Breastfeeding is a healthy behavior that can decrease postpartum depression

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According to the United States Centers for Disease Control and Prevention, between 11 and 20 percent of women who give birth each year in the U.S. have postpartum depression symptoms, which is the greatest risk factor for maternal suicide and infanticide.

Given that there are 4 million births annually, this equates to almost 800,000 women with postpartum depression each year.

Current biological and psychosocial models of breastfeeding suggest that breastfeeding could possibly reduce a woman’s risk for postpartum depression.

However, prior studies only have looked at the initiation of breastfeeding and breastfeeding length.

In addition, small and often homogenous samples have yielded ungeneralizable results lacking in statistical power with biased results due to higher levels of education, income, and proportions of white participants compared to the general population of the sampled country.

Researchers from Florida Atlantic University’s Christine E. Lynn College of Nursing and collaborators are the first to examine current breastfeeding status in association with postpartum depression risk using a large, national population-based dataset of 29,685 women living in 26 states.

Results of the study, published in the journal Public Health Nursing, demonstrate that postpartum depression is a significant health issue among American women with nearly 13 percent of the sample being at risk.

Findings showed that women who were currently breastfeeding at the time of data collection had statistically significant lower risk of postpartum depression than women who were not breastfeeding. In addition, there is a statistically significant inverse relationship between breastfeeding length and risk of postpartum depression.

As the number of weeks that women breastfed increased, their postpartum depression decreased. An unexpected finding was that there was no significant difference in postpartum depression risk among women with varying breastfeeding intent (yes, no, unsure).

“Women suffering from postpartum depression, which occurs within four weeks and up to 12 months after childbirth, endure feelings of sadness, anxiety and extreme fatigue that makes it difficult for them to function,” said Christine Toledo, Ph.D., senior author and an assistant professor in FAU’s Christine E. Lynn College of Nursing.

“Women with postpartum depression who are not treated also may have negative outcomes, including difficulty bonding with and caring for their children, thoughts of harming themselves or their infant, and also are at an increased risk of substance misuse.”

Woman who have experienced postpartum depression have a 50 percent increased risk of suffering further episodes of postpartum depression in subsequent deliveries. In addition, they have a 25 percent increased risk of suffering further depressive disorders unrelated to childbirth up to 11 years later. Postpartum depression increases maternal morbidity and is associated with increased risks for cardiovascular disease, stroke and type-2 diabetes.

For the study, Toledo and collaborators from the University of Miami School of Nursing and Health Studies, University of North Carolina School of Nursing, Chapel Hill, Seattle University of Nursing, and The University of British Columbia School of Nursing, analyzed dataset from the 2016 Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire to investigate the association of breastfeeding practices taking into consideration significant covariates such as age, race, marital status, education, abuse before and during pregnancy, cigarette smoking, among others.

“Findings from this important study suggest that breastfeeding is a cost efficient and healthy behavior that can decrease a woman’s risk for postpartum depression,” said Safiya George, Ph.D., dean, FAU Christine E. Lynn College of Nursing.

“Nurses in particular play an important role in educating and promoting both the maternal health benefits of breastfeeding and infant benefits such as providing necessary nutrients and protecting them against allergies, diseases and infections.”

Study co-authors are Rosina Cianelli, Ph.D.; Giovanna De Olivera, Ph.D.; and; Karina Gattamorta, Ph.D., all with the University of Miami School of Nursing and Health Studies; Natalia Villegas Rodgriguez, Ph.D., University of North Carolina School of Nursing, Chapel Hill; Danuta Wojnar, Ph.D., Seattle University of Nursing; and Emmanuela Ojukwu, Ph.D., The University of British Columbia School of Nursing.

Funding: The study was funded by the Ph.D. Scholarly Award by the Sigma Theta International, Beta Tau Chapter.


Oxytocin is an essential lactation hormone released during breastfeeding that causes milk ejection and appears to have calming effect on the mother.[1] Administration of exogenous oxytocin to mothers having difficulty in breastfeeding has not been clearly shown to have a beneficial effect on lactation success or in the treatment of breast engorgement. It might be of benefit in women who have lost the neuronal connection between the breast and hypothalamus. Effects on the infant are unlikely when given during breastfeeding.

Numerous studies suggest that oxytocin given during labor can negatively affect breastfeeding, possibly by reducing sucking behavior in the newborn in a dose-dependent manner, or by decreasing postpartum oxytocin release although study methodology and consistency has varied considerably.[2-15] This effect might be most important during the initiation of breastfeeding, but may not persist after lactation is established.[16]

One study found that only oxytocin in conjunction with epidural analgesia reduced breastfeeding, but not oxytocin alone.[17] Another study found that all rhythmic reflexes, the antigravity reflex, and total primitive neonatal reflexes were inhibited by intrapartum oxytocin administration, unrelated to dose, which could adversely affect breastfeeding.[18] Some evidence exists that peripartum oxytocin administration might increase the risk of postpartum depression.[15]

Effects on Lactation and Breastmilk

Intranasal oxytocin is reportedly used by some midwives in Switzerland as a galactogogue.[19] It has been used as part of regimens used by adoptive mothers who wish to breastfeed.[20]

A small study found no difference in symptoms between subcutaneous oxytocin 2.5 international units daily and placebo after 3 days of treatment for breast engorgement.[21,22]

An early randomized, placebo-controlled trial used oxytocin nasal spray in the mothers of newborns, but lactation management fell far short of what is considered acceptable nowadays. The study found that the spray might be useful in decreasing breast engorgement slightly in the mothers of fullterm infants, but no difference was found in the average infant weight loss between birth and day 4 in the oxytocin and placebo groups.[23]

Two similarly designed trials studied oxytocin nasal spray in mothers of preterm newborns who were pumping milk for their infants. The first studied mothers of infants born before 38 weeks and used a total of 3 units of intranasal oxytocin (Syntocinon-Sandoz, 40 units/mL) before pumping each breast for10 minutes a breast pump four times daily.

Among primiparous mothers, milk production during days 2 to 5 days postpartum was 1964 mL in those who used oxytocin and 510 mL in those who received placebo spray. Because of the large and statistically significant effect of oxytocin among primiparous women, the trial was stopped after only 8 primiparous mothers had been studied. No statistically significant difference was found between oxytocin and placebo among 4 multiparous women who were attempting to breastfeed for the first time. The paper did not report giving the mothers any instructions in lactation technique.[24]

Fifty-one mothers who delivered an infant of less than 35 weeks gestation were studied. Twenty-seven mothers used 4 units of intranasal oxytocin (Syntocinon-Novartis, 40 units/mL), and 24 mothers received an identical placebo spray before pumping with a breast pump.

All mothers were given instructions on using hand massage before pumping and advised to pump every 3 hours. No difference in milk production over the first 5 days postpartum was found between mothers who received oxytocin (median 667 mL) and placebo (median 530 mL), although women receiving oxytocin produced slightly more milk on day 2 of the study. Parity had no effect in this study.[25]

Several factors might explain the differences in findings between the studies. Because of the great interpatient variability in milk production documented in the recent study and the small number of patients in the first study, the finding in the earlier study may have been due to chance. A 50% higher dose of oxytocin was used in the first study, which may have caused a greater effect. Another plausible explanation is the good lactation support given to mothers in the recent larger study that seemed to be lacking in the early study.

Two case reports indicate that oxytocin nasal spray may facilitate letdown in tetraplegic women who have lost the neuronal connection between the nipple and the hypothalamus.[26]

A study of mothers who received oxytocin during labor found that on the second day postpartum, oxytocin infusion decreased endogenous oxytocin levels dose-dependently. Epidural analgesia in combination with oxytocin infusion influenced endogenous oxytocin levels negatively. Oxytocin infusion also increased serum prolactin.[14]

Logistic regression of data from 585 mothers who had epidural analgesia during labor found that mothers who had received exogenous oxytocin had a 3.3 times greater risk of delayed onset of lactation than women who did not.[7]

An observational study of 20 primiparous women found that those who were exclusively breastfeeding at 3 months (63%) had received a lower dose of oxytocin during labor (mean total dosage 1363 milliIunits) than those who were not exclusively breastfeeding (mean total dosage 3088 milliIunits). This result was attributed to an inhibitory effect on neonatal sucking by the infant caused by oxytocin.[2]

A small, nonrandomized cohort study found that the newborn infants whose mothers received synthetic oxytocin to induce or maintain labor had a decreased level of prefeeding organization one hour after birth.[6]

A retrospective cohort study in Spain compared breastfeeding outcomes between mothers who received oxytocin during labor (n = 189) and mothers who did not, including those who delivered via elective Cesarean section (n = 127). Mothers who received oxytocin during the first and second stages of labor had a 45% increased risk of bottle feeding and a 129% increased risk of breastfeeding discontinuation by 3 months of age. Effects were most pronounced in women under 27 years of age.[5]

A small prospective study in California compared women who received an epidural infusion of fentanyl and ropivacaine to mothers who did not receive an epidermal during labor. All mothers had normal vaginal deliveries and their infants had 1 uninterrupted hour of skin-to-skin contact immediately postpartum.

The study found inverse relationships between the amount of fentanyl and the amount of oxytocin received during labor and the time of the first suckling. Because women who received more fentanyl also tended to receive more oxytocin, the study could not clearly separate the effects of the two drugs.[9]

A small prospective cohort study in Spain followed mothers by telephone postpartum to determine their breastfeeding status. Mothers who had received oxytocin during labor were breastfeeding at a similar rate as those who had not at 1, 3 and 6 months postpartum.[27]

A nonblinded, nonrandomized study compared breastfeeding among the infants of mothers who received oxytocin during delivery (n = 70) and those who did not (n = 90) in two Iranian hospitals. Mothers were primiparous and infants were full term. Infant breastfeeding behavior was assessed to be either successful or unsuccessful within 2 hours of delivery. Infants whose mothers received oxytocin were judged to successfully breastfeed 48.6% compared to 82.2% among the infants of mothers who did not receive oxytocin. Use of opiate pain relievers in the two groups was not stated.[28]

A retrospective cohort study compared breastfeeding results between women who did and did not receive oxytocin during labor. After correcting for confounding factors, the study found that exogenous oxytocin impaired breastfeeding during the first hour postpartum, but not at 3 months postpartum. High pregestational body mass index was the best predictor of an impaired third month’s postpartum breastfeeding.[12]

A retrospective case-control study conducted in two hospitals in central Iran compared breastfeeding behaviors in the first 2 hours postdelivery by infants of 4 groups of primiparous women with healthy, full-term singleton births who had vaginal deliveries. The groups were those who received no medications during labor, those who received oxytocin plus scopolamine, those who received oxytocin plus meperidine, and those who received oxytocin, scopolamine and meperidine. The infants in the no medication group performed better than those in all other groups, and the oxytocin plus scopolamine group performed better than the groups that had received meperidine.[13]

A prospective cohort study in Spain found no relationship between oxytocin dose during labor or postpartum with the duration of breastfeeding. However, elective cesarean section without oxytocin resulted in the greatest risk of stopping exclusive breastfeeding.[29]

An observational study in Sweden compared nursing behaviors of the infants of mothers who received intravenous oxytocin or intramuscular oxytocin with or without receiving epidural analgesia with sufentanil and bupivacaine. Infants of mothers who received oxytocin infusions alone during labor breastfed as well as those of mothers who had no interventions during labor. Mothers who received oxytocin plus epidural analgesia had reduced breastfeeding behaviors and more weight loss at 2 days postpartum than those who did not receive epidural analgesia. The mothers of infants who breastfed well had greater variability in serum oxytocin than those whose infants did not breastfeed well.[17]

reference link : https://www.ncbi.nlm.nih.gov/books/NBK501490/


Original Research: Closed access.
“The significance of breastfeeding practices on postpartum depression risk” by Christine Toledo et al. Public Health Nursing

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