Rethinking depression in new mothers

The Baby Friendly Conference brings together the latest research, innovations and debates around infant feeding and parent-infant relationships. Below, Dr Kathleen Kendall-Tackett shares a preview of her Conference talk, in which she examines the latest research on perinatal depression and the profound impact that this can have on breastfeeding and the wellbeing of mums and babies.

Rethinking Depression in New Mothers: Current Research Trends and Their Implications for Practice

Research in the field of perinatal depression continues to evolve and is sufficient for us to make sound clinical decisions. The most recent research challenges our assumptions and shows that the scope of this problem is much broader than we have previously believed. It also shows that depression and posttraumatic stress disorder (PTSD) in pregnancy increase the risk of preterm birth—the number one cause of infant mortality worldwide. Current studies show that birth interventions, such as epidurals, are related to both breastfeeding difficulties and depression. Moreover, depression is a direct threat to breastfeeding. Depressed mothers are significantly less likely to initiate or continue breastfeeding. Therefore, perinatal depression falls squarely within the purview of breastfeeding supporters. It is our problem. Fortunately, when breastfeeding is going well, it actually lowers mothers’ risk of depression. This is true even when mothers have histories of significant psychological trauma. Taking action to protect mothers’ mental health is crucial in order to support breastfeeding and, in so doing, give more babies the best possible start in life.

Why “10% to 15% of New Mothers” is a misleading statistic

When discussing perinatal depression, experts often say it affects “10% to 15% of new mothers.” That percentage dramatically underestimates the true incidence. Recent studies have revealed that 10% to 15% describes mostly white middle-class mothers who have the opportunity to seek care.  As such, 10% to 15% is a statistic of privilege. Unfortunately, most depressed mothers will never see a mental health provider. Yet their needs are every bit as urgent—if not more so.

What is the true incidence?

A study of 1,507 mothers from Australia found that 31% of mothers were depressed in the first 4 years. Risk factors included young maternal age, stressful life events, adversity, intimate partner violence (IPV), and low income (Woolhouse, Gartland, Mensah, & Brown, 2015). In the US, a nationally representative sample of 86,000 mothers and fathers found that 39% of mothers and 21% of fathers have been depressed in their first 12 years as a parent. Risk of depression is highest in the first year (Dave, Petersen, Sherr, & Nazareth, 2010).

Women in high-risk groups are especially vulnerable. For example, a review of 8 Canadian studies found that up to 42% of immigrant, asylum-seeking women were depressed (Collins, Zimmerman, & Howard, 2011).  A review of 67 studies found that violence against women during pregnancy increased the risk of depression and PTSD in the postpartum period by 3 times (Howard, Oram, Galley, Trevillion, & Feder, 2013). Similarly, mothers had higher rates of depression if they had been exposed to natural disasters in two different studies from China and the US (Qu et al., 2012; Xiong et al., 2010).

Depression, PTSD, and the Number One Cause of Infant Mortality

One of the more alarming findings was the relationship between depression and PTSD, and preterm birth. The World Health Organization considers preterm birth to be the number one cause of infant mortality worldwide.

For example, a study of 16,334 women at US Veteran’s Administration Hospitals found that the rate of preterm birth was 7.4% for women with no PTSD, 8% if they had previous PTSD, and 9.2% in women with current PTSD (Shaw, Asch, Frayne, Shaw, & Phibbs, 2014). Another US study of 2,654 women found that the combination of PTSD and major depression increased the risk of preterm birth by 4 times (Yonkers et al., 2014). Unfortunately, those two conditions often co-occur. It is therefore suprising that we are not routinely screening for both depression and PTSD during pregnancy when it has such an impact on preterm birth and, in turn, infant mortality.

Depression, Breastfeeding Difficulties, and Birth Interventions

Birth interventions can also increase the risk of both depression and breastfeeding difficulties. For example, a study of 5,332 mothers in the UK found that mothers who had forceps-deliveries or unplanned cesareans had more breastfeeding difficulties and depression at 3 months postpartum (Rowlands & Redshaw, 2012).  Similarly, a study of 1,280 mothers from Hong Kong found that induction, opioid pain medications, and emergency cesareans were related to lower rates of both “any” and “exclusive” breastfeeding (Bai, Wu, & Tarrant, 2013).

Epidurals have been particularly controversial. Current evidence suggests that women are less likely to exclusively breastfeed if they had epidurals. A prospective study of 1,280 mothers from Australia found that women who had epidurals were more likely to be partial breastfeeding or have breastfeeding difficulties in the first week postpartum, and were twice as likely to stop breastfeeding before 24 weeks (Torvaldsen, Roberts, Simpson, Thompson, & Ellwood, 2006).

In our study of 6,410 new mothers in the first year postpartum, we found that women who had unassisted vaginal deliveries had significantly higher rates of exclusive breastfeeding than women who had any other type of birth. Women who had epidurals had significantly lower rates of exclusive breastfeeding, and had higher depressive symptoms, even after controlling for possible confounding variables (Kendall-Tackett, Cong, & Hale, 2015).

Depression Threatens Breastfeeding, but Breastfeeding Protects Maternal Mood

Not surprisingly, depression, anxiety, and PTSD directly threaten breastfeeding (Mathews, Leerkes, Lovelady, & Labban, 2014). For example, anxiety at 3 months postpartum reduced odds of exclusive breastfeeding by 11% at 6 months (Adedinsewo et al., 2014). A study of 2,400 births in the US found that a complex pregnancy was associated with 30% lower odds of exclusive breastfeeding. However, supportive hospital practices increased odds of any or exclusive breastfeeding by 2 to 4 times (Kozhimannil, Jou, Attansio, Joarnt, & McGovern, 2014).

Fortunately, exclusive breastfeeding lowers the risk of depression. It improves sleep quality and quantity and downregulates the inflammatory response system (Groer & Kendall-Tackett, 2011; Kendall-Tackett, Cong, & Hale, 2011). Even when women have been sexually assaulted, exclusive breastfeeding attenuates the stress response, lessens the impact of trauma, and lowers their risk of depression (Kendall-Tackett, Cong, & Hale, 2013).

These are only a few of the recent findings. As you can see, the field continues to grow and expand. As we learn more, we can continue to improve the services we provide to new mothers. But first, we need to think differently about depression, realizing how common it is, and help mothers access services they need. Depression in new mothers affects everyone. Fortunately, there is much we can do.

Bio

Dr. Kendall-Tackett is a health psychologist and International Board Certified Lactation Consultant, and the Owner and Editor-in-Chief of Praeclarus Press, a small press specializing in women’s health. Dr. Kendall-Tackett is Editor-in-Chief of two peer-reviewed journals: Clinical Lactation and Psychological Trauma. She is Fellow of the American Psychological Association in Health and Trauma Psychology, Past President of the APA Division of Trauma Psychology, and a member of the Board for the Advancement of Psychology in the Public Interest. Dr. Kendall-Tackett has won many awards for her work including the 2016 Outstanding Service to the Field of Trauma Psychology from the American Psychological Association. Dr. Kendall-Tackett has authored more than 400 articles or chapters, and is currently completing her 35^thbook, The Phantom of the Opera: A Social History of the World’s Most Popular Musical. Her most recent book is Depression in New Mothers, 3^rd Edition (2016) is published by Routledge in the UK.

References

Adedinsewo, D. A., Fleming, A. S., Steiner, M., Meaney, M. J., Girard, A. W., & MAVAN team. (2014). Maternal anxiety and breastfeeding: Findings from the MAVAN (Maternal Adversity, Vulnerability and Neurodevelopment) Study. Journal of Human Lactation, 30(1), 102-109.

Bai, D. L., Wu, K. M., & Tarrant, M. (2013). Association between intrapartum interventions and breastfeeding duration. Journal of Midwifery and Women’s Health, 58(1), 25-32. doi:10.1111/j.1542-2011.2012.00254.x.

Collins, C. H., Zimmerman, C., & Howard, L. M. (2011). Refugee, asylum seeker, immigrant women and postnatal depression: Rates and risk factors. Archives of Women’s Mental Health, 14, 3-11.

Dave, S., Petersen, I., Sherr, L., & Nazareth, I. (2010). Incidence of maternal and paternal depression in primary care: A cohort study using a primary care database. Archives of Pediatric & Adolescent Medicine, 164(11), 1038-1044.

Groer, M. W., & Kendall-Tackett, K. A. (2011). How breastfeeding protects women’s health throughout the lifespan: The psychoneuroimmunology of human lactation. Amarillo, TX: Hale Publishing.

Howard, L. M., Oram, S., Galley, H., Trevillion, K., & Feder, G. (2013). Domestic violence and perinatal mental disorders: A systematic review and meta-analysis. PLoS Medicine, 10(5), e1001452. Retrieved from

Kendall-Tackett, K. A., Cong, Z., & Hale, T. W. (2011). The effect of feeding method on sleep duration, maternal well-being, and postpartum depression. Clinical Lactation, 2(2), 22-26.

Kendall-Tackett, K. A., Cong, Z., & Hale, T. W. (2013). Depression, sleep quality, and maternal well-being in postpartum women with a history of sexual assault: A comparison of breastfeeding, mixed-feeding, and formula-feeding mothers        Breastfeeding Medicine, 8            (1), 16-22.

Kendall-Tackett, K. A., Cong, Z., & Hale, T. W. (2015). Birth interventions related to lower rates of exclusive breastfeeding and increased risk of postpartum depression in a large sample. Clinical Lactation, 6(3), 87-97.

Kozhimannil, K. B., Jou, J., Attansio, L. B., Joarnt, L. K., & McGovern, P. (2014). Medically complex pregnancies and early breastfeeding behaviors: A retrospective analysis. PLoS One, 9(8), 310. doi:10.1371/journal.pone.0104820

Mathews, M. E., Leerkes, E. M., Lovelady, C. A., & Labban, J. D. (2014). Psychosocial predictors of primiparous breastfeeding initiation and duration. Journal of Human Lactation, 30(4), 480-487.

Qu, Z., Wang, X., Tian, D., Zhao, Y., Zhang, Q., He, H., . . . Guo, S. (2012). Posttraumatic stress disorder and depression among new mothers at 8 months later of the 2008 Sichuan earthquake in China.Archives of Women’s Mental Health, 15, 49-55.

Rowlands, I. J., & Redshaw, M. (2012). Mode of birth and women’s psychological and physical wellbeing in the postnatal period. BMC Pregnancy and Childbirth, 12(138). doi:http://www.biomedcentral.com/1471-2393/12/138

Shaw, J. G., Asch, S. M., Frayne, S. M., Shaw, K. A., & Phibbs, C. S. (2014). Posttraumatic stress disorder and risk of spontaneous preterm birth. Obstetrics & Gynecology, 124(6), 1111-1119. doi:10.1097/AOG.0000000000000542.

Torvaldsen, S., Roberts, C. L., Simpson, J. M., Thompson, J. F., & Ellwood, D. A. (2006). Intrapartum epidural analgesia and breastfeeding: A prospective cohort study. International Breastfeeding Journal, 1(24). doi:10.1186/1746-4358-1-24

Woolhouse, H., Gartland, D., Mensah, F., & Brown, S. J. (2015). Maternal depression from early pregnancy to 4 years postpartum in a prospective pregnancy cohort study: Implications for primary health care. British Journal of Obstetrics & Gynecology, 122, 312-321. doi:10.1111/1471-0528.12839.

Xiong, X., Harville, E. W., Mattison, D. R., Elkind-Hirsch, K., Pridjian, G., & Buekens, P. (2010). Hurricane Katrina experience and the risk of post-traumatic stress disorder and depression among pregnant women. American Journal of Disaster Medicine, 5(3), 181-187.

Yonkers, K. A., Smith, M. V., Forray, A., Epperson, C. N., Costello, D., Lin, H., & Belanger, K. (2014). Pregnant women with posttraumatic stress disorder and risk of preterm birth. JAMA Psychiatry, 71(8), 897-904.