies,^{58
–60,62,64

–93} nine cross-sectional studies,^{94

–102} seven retrospective cohort studies,^{61,63,103

–107} three randomized control trials,^108
–110 one retrospective case–control,⁵⁷ and one prospective case–control.¹¹¹

Twenty-five different countries are represented in this review (Table 1). Sample sizes ranged from 29 participants⁹¹ to 186,452 participants.⁷³

Table 1 also depicts the definition of breastfeeding and the mental health symptom(s) studied with the screening tool and cutoff score used for each study. It depicts when breastfeeding data were gathered and at what time point mental health was assessed, such as before hospital discharge, early postpartum (up to six weeks postpartum), and late postpartum (between six weeks and 12 months postpartum).

Postpartum depression symptoms were the most represented maternal mental health outcome in this review (52 studies).^{57

–61,63

–70,72

–104,106

–111} This was followed by postpartum anxiety symptoms (nine studies).^{63,64,66,73,74,81,105,109,111}

Effect of breastfeeding on mental health

Nineteen studies^{57,60,61,63
–65,67,68,71,74,76
–78,84,90,93,99,105,106} reported no statistically significant relationship between breastfeeding and mental health. Thirty-six studies^{58,59,62,66,69,70,72,73,75,79

–83,85

–89,91,92,94

–98,100

–104,107

–111} found a statistically significant relationship, 29 of which found that breastfeeding was associated with fewer mental health symptoms,^{58,59,62,66,69,70,72,75,79

–82,85,88,89,92,94

–97,100,102
–104,107

–111} one of which found that breastfeeding was associated with increased maternal mental health symptoms,⁹¹ and six of which described a mixed association between breastfeeding and mental health.^{73,83,86,87,98,101}

Effect of breastfeeding on postpartum depression symptoms

The majority of studies, 52 in total, examined the relationship between breastfeeding and symptoms of postpartum depression^{57

–61,63

–70,72

–104,106

–111} (Table 2). Of these, 34 studies identified a statistically significant relationship.^{58,59,66,69,70,72,75,79

–83,85

–89,91,92,94

–98,100

–104,107

–111}

Table 2.

Effect of Breastfeeding on Postpartum Depression Symptoms

Authors	Statistically significant?	Association	Result
Abou-Saleh et al.⁸⁹	Yes	Inverse	Postpartum women who breastfed had significantly lower EPDS scores (p < 0.05) and PSE scores (p < 0.05) than those who did not breastfeed.
Ahn and Corwin⁹⁰	No		There was no significant association between the pattern of feeding and depressive symptoms at 6 months postpartum
Alder and Cox⁶¹	No		Nearly twice as many mothers who were totally breastfeeding had symptoms of depression at 12 weeks postpartum compared with those partially breastfeeding (41% vs. 21%), however, this relationship was not statistically significant
Allen et al.⁷⁷	No		No significant differences were observed in mood between the 30 days before the termination of breastfeeding compared with the 30 days after, among those who terminated during follow-up (B = 0.80, 95% CI: 2.34–0.75)
Assarian et al.¹¹¹	Yes	Inverse	Mothers who were mixed breastfeeding or not breastfeeding were more likely to be diagnosed with depression than mothers who were exclusively breastfeeding (p = 0.001, OR = 5.48).
Bonnin⁹¹	Yes	Direct	Mothers who breastfed were more depressed through the first week postpartum than those who bottle fed (mean 2.02 vs. 1.57, t = 3.27, p = 0.001)
Borra et al.⁸⁰	Yes	Inverse	For the sample as a whole, the results demonstrate little evidence for a causal relationship between breastfeeding and postpartum depressionFor mothers without previous depression who planned to breastfeed, actually breastfeeding decreased the risk of postpartum depression and not breastfeeding as planned increased the risk of postpartum depression (p < 0.01)
Carta et al.¹¹⁰	Yes	Inverse	There was a significant relationship between mean EPDS at screening time and delayed breastfeeding (0.201, p = 0.01)
Chaudron et al.⁶⁵	No		Women who breastfed their infants were not significantly different in their development of depression from women who bottle-fed their infants.
Chojenta et al.⁹²	Yes	Inverse	Breastfeeding for less than 6 months was significantly associated with postnatal depression. Unadjusted OR = 1.708 (95% CI: 1.47–1.96). Adjusted OR = 1.29 (95% CI: 1.12–1.50) p < 0.001.
Chong et al.⁶⁷	No		The direct effect from breastfeeding duration to depression at 9 months postpartum was nonsignificant (p = 0.79) indicating that a longer duration of BF was not related to lower depression at 9 months postpartum
Cooke et al.⁶⁴	No		Breastfeeding status (breastfeeding/ceased breastfeeding) was not significantly associated with EPDS scores at 3 months postpartum (p = 0.22)Breastfeeding duration was not significantly associated with postnatal EPDS status at 3 months postpartum (p = 0.80)
Dagher et al.⁹³	No		Postpartum depressive symptoms were positively associated with breastfeeding; however, this result was not significant (coefficient 0.5269, SE 0.2462, 95% CI: 0.0439–1.0099)
de Jager et al.⁶³	No		Women who exclusively breastfed <6 months had a mean DASS-21 of 9.4 (SD 9.7) for depression, and women who were exclusively breastfed >6 months had a DASS-21 of 6.0 (SD 6.4) for depression, p = 0.057.Higher DASS-21 scores reflect elevated symptomatology
Ding et al.⁷⁹	Yes	Inverse	When all variables were included in a model to predict PPD, breastfeeding was protective (continued breastfeeding at 42 days postpartum had an aOR = 0.02, 95% CI: 0.00–0.07, p < 0.001)
Eastwood et al.¹⁰²	Yes	Inverse	Not breastfeeding was associated with EPDS >9 (OR = 1.2, 95% CI: 1.1–1.3) and EPDS >12 (OR = 1.3, 95% CI: 1.2–1.4)When factors were analyzed in a multivariate logistic regression model, not breastfeeding was associated with EPDS >9 (OR = 1.1, 95% CI: 1.02–1.2) and EPDS >12 (OR = 1.2, 95% CI: 1.1–1.4)
Falah-Hassani et al.⁶⁶	Yes	Inverse	Not breastfeeding at 1 week (OR = 1.73, 95% CI: 1.02–2.93) was significantly associated with comorbid depressive symptomatology and anxiety.
Figueiredo et al.⁸²	Yes	Inverse	In the group of women who initiated breastfeeding, depression scores decreased from childbirth to the 3-month postpartum period (F = 4.60, p < 0.05).Women who exclusively breastfed for 3+ months had lower depression scores at 3 months postpartum when compared with the first (p < 0.001), second (p < 0.001), and third trimester (p < 0.05), and also at childbirth (p < 0.001), whereas women who did not initiate or ceased exclusive breastfeeding early had lower depression scores at 3 months postpartum when compared with the first pregnancy trimester (p < 0.05)
Green et al.⁸³	Yes	Mixed	Women who bottle-fed at 3 months had significantly higher postnatal depression scores (x ² = 12.20, p = 0.002) than women who were breastfeeding. This relationship was not found at 6 months postpartum.
Haga et al.⁸⁴	No		Breastfeeding did not predict later depressive symptoms (Breastfeeding at 4 months > depression 6 months [B = −0.02, p = 0.707]; BF at 6 months > depression 12 months [β = +0.02, p = 0.731])
Hahn-Holbrook et al.⁸⁵	Yes	Inverse	Breastfeeding at 3 months postpartum predicted lower risk of subsequent depressive symptomatology over the 2-year period after (Coefficient = 0.03, p < 0.02)Exclusive breastfeeding did not significantly predict less depressive symptomatology, although using a percentage of child's diet made up by breast milk as a continuous variable revealed a trend in the predicted direction (p = 0.06).
Hamdan and Tamim⁸⁶	Yes	Mixed	The use of formula was associated with depression diagnoses, where women using formula were more likely to be diagnosed (p = 0.003)No significant differences in diagnoses of depression based on breastfeeding status (p < 0.05), length of breastfeeding (p < 0.04), or whether mom was currently breastfeeding at 2 months (p < 0.004).
Hamdan and Tamim⁸⁷	Yes	Mixed	Breastfeeding at 2 months had a 9% rate of diagnosis with PPD versus 17.7% in those not currently breastfeeding (p = 0.38); this result was not significant.Breastfeeding at 4 months had a significant risk of PPD diagnosis: 3.3% in those currently breastfeeding versus 26.3% in those not currently breastfeeding (p < 0.0025).
Heinrichs et al.¹⁰⁹	Yes	Inverse	There was a main effect of subject group on mood [F(1,41) = 4.87; p = 0.033], with elevated mood in breastfeeding women.
Henshaw et al.⁶⁸	No		Breastfeeding exclusivity did not contribute significantly to prediction of mood outcomes.
Imširagić et al.⁵⁹	Yes	Inverse	Odds for postnatal depression symptomatology (through EPDS) at 3–5 days postpartum were increased by unsuccessful breastfeeding initiation (aOR = 2.58, 95% CI: 1.35–4.91).Compared with exclusive breastfeeding, women that were not breastfeeding had increased odds for positive EPDS (OR = 2.15, 95% CI: 1.06–4.38) at 6–9 weeks postpartum.
Jardri et al.⁸⁸	Yes	Inverse	Stopping BF during first month for nonmedical reasons was found to be linked to depression at 8 weeks postpartum (through MINI), (aOR = 5.4, 95% CI: 1.4–20.3).
Jobst et al.⁶⁰	No		Duration of breastfeeding did not predict diagnosis of depression.
Kendell et al.⁷⁴	No		The average ratings on the depression, tears, anxiety, and mood instability scales tend to rise during the first few days after delivery and to fall slowly and steadily thereafter, independent of whether the mother is breastfeeding or bottle feeding.The day 5 peak was unaffected by method of feeding.
Khalifa et al.⁷⁰	Yes	Inverse	Exclusive breastfeeding for the first 3 months postpartum decreased the odds of depression by 80%, OR = 0.2 (95% CI: 0.06–0.70, p = 0.04)
Koutra et al.⁵⁸	Yes	Inverse	Breastfeeding duration less than 2 months was related to a 77% increase in the odds for PPD (OR = 1.77, 95% CI: 1.19–2.64, p = 0.001).
Liu et al.¹⁰³	Yes	Inverse	Women who fed their infants through mixed or formula feeding were more susceptible to postpartum depression than exclusive breastfeeders (χ ² = 25.598, p < 0.001).
Maimburg and Vaeth¹⁰⁸	Yes	Inverse	Women who never breastfed (OR = 6.41, 95% CI: 1.92–21.44, p = 0.003) or were not breastfeeding their child 6 weeks after birth (OR = 3.10, 95% CI: 1.65–5.85, p = 0.001) had a higher risk of PPD versus women who were breastfeeding 6 weeks postpartum.
Maliszewska et al.⁹⁶	Yes	Inverse	Initial breastfeeding (ORa = 0.31, 95% CI: 0.11–0.9, p = 0.03) was a potential protective factor against PPD.
Mancini et al.⁹⁵	Yes	Inverse	Exclusive bottle feeding (risk ratio = 2.0, 95% CI: 1.6–2.4) was a predictor of a positive PDSS screen.
McCoy et al.¹⁰⁷	Yes	Inverse	Breastfeeding was associated with a significantly lower occurrence of PPD than formula feeding only (p < 0.001).The relative risk factor for formula feeding only was 2.04 (p < 0.05).
Mosack and Shore⁹⁹	No		None of the variables in the regression model besides history of depression was a significant predictor of depression scores, including breastfeeding.
Nam et al.¹⁰⁴	Yes	Inverse	Women who discontinued breastfeeding within 12 weeks of delivery had a higher risk of PPD than those who continued breastfeeding (hazard ratio = 3.23, 95% CI: 1.90–5.49, p < 0.0001).
O'Neill et al.⁷⁶	No		No significant relationship was found between breastfeeding and postnatal depression.
Otto et al.¹⁰⁶	No		No statistically significant relationship was observed between infant feeding method and EPDS scores (p = 0.669).
Pope et al.¹⁰⁰	Yes	Inverse	Longer duration of exclusive breastfeeding was significantly associated with lower EPDS scores (r = −0.05; p < 0.05); the effect size was negligible.
Reifsnider et al.⁷⁸	No		At 1-month postpartum, women who reported no breastfeeding had, on average, higher EPDS scores (M = 5.18) than those who reported exclusive breastfeeding (M = 3.64).At 6 months postpartum, women who reported exclusive breastfeeding had higher EPDS scores (M = 5.43) than women who reported no breastfeeding (M = 4.39).Women who were nonexclusively breastfeeding at 1 and 6 months postpartum had the lowest EPDS scores.None of the results was statistically significant.
Roomruangwong et al.⁵⁷	No		There was no significant relationship between infant feeding practice and postpartum depression.
Shah and Lonergan⁹⁴	Yes	Inverse	The odds ratio for postpartum depression (PPD) was 2.3 (95% CI: 1.27–4.44) times more among nonexclusive breastfeeding mothers during the initial 6 weeks after delivery as compared with exclusively breastfeeding women (p = 0.006).
Sibolboro and Mezzacappa⁹⁸	Yes	Mixed	Breastfeeding by primiparas was not associated with significantly decreased odds of having depression compared with bottle feeders (OR = 0.60, 95% CI: 0.24–1.46, p = 0.26).Breastfeeding by multiparas was associated with significantly decreased odds of having depression compared with bottle feeders (OR = 0.41, 95% CI: 0.19–0.87, p = 0.02).
Sword et al.⁷²	Yes	Inverse	Noninitiation of breastfeeding was associated with a higher risk of postpartum depression (OR = 1.74, 95% CI: 1.09–2.79, p = 0.0202)
Warner et al.⁷⁵	Yes	Inverse	Bottle feeding at 6 weeks was associated with a higher risk of postpartum depression: OR = 1.85 (95% CI: 1.39–2.46).
Wei et al.¹⁰¹	Yes	Mixed	Mothers who bottle-fed their infants had significantly higher incidences of major and minor depression (27.4%) at 6 weeks postpartum than mothers who exclusively breastfed their infants (17.7%).Mothers who exclusively breastfed their infants had slightly higher rates of depression at 6 weeks postpartum than mothers who nonexclusively breastfed their infants
Xu et al.⁷³	No		No significant relationship between breastfeeding status and hospitalization within 1 year postpartum for depression
Ystrom⁸¹	Yes	Inverse	At 6 months postpartum, bottle feeding was associated with the greatest risk of depression and anxiety symptoms (B = 0.24; 95% CI: 0.21–0.28), followed by mixed breastfeeding (B = 0.08; 95% CI: 0.05–0.11)
Yusuff et al.⁶⁹	Yes	Inverse	Mothers who breastfed exclusively for three months postpartum had significantly lower mean EPDS scores at both 1 (p = 0.017) and 3 (p = 0.003) months postpartum than others with a shorter duration of exclusive breastfeeding.
Zainal et al.⁹⁷	Yes	Inverse	Nonexclusive breastfeeding predicted postpartum depression (p < 0.01, adjusted OR = 23.7, 95% CI: 3.1–179.7)

Inverse: breastfeeding decreased the risk of postpartum depressive symptomatology. Direct: breastfeeding increased the risk of postpartum depressive symptomatology

PSE, present state examination; PPD, postpartum depression; MINI, Mini International Neuropsychiatric Index.

A total of 28 studies^{58,59,66,69,70,72,75,79

–82,85,88,89,92,94

–97,100,102
–104,107

–111} found that breastfeeding was associated with a decreased risk of postpartum depression symptomatology. A single study⁹¹ reported that breastfeeding increased the risk of depressed mood during the first week postpartum. Five studies^{83,86,87,98,101} identified both positive and negative effects of breastfeeding on mental health, either between different subgroups ^86,98,101 or at different time points^83,87 For example, one study found bottle feeding was associated with the highest risk of depression symptoms, followed by exclusive breastfeeding, and mixed breastfeeding with the lowest risk.¹⁰¹

The final study⁷³ is reported separately given its large sample size and that its primary endpoint was postpartum hospital admission with psychiatric diagnosis; this would indicate more severe disease than the other studies. There were 186,452 included participants and no statistically significant relationship between breastfeeding status and postpartum depression symptoms was found. However, since hospitalization was used as the endpoint, this article did not report data on women who had depression symptoms but were not hospitalized. This article will continue to be reported on separately given its large sample size compared with other studies, its markedly different endpoint compared with other studies, and questionable directionality of the association between breastfeeding and mental health.

Effect of breastfeeding on postpartum anxiety symptoms

Of the nine studies in which the mental health outcome was postpartum anxiety symptomatology (Table 3), four^66,73,81,109 identified a statistically significant relationship. Three studies^66,81,109 reported that breastfeeding was associated with a reduced risk of postpartum anxiety symptoms. One study⁷³ found that nonbreastfeeding reduced the risk of hospitalization from anxiety disorder. However, as reported above, this study used hospitalization as its endpoint and, therefore, is not comparable to the remainder of studies.

Table 3.

Effect of Breastfeeding on Postpartum Anxiety Symptoms

Authors	Statistically significant?	Association	Result
Assarian et al.¹¹¹	No		There was no significant relationship between infant feeding status and anxiety disorder
Bandelow et al.¹⁰⁵	No		Breastfeeding did not have a significant effect on panic manifestations in the postpartum period.During the postpartum period, PMQs were not significantly different between women who had breastfed their children (125 pregnancies, PMQ = 0.22) and had not breastfed their children (42 pregnancies; PMQ = 0.13; Wilcoxon–Mann–Whitney test, U = 2234, p = 0.15)
Cooke et al.⁶⁴	No		Breastfeeding duration was not significantly associated with Postnatal State–Trait Anxiety Inventory (STAI) scores at 3 months postpartum (p = 0.83)
de Jager et al.⁶³	No		Women who exclusively breastfed <6 months had a mean Depression Anxiety Stress Scale 21 (DASS-21) of 7.0 (SD 8.5) for anxiety, and women who exclusively breastfed for >6 months had a mean DASS-21 of 5.8 (6.3) for anxiety, p = 0.439.
Falah-Hassani et al.⁶⁶	Yes	Inverse	Not breastfeeding at 1 week (OR: 1.73, 95% CI: 1.02–2.93) was significantly associated with comorbid depressive symptomatology and anxiety.
Heinrichs et al.¹⁰⁹	Yes	Inverse	BF led to significantly decreased anxiety responses [F = 4.21; p = 0.047]
Kendell et al.⁷⁴	No		The average ratings on the anxiety scales tend to rise during the first few days after delivery and to fall slowly and steadily thereafter, independent of whether the mother is breastfeeding or bottle feeding.
Xu et al.⁷³	Yes	Direct	Nonbreastfeeding decreased the risk of hospitalization within 1 year postpartum with a diagnosis of anxiety disorder (ARR = 0.6; 95% CI: 0.5–0.9)
Ystrom⁸¹	Yes	Inverse	At 6 months postpartum, bottle feeding was associated with the greatest risk of depression and anxiety symptoms (B = 0.24; 95% CI: 0.21–0.28), followed by mixed breastfeeding (B = 0.08; 95% CI: 0.05–0.11)

Inverse: breastfeeding decreased the risk of postpartum anxiety symptomatology. Direct: breastfeeding increased the risk of postpartum anxiety symptomatology.

PMQ, panic manifestation quotient.

Effect of breastfeeding on other mental health symptoms

Three studies^62,71,73 looked at a variety of other mental health outcomes (Table 4). Two of these studies^62,73 reported statistically significant results. The large aforementioned study⁷³ found no effect of breastfeeding on hospitalization with adjustment disorder or a personality disorder. They did however, find that non-breastfeeding was associated with an increased risk of hospitalization with bipolar disorder or schizophrenia within 1 year postpartum. Another study⁶² found that exclusive breastfeeding was associated with a decreased risk of symptoms of postpartum PTSD. The final study⁷¹ reported no relationship between breastfeeding and postpartum psychosis symptoms.

Table 4.

Effect of Breastfeeding on Other Postpartum Mental Health Symptoms

Authors	Mental Health Symptoms	Statistically Significant?	Association	Results
Beck et al.⁶²	PTSD	Yes	Inverse	Women who did not exclusively breastfeed at 1 month after birth had significantly higher PSS-SR scores than women who were not exclusively breastfeeding at 1 month postpartum (p < 0.001)Women who did not BF as long as they wanted had significantly higher PSS-SR scores than women who did breastfeed as long as they wanted (p < 0.001)Depressive symptoms on the PHQ-2 and total physical problems explained 55% of the variance in posttraumatic stress symptoms scores
Bergink et al.⁷¹	Psychosis	No		There was no difference in the prevalence of breastfeeding in women with postpartum psychosis compared with controls.
Xu et al.⁷³	Bipolar Disorder	Yes, Inverse	Inverse	Nonbreastfeeding increased the risk of hospitalization within 1 year postpartum with a diagnosis of bipolar, disorder (ARR = 1.9; 95% CI: 1.1–3.5)
	Psychosis	Yes, mixed	Mixed	Nonbreastfeeding increased the risk of hospitalization within 1 year postpartum with a diagnosis of schizophrenia (ARR = 2.0; 95% CI: 1.3–3.1)No relationship between breastfeeding status and acute psychotic episode
	Adjustment Disorder	No		No relationship between breastfeeding status and adjustment disorder
	Personality Disorder	No		No relationship between breastfeeding status and hospitalization for personality disorder

Inverse: breastfeeding decreased the risk of postpartum mental health disorder symptomatology. Direct: breastfeeding increased the risk of postpartum mental health disorder symptomatology.

PSS-SR, posttraumatic symptom scale, self-report version; PHQ, patient health questionnaire.

Breastfeeding difficulties, breastfeeding self-efficacy, and maternal role attainment

Eight studies^{57

–64} reported on the effect of breastfeeding difficulties on postpartum mental health outcomes (Table 5). Breastfeeding difficulties had varied definitions, including latching problems, nipple pain, negative emotions during infant feeding, breast infection, and lack of milk supply. Five studies^57

–60,62 found that breastfeeding challenges or noninitiation of breastfeeding despite intention to do so was associated with higher risk of symptoms of maternal mental health conditions, including depressive symptomatology or posttraumatic stress symptoms. For example, Beck et al. found that women with more physical challenges to breastfeeding and women who did not breastfeed as long as they desired had higher PTSD symptomatology.⁶²

Table 5.

Effects of Breastfeeding Challenges and Self-Efficacy

Authors	Summary of results
Breastfeeding difficulties
Alder and Cox⁶¹	Mixed breastfeeders reported more feeding problems in the first 3 months than exclusive breastfeeders (76% vs. 44%, p < 0.02)
Beck et al.⁶²	Women with more physical problems (e.g., sore nipples, breast infection, or nonbreastfeeding-related problems) in the first 2 months postpartum (r = 0.69, r ² = 0.48, p < 0.001) and 6 months later (r = 0.24, r ² = 0.06, p < 0.01) had significantly higher posttraumatic stress symptoms than women with fewer physical problems
Cooke et al⁶⁴	A Chi-squared analysis (χ ² = 0:28, p = 0.96) indicated there was no relationship between breastfeeding duration and perceived breastfeeding problems (yes/no) in the first 2 weeks after birth (χ ² = 0.28, df = 3, p = 0.96)Women who had high Maternal Role Attainment were less likely to stop breastfeeding within the first 3 months (21%) than woman with low MRA (39%)Women with high Maternal Role Attainment scores 2 weeks after birth who ceased breastfeeding before 3 months had the highest average EPDS scores at 3 months compared with women who continued to breastfeed and women who ceased breastfeeding but who had low Maternal Role Attainment scores. (p = 0.001)
de Jager et al.⁶³	Women who exclusively breastfed for six or more months postpartum had lower scores on reported breastfeeding difficulties (p < 0.001).
Imširagić et al.⁵⁹	Univariate modeling: unsuccessful breastfeeding initiation increased odds for clinically significant EPDS at 3–5 days postpartum (OR = 2.94, 95% CI: 1.76–4.92)Multivariate modeling: unsuccessful breastfeeding initiation increased odds for clinically significant EPDS at 3–5 days postpartum (OR = 2.58, 95% CI: 1.35–4.91)
Jobst et al.⁶⁰	Breastfeeding problems showed a trend toward a significant prediction of postpartum depressive symptoms.Breastfeeding problems significantly predicted MADRS 7 weeks after delivery (model 1: β = 0.233; t = 2.135; p = 0.036^a).However, breastfeeding problems did not predict MADRS 6 months postpartum (model 2: β = 2.131; t = 0.843; p = 0.402).
Koutra et al.⁵⁸	Women with breastfeeding difficulties were more likely to have higher EPDS scores (β coefficient 0.77, 95% CI: 0.02–1.53, p < 0.05).
Roomruangwong et al.⁵⁷	Infant feeding difficulties were a statistically significant risk factor for postpartum depression (F = 12.10; p = 0.0005)
Breastfeeding self-efficacy
Chaudron et al.⁶⁵	Of the women who were breastfeeding at 1 month postpartum, women who worried about breastfeeding were significantly more likely to become depressed than those who did not worry (RR = 3.0, 95% CI: 1.041–9.216, p = 0.04)
Chong et al.⁶⁷	The higher the mothers' prenatal breastfeeding efficacy, the lower their depression at 9 months postpartum, (β = −0.63, SE = 0.25, p = 0.013)
de Jager et al.⁶³	Women who exclusively breastfed for 6 or more months postpartum had higher scores on their level of breastfeeding self-efficacy (p < 0.001)
Falah-Hassani et al.⁶⁶	Satisfaction with breastfeeding progress (well, satisfactory, not well, terrible), Maternal confidence in breastfeeding at 1 week and 4 weeks postpartum was assessed using the 14-item Breastfeeding Self-Efficacy Scale-Short FormDissatisfaction with breastfeeding progress (OR = 2.20, 95% CI: 1.02–4.78) was significantly associated with comorbid depressive symptomatology and anxietyConfidence with BF was associated with decreased odds of comorbid symptoms; 1 week: OR = 0.50 (95% CI: 0.41–0.62), aOR = 0.66 (95% CI: 0.49–0.88); 4 weeks: OR = 0.50 (95% CI: 0.40–0.63)
Henshaw et al.⁶⁸	Higher breastfeeding self-efficacy scores predicted less depressive symptoms at 6 weeks postpartum (p < 0.001)

Maternal Role Attainment, Women who had high Maternal Role Attainment (MRA) have strong beliefs about the importance of breastfeeding for fulfilling the maternal role; MADRS, Montgomery–Asberg Depression Rating Scale.

Five studies^63,65

–68 examined the effects of breastfeeding self-efficacy, or a woman's confidence in breastfeeding, on mental health outcomes (Table 5). Four of these^65

–68 found that worry about breastfeeding or dissatisfaction with breastfeeding progress was significantly associated with higher depressive symptomatology at various time points. The fifth study⁶³ reported that higher maternal self-efficacy was associated with durations of exclusive breastfeeding greater than six months postpartum.

Two studies^63,68 investigated the interplay between breastfeeding difficulties and self-efficacy, and how these factors combined contribute to maternal mental health outcomes. Henshaw et al. found no significant relationship between self-efficacy, ease of breastfeeding, and mood outcomes when examined together, although breastfeeding problems had an independent effect on depression.⁶⁸ De Jager et al. reported that women who had higher levels of breastfeeding self-efficacy and fewer breastfeeding difficulties were more likely to exclusively breastfeed for six months or more.⁶³

Cooke et al. explored the concept of Maternal Role Attainment (MRA) in the context of breastfeeding using the MRA subscale of the Maternal Breastfeeding Evaluation Scale (MBFES), which describes the extent to which a woman views successful breastfeeding as an important part of her identity as a mother.⁶⁴ Women who had higher MRA subscale scores were less likely to stop breastfeeding at three months postpartum than women with lower scores, however, if they did stop breastfeeding, they had higher EPDS scores.⁶⁴ Women with low MRA and no breastfeeding difficulties were more likely to stop breastfeeding than those with higher MRA who experienced breastfeeding challenges.

Discussion

This systematic review synthesized heterogeneous literature regarding the effects of breastfeeding on postpartum maternal mental health. The mixed results suggest there is a complex relationship influenced by numerous factors. The majority of studies concluded that breastfeeding is associated with fewer mental health symptoms or there was no relationship between breastfeeding and maternal mental health. However, when breastfeeding challenges and low self-efficacy were present, there was an association with increased mental health symptomatology.

Biological effects of breastfeeding

There is biologic plausibility for breastfeeding to have protective effects on perinatal mental health through release of oxytocin. In their systematic review, Uvnäs Moberg et al. concluded that breastfeeding resulted in an immediate release of oxytocin, especially in multiparous women, and was associated with decreased maternal cortisol levels and anxiety.¹¹² This suggests that breastfeeding may have immediate short-term effects on maternal mood. These positive effects of breastfeeding are likely mediated by the robust activation of the reward pathway by oxytocin, dopamine, and the overall neural response to the act of breastfeeding.^113,114

These beneficial effects of oxytocin and related maternal hormones are maximized in positive breastfeeding environments, where there are synergistic benefits to the mother and child due to the transmission of oxytocin through breast milk and synchronicity in diurnal endocrine rhythms and behavior.¹¹⁵

Breastfeeding challenges can be an intense, chronic stressor for mothers, which is likely to disrupt the typical role of oxytocin in the modulation of maternal mood. Disruptions in the oxytocinergic system have been associated with postpartum depression,^116,117 and symptoms of anxiety in mothers have been associated with low levels of oxytocin.¹¹⁸ However, clinical trials with intranasal oxytocin administration in depressed mothers have had conflicting results, with acute oxytocin increasing general sadness but improving positive perceptions of the maternal-infant relationship.¹¹⁹

Breastfeeding challenges

There are misconceptions that breastfeeding is “natural” and is thus easy and intuitive. In reality, many women perceive and/or experience inadequate support from their community, including health care providers, not only during breastfeeding, but also with cessation.^42,43,120 In this review, we found that breastfeeding difficulties, including nipple pain, latching difficulties, diminished milk supply, or unsuccessful breastfeeding initiation are associated with an increased risk of negative mental health symptoms. As Williams notes, “seldom do we willingly encourage others to picture their future breastfeeding experience to include traumatized nipples, screaming, back-arching, breast-refusing infants, or hours spent in a love–hate relationship with the breast pump or other gadgets.”¹²¹

These challenges may lead to a shorter duration of breastfeeding than intended or desired, and subsequent feelings of inadequacy or failure, which may increase the risk of postpartum depression symptoms. It is important to identify women with breastfeeding challenges and increase both lactation support and mental health counseling. Breastfeeding recommendations must be individualized and consider the potential negative impact of breastfeeding challenges on maternal mental health. In such situations, recommendations may include discontinuing breastfeeding.

MRA and the role of stigma

The results from Cooke et al., who reported on MRA, suggest that a woman who views breastfeeding as integral to her role as a mother may be more likely to continue breastfeeding despite difficulties. Those with higher MRA scores have greater expectations of themselves to breastfeed, and when this does not continue, may feel even more disappointed and guilty than those who view breastfeeding as less essential to their maternal role.⁶⁴

The extent to which a mother considers breastfeeding an integral factor in her maternal role may depend on the cultural importance placed on breastfeeding and the stigma associated with nonbreastfeeding. As noted in previous literature,¹²² stigma negatively impacts mental health and prevents recovery from mental illness. The cultural support of breastfeeding may positively impact maternal mental health if initiation of breastfeeding is successful and continues, but may negatively impact maternal mental health if breastfeeding is unwanted or challenging.¹²³

Societal pressures to breastfeed may influence one's self-imposed pressure to do so as well. However, as described by Mozingo et al., women who stopped breastfeeding within two weeks of initiation consistently described an incongruity between their idealized thoughts of breastfeeding and the reality of their actual experience, resulting in a sense of failure, guilt, disappointment, or shame about breastfeeding cessation, and self-doubt.¹²⁰ This finding has been supported in related investigations.^42,43

Likely in relation to the cultural stigma associated with not breastfeeding, it is unsurprising that the literature suggests the interplay between infant feeding method and maternal mental health outcomes is impacted by factors, including maternal self-efficacy in breastfeeding, physical challenges with breastfeeding, and the extent to which a woman believes breastfeeding is an important part of her maternal identity. These factors may cause breastfeeding challenges to worsen mental health symptoms in some women.

Strengths

This review synthesizes associations between breastfeeding and multiple maternal mental health outcomes. While literature exists addressing the relationship between maternal mental health on breastfeeding, this review aimed to explore the relationship in the opposite direction. Importantly, we investigated the impact of breastfeeding challenges and breastfeeding self-efficacy on maternal mental health, which are relationships that merit further exploration in the literature.

This review includes a large number of studies and total participants. It is a multinational review with studies from 25 different countries from North America, Europe, Asia, and Australia, representing many cultures, which have differing views on mental health and breastfeeding practices. The wide representation of countries contributes to the generalizability of these study results across many populations globally.

Limitations

This review has several limitations, namely that our interpretive abilities are limited due to the very heterogeneous nature of the existing literature. The authors of the original included articles used diverse methods of defining and measuring breastfeeding, and at times, the definitions of breastfeeding were not always explicitly stated. Similarly, mental health outcomes were measured at different time points postpartum with various measurement tools, which impacted the ability to compare outcomes in a standardized way. Additionally, in the included studies, mental health before initiation of breastfeeding was reported in diverse ways.

Many studies excluded women with a history of mental illness,^{57,58,71,78,79,88,94,97,103,105,109,111} however, the mental illnesses excluded were not consistent across studies, as some excluded women with a history of any mental illness and others excluded women with a history of only certain mental illnesses. Other studies excluded participants with current psychotropic medication use.^59,90,107

In more than one third of the included studies,^{60

–63,69,70,75
–77,83,89,91,95,98,99,102,106,108} there was no assessment of mental health before initiation of breastfeeding. We did not formally abstract or analyze data specific to mental health conditions with preconception or pregnancy onset; this is an opportunity for future research.

It is possible that some of the protective effects of breastfeeding on maternal mental health described in this review are due to the stable or supportive psychosocial conditions in women who breastfeed compared with women who do not, leading to potential selection bias. However, the information gathered in these studies is not sufficient to address this limitation, and further understanding of the psychosocial conditions of women who do and do not breastfeed and their impact is warranted.

The preparation of this article was delayed due to the COVID-19 pandemic. It is limited by not including studies published after our original search was conducted and through the pandemic. However, given the impact of the pandemic on mental health, even with an updated search, we would choose to exclude articles published after the onset of the pandemic.

Additionally, it is worthy of noting that all systematic reviews are limited by publication bias, which references the decreased likelihood of studies with negative effects or nonstatistically significant findings to be published, resulting in peer-reviewed publications being skewed toward research with positive results. Outcome reporting bias also addresses the fact that many studies collect a wide range of outcomes yet often all are not reported. For example, the data presented on breastfeeding challenges were compelling. For the studies that did not report this, we do not know if it was not collected at all or was not reported.

Finally, the clinical significance of the results in the original articles was not always reported. Small differences in EPDS scores have unknown clinical significance. As breastfeeding can be challenging for mothers, it is imperative that mothers know the clinical, not only statistical, significance of exclusive breastfeeding on their risk of mental illness to make personal decisions about initiating or continuing breastfeeding in the context of experiencing breastfeeding challenges.

Future research should more clearly elucidate the relationship between breastfeeding and maternal mental health by measuring maternal mental health before and after breastfeeding onset to examine causality between breastfeeding and maternal mental health rather than mere association. Future studies should consistently examine outcomes within the DSM-5 definitions and criteria using validated tools, and researchers should comment on the clinical significance of their results.

To more fully understand the relationship between breastfeeding challenges and mental health, we need to more fully explore the actual breastfeeding experiences of people with perinatal mood and anxiety disorders, as well as conducting more focused research with people who intend to breastfeed but did or could not. Phenomenological approaches that capture women's own words would help to inform a future body of research that adequately addresses some of the limitations mentioned above, along with standardized data definitions.

Recommendations

Beyond research, there are practical recommendations that can be derived from the studies included in this review and the clinical experience of its authors. First and foremost, perinatal individuals should be asked how they are feeding, or planning to feed their baby (as opposed to being asked if they are breastfeeding). This simple, open-ended and nonleading question goes a long way toward destigmatizing lack of intention to breastfeed, breastfeeding challenges or cessation, and mixed or formula feeding.

If and when a woman shares her intention to breastfeed, and especially if it is her first time, she should be informed about the full range of possible experiences, including common challenges and stressors.^124,125 Honesty and transparency about breastfeeding will likely mitigate feelings of guilt or failure that many women feel when their breastfeeding experience does not match their plans and expectations.^126,127 Additionally, all perinatal mental health assessments should include questions about feeding intention and experience, so that women are not bearing the burden of bringing up a potentially difficult topic.¹²⁸

Any discussion about infant feeding should incorporate all aspects of the patient's life, including her partnership status, level of familial and social support, exposure to systemic racism and other structural stressors, work situation and financial status, and everyday logistics such as commuting, caregiving, and the ease of providing for her and her family's most basic needs.^129,130 Women who do present with significant breastfeeding challenges and perinatal mental health issues should be supported to make whatever decision is best for themselves and their families. Professionals should refrain from presenting all-or-nothing scenarios, given that many women combine breast and formula feeding in ways that allow them to enjoy successful, and if they so choose, long-lasting breastfeeding relationships with their children.^131,132

Conclusions

There is a complex relationship between breastfeeding and maternal mental health. When considering the impact of breastfeeding on maternal mental health, we need to take into account one's perception of breastfeeding and the breastfeeding experience. While we found that breastfeeding was often associated with fewer maternal mental health symptoms, this was not the case when breastfeeding difficulties or a discordance between maternal role expectations and actual experience were present. In fact, difficulties and discordance were associated with poorer mental health outcomes.

The effect of breastfeeding on maternal mental health outcomes appears to be dependent on the emphasis an individual person places on the importance of breastfeeding for motherhood. For some, breastfeeding is an important part of their maternal identity, and difficulties with breastfeeding may put them at risk for depression, anxiety, or other mental health conditions. For others, maternal identity is formed in other ways and stopping breastfeeding may not put them at similar risks.

With this review, we sought to decrease the stigma surrounding lack of breastfeeding or mixed feeding, as breast may not always be the best option. Further research is needed to elucidate the relationship between breastfeeding and maternal mental health so that clinicians can best individualize breastfeeding counseling for their patients, which at times, may include breastfeeding cessation in the event of negative maternal mental health outcomes.

Footnotes

Acknowledgment

The authors thank Florent Pittet for his assistance with the screening of articles for this review.

Authors' Contributions

The co-first authors on this article contributed equally at all stages of the review, including screening, data abstraction and analysis, and writing the article. All other authors met all four criteria for authorship, including substantial contributions to the design of the review, analysis and interpretation of data, drafting or revising the work, and final approval of the version to be published.

Author Disclosure Statement

Dr. Byatt has received salary and/or funding support from Massachusetts Department of Mental Health through the Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms). She is also the statewide Medical Director of MCPAP for Moms and the Executive Director of Lifeline for Families. She has served on the Medscape Steering Committee on Clinical Advances in Postpartum Depression and the Behavioral Health Network of Excellence for the Kinetix Group. She received honoraria from Medscape, Mathematica, and the Global Learning Collaborative.

Dr. Moore Simas is a consultant for the Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms), as Obstetric Engagement Liaison. She is also the Medical Director of Lifeline for Moms, which is part of the University of Massachusetts Chan Medical School.

None of the other authors has any disclosures to report.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Appendix SA1

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