This was a cross-sectional study to evaluate the relationship between maternal mood symptoms during pregnancy and EBF at 6 weeks postpartum. A higher risk of non-EBF in mothers who experienced depression during pregnancy, but not in mothers with anxiety during pregnancy, was observed in the logistic regression model analysis. However, no interaction was found between the presence of depressive symptoms during pregnancy and other factors on EBF at 6 weeks postpartum.
Previous studies have suggested an association between maternal mood disorders and suboptimal breastfeeding outcomes [20–22]. Cato et al. reported that depressive symptoms during pregnancy increase the odds of non-EBF at 6 weeks postpartum [18]. Figueredo et al. found that depression in pregnancy increased the risk of early cessation of EBF [20]. Similarly, our research also indicated that EBF was negatively affected by depression during pregnancy. However, Sharifi et al. [13] and Fukui et al. [23] reported that depression was not associated with failure to breastfeed exclusively. A possible explanation for the difference in results could be that they are limited to a point in the perinatal period, regardless of the pregnancy period. In addition, our findings demonstrating that anxiety disorders during pregnancy are not significantly associated with EBF is consistent with those of previous studies [15, 23, 24]. However, a North Carolina study reported that anxiety symptoms were associated with earlier introduction of formula supplementation and cessation of breastfeeding [25]. In their study, participants with a history of depression or anxiety were not excluded, which may have led to discrepancies in their research conclusions.
This study confirms and extends earlier work on the association between depressive symptoms during pregnancy and EBF. Depression in pregnancy impairs the practice of EBF, which could be explained from psychological and biological standpoints.
Available evidence suggests that maternal depression is related to reduced breastfeeding self-efficacy [15], particularly with breastfeeding initiation [21], which is the most significant predictor of subsequent breastfeeding behavior [26]. Women with depressive symptoms during pregnancy are more likely to develop postpartum depression (PPD) [27]. Moreover, PPD contributed to reducing the practice of EBF [28]. Hence, it could be speculated that women who have experienced depression during pregnancy may increase the risk of non-EBF practice. In addition, pregnant women who are depressed during pregnancy may opt to use antidepressant drugs depending on their condition. Clinicians may recommend avoiding breastfeeding for parturient women who are on psychiatric medications owing to the possibility that these medications may be secreted in their breast milk [29, 30]. Additionally, both antenatal and postpartum depressive symptoms adversely affect postpartum mother-infant bonding [31, 32]. Poor mother-infant bonding reduces breastfeeding self-efficacy and autonomous breastfeeding motivation [33–35]. Consequently, mothers with depression during pregnancy may be less likely to breastfeed exclusively.
Furthermore, the finding that mothers with depressive symptoms during pregnancy had an increased risk of non-EBF suggests the existence of neuroendocrine mechanisms. Oxytocin (OT), a neuropeptide hormone synthesized in the hypothalamus, is critical in breastfeeding physiology because it stimulates milk ejection [36]. A review study demonstrated that depressive symptoms were inversely correlated with OT levels [37]. These results are in agreement with earlier findings showing that perinatal depression is associated with diminished OT release, further triggering failed establishment of lactation [38, 39]. Accordingly, women with a history of depression during pregnancy are less likely to implement EBF.
The main strengths of this study are the large sample size and adjustment for several potential confounders, including sociodemographic characteristics, maternal pregnancy, childbirth-related factors, and infant-related factors. Nevertheless, there are some limitations to this study. First, a cross-sectional study design cannot infer direct causality between depression during pregnancy and EBF. Second, we used self-reported methods to assess mothers’ moods during pregnancy, not on scales, although it has been proven feasible in a previous study [16]. Third, the study was a single-center study; therefore, the results should be generalized with caution. More multicenter cohort studies are required to verify our results.