May 2, 2022
FACTS Mental Health Awareness Series
Breastfeeding Satisfaction and Symptoms of Postpartum Depression: A Research Synopsis
By Calley Gober
Editor’s Note: As May is Mental Health Awareness month, we will feature a series of articles that discuss the intersections between reproductive health and psychological wellbeing. We begin with a research summary discussing postpartum depression and factors that contribute to this mood disorder, including breastfeeding satisfaction. Calley Gober reviewed the 2020 article, Association between maternal satisfaction with breastfeeding and postpartum depression symptoms, while a medical student in our FACTS elective.
Postpartum depression (PPD) is a mood disorder defined by the same diagnostic criteria as Major Depressive Disorder (MDD) but typically occurs within four weeks of delivery. The DSM-5 criteria for MDD and PPD include depressed mood and/or loss of interest and at least four of the following symptoms within a two-week period: loss of weight or appetite, changes in sleep patterns, psychomotor disturbances, loss of energy, feelings of guilt or worthlessness, decreased concentration, and suicidal ideation. , Additionally, these symptoms must impair the patient’s functioning and cannot be attributed to another disease or substance.  For an accurate diagnosis, PPD must also be distinguished from the “Baby Blues,” which occurs in 50 to 70% of women and is thought to be the result of normal physiologic shifts during the postpartum period. Women with the baby blues typically experience irritability, anxiety, or sleep disturbance within the first week after birth with symptoms resolving spontaneously within 10 days.  Similarities between “Baby Blues” and PPD make thorough diagnosis and follow-up imperative in all women, but especially those identified as at-risk.
Myriad factors contribute to the development of PPD; the most significant include prior history of depression (during or outside of pregnancy and postpartum periods), unplanned pregnancy, difficult pregnancy, life stress, lack of social support, poor relationships, difficult infant temperament, low self-esteem, low socioeconomic status, and single motherhood.  In contrast, protective factors include education on PPD symptoms and social support for both mom and her family. Research also indicates breastfeeding mothers may be significantly less likely to develop PPD. , ,
Given breastfeeding may reduce risk for PPD, it is crucial to identify factors that impact the success or failure of breastfeeding. Foundational studies have shown that women with “lower levels of satisfaction in breastfeeding have a 3- to 15-fold higher chance of interrupting breastfeeding,” (6) thus eliminating potential protective benefits against PPD, as well as other benefits for the mother-baby dyad. Specifically, a study conducted by Avilla et al., “Association between maternal satisfaction with breastfeeding and postpartum depression symptoms,” aimed to examine the association between maternal satisfaction with breastfeeding and PPD in the first month after childbirth. 
Researchers conducted a cross-sectional study from two maternity services in Porto Alegre, Brazil. Eligibility criteria included mothers who resided in the municipality of Porto Alegre; gave birth to live-born child; breastfed at least once; had no neonatal complications and/or malformations that could interfere with breastfeeding; and never experienced mother or child problems that resulted in an admission to the intensive care unit. Women who met these criteria were randomly selected and invited to participate. One month after birth, each participant was scheduled for a 1-hour interview. Three assessments were conducted: 1) a demographic and health history questionnaire, 2) a self-report on breastfeeding satisfaction using the Maternal Breastfeeding Evaluation Scale (MBFES), and 3) a self-report on symptoms of PPD using the Edinburgh Postnatal Depression Scale (EPDS).
More than 350 women were initially included in the study, but only 287 were interviewed as nearly 70 were lost to follow up. The 287 who were included in the study were aged 16-45 years (mean = 29). The majority of women had white skin color, completed at least secondary school, and were living with their husbands or partners. The group of women who did not follow up generally had fewer years of schooling (p<0.01) when compared to the final population and also had predominately white skin color (p=0.032). The following covariables showed moderate association with increased maternal satisfaction with breastfeeding: lower maternal age, non-white maternal skin color, living with the infant’s father, planned pregnancy, vaginal delivery, exclusive breastfeeding at 30 days, absence of breastfeeding problems, and a negative screening test result for PPD. Notably, satisfaction with breastfeeding was 47% higher among women who screened negative for PPD when compared to those who screened positive for the disorder.
“Satisfaction with breastfeeding was 47% higher among women who screened negative for postpartum depression.”
This study indicates an association between higher satisfaction in breastfeeding and lower rates of PPD. However, it does not indicate whether low satisfaction in breastfeeding can contribute to postpartum depression, or if the opposite is true, that PPD, its precursors, and symptoms contribute to low satisfaction in breastfeeding. The study does consider that a lower level of maternal satisfaction could cause or aggravate PPD, and that the breastfeeding relationship can be hindered by pre-existing or developing PPD.
Study results must also be interpreted in light of a few key drawbacks: while attempting to simulate an inclusive population of Brazilian women, researchers excluded women living in “dangerous” neighborhoods. Yet these women likely possess increased life stressors and less access to social support like trained health practitioners, both known risk factors for PPD. Additionally, the 67 women lost to follow up were noted to have lower education levels then the studied group–another risk factor for PPD. Additionally, 30 days may not be the most appropriate time for a study to evaluate breastfeeding satisfaction and PPD symptoms. Women must experience two full weeks of symptoms to consider the diagnosis of PPD rather than “Baby Blues,” and, it is possible that at 30 days, PPD has yet to even fully present in some women. Furthermore, at 30 days, the breastfeeding relationship between the mother-baby dyad is still developing, even for mothers who have breastfed previously. With more time, satisfaction might increase or decrease. A longitudinal study over the course of the full first year postpartum may give insight needed to further understand this relationship.
The study also did not investigate the causes of maternal dissatisfaction with breastfeeding, simply noting an existing association between satisfaction and lower PPD rates. There are likely many contributing factors leading to maternal dissatisfaction with breastfeeding that also overlap with risk factors for PPD. It is critical that practitioners remain attentive to this patient population and be aware of methods for intervention.
One possible intervention may be the introduction of fertility awareness-based methods even before women become pregnant. Learning cycle charting with a trained instructor* can help women become more in tune with their bodies and the emotional and physical symptoms they can experience. It also provides an entry point to ask questions and get help, as well as to simply have someone checking in on them after pregnancy. A woman’s chart pattern may elucidate preventable risk factors that would contribute to breastfeeding dissatisfaction, discontinuation, and/or PPD. For example, excessive lochia in the postpartum phase could cause iron deficiency anemia leading to fatigue, which is highly correlated to PPD.  Prior to pregnancy, charting can be used to identify hormonal imbalances, such as hypothyroidism and low progesterone If corrected, women may experience great improvements in mood and energy. In fact, progesterone supplementation has been shown to be an effective treatment for PPD. 
“Additional studies on whether FABMs and cycle charting may positively impact postpartum depression rates could be beneficial as well.”
Further studies are needed to clarify the association between known risk factors for PPD with maternal dissatisfaction with breastfeeding. Additional studies on whether FABMs and cycle charting may positively impact PPD rates could be beneficial as well. As future research is conducted, it is also important to consider the challenges of charting with cervical mucus-only methods following pregnancy in the postpartum phase. Low estrogen and progesterone levels may make it difficult to track mucus patterns but the information obtained through FABM charting may still be helpful for medical management. For many women, charting may increase self-esteem by empowering them to know and accept their body.  Finally, since most methods encourage husbands or partners to become more involved, it may lead them to be more supportive overall, which plays an important role in breastfeeding as well.
* Read this author’s blog post on the important role FABM instructors play in providing appropriate education and support for women interested in charting their cycle to enhance their body literacy. As she so astutely notes, “FABM users can benefit greatly from an instructor who partners with them as their goals and needs evolve throughout their reproductive years”.
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 Avilla JC, Giugliani C, Bizon AMBL, Martins ACM, Senna AFK, Giugliani ERJ. Association between maternal satisfaction with breastfeeding and postpartum depression symptoms. PLoS One. 2020;15(11):e0242333. doi:10.1371/journal.pone.0242333
 Corwin EJ, Brownstead J, Barton N, Heckard S, Morin K. The impact of fatigue on the development of postpartum depression. J Obstet Gynecol Neonatal Nurs. 2005;34(5):577-586. doi:10.1177/0884217505279997
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 Fehring RJ, Lawrence DM. Spiritual Well-Being, Self-Esteem and Intimacy among Couples using Natural Family Planning. Linacre Q. 1994;61(3):18-29. doi:10.1080/20508549.1999.11878261
About the Author
Calley Gober is a soon-to-be graduate of the Chicago College of Osteopathic Medicine, where she is a Pre-Doctoral Osteopathic Manipulative Medicine Teaching and Research Scholar. She is excited to continue her career in medicine as an OBGYN in Muskegon, MI at Mercy Health. She keeps busy with her sourdough baking, green growing, and home DIYs.