Breastfeeding & maternal mental health
How breastfeeding challenges, attitudes, and stigma can affect postpartum mental health
“Of course there’s nothing wrong with giving your baby formula. I even know of some kids who were formula fed and got into Harvard!” This was the condescending “reassurance” I received from a lactation consultant two days after I gave birth. Formula supplementation helped my newborn with a health issue and the last thing I wanted was a “well-meaning” comment from someone who made clear her own biases around feeding choices.
“Oh, we're well aware,” my husband chirped back, more sassy than usual. “My wife was formula fed.”
How you decide to feed your infant is maybe the most fraught topic around early parenting, possibly more so than sleep training. Everyone has an opinion about it. “Breast is best,” “Formula is so expensive, while breast milk is free,” “There's no more natural way to bond with your infant than breastfeeding.” It's terrifying how quickly you internalize the societal pressure that if one can breastfeed, one should breastfeed. This was not made easier for some when the American Academy of Pediatrics updated their guidelines in support of breastfeeding for two years or longer. While putatively to help reduce the stigma around those who choose to breastfeed for longer than a year (which is also a very real thing) and to support policies intended to make breastfeeding easier, some argued it increased the existing cultural stigma against those who choose not to breastfeed.
Even as someone who was never breastfed (I was adopted as an infant), I was shocked at how much pressure I put on myself after I gave birth to do so, and how much I blamed myself when I felt I was not living up to these unnamed expectations around breastfeeding. One friend hid her cans of formula away whenever judgmental family members visited. Another was constantly asked why she didn’t just change to formula after she was experiencing some breastfeeding challenges. One woman told me about a friend of hers that felt so much pressure to breastfed, she did so until a doctor told her to stop because one of her nipples had literally torn in half. You just can’t win. So many of my mom friends experienced guilt, shame, and distress around their feeding choices to the detriment of their well-being.
A recent review from Yuen and colleagues (2022) published in Journal of Women’s Health summarized 55 articles that attempted to examine the relationship between breastfeeding and mental health symptoms. They included studies of women1 who varied in how much they breastfed (from exclusive breastfeeding to combination feeding with breast milk and formula) as well as studies that included women experiencing breastfeeding difficulties.
Overall, the results were kind of messy. For example, the majority of studies examined the relationship between breastfeeding and postpartum depression symptoms (52 studies). Eighteen studies did not find a significant relationship between breastfeeding and depression symptoms, suggesting that they were unrelated. On the other hand, 28 studies found that breastfeeding was associated with a decreased risk of depression symptoms. Similarly, of the nine studies that examined the relationship between breastfeeding and postpartum anxiety symptoms, five did not find a significant relationship between the two, while three studies found that breastfeeding was associated with a decreased risk of anxiety symptoms.
This makes some biological sense. Oxytocin is a critical hormone associated with milk release and is also related to things like mother-infant bonding and positive emotion. There’s a reason that many women experience surges of love and affection towards their infant when they breastfeed, and these feelings may serve as protective factors against depression and anxiety for some parents.
However, what happens when breastfeeding doesn’t quite go as planned? The authors summarized a smaller subset of studies that were more interested in how breastfeeding difficulties and attitudes to breastfeeding affected mental health. For example, the authors summarized five studies that found that breastfeeding difficulties (e.g., latching problems, infection, nipple pain, etc.) were associated with more severe depression or PTSD symptoms. Further, mothers that had a strong desire to breastfeed but did not start or otherwise did not continue for as long as they liked also had higher rates of mental health symptoms. The researchers also summarized four studies that showed that mothers who worried or were otherwise dissatisfied with their breastfeeding progress had more severe depression symptoms.
So what does this all mean? The researchers’ conclusions summarize things better than I could:
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 […]
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. (p. 803)
Of course, no study (or review) is perfect. The researchers did not include studies that examined the relationship between breastfeeding and more vague indicators of “maternal distress” not associated with a specific mental health condition. Additionally, they noted that many studies either excluded women with a diagnosed mental health condition or otherwise did not measure mental health prior to breastfeeding, limiting our ability to interpret results broadly. Further, many studies included in the review did not report or assess a mother’s intention to breastfeed prior to giving birth - we can see from the few studies that did that this most likely has a significant influence on the relationship between breastfeeding and maternal mental health. Finally, and this is less of a criticism and more of a “I want to see this study!” comment, I would love to see a similar systematic review on combination feeding or exclusive formula feeding and parental mental health. For example, I wonder if the opportunity to allow the non-lactating caregiver(s) to be part of the feeding process has mental health benefits for all parents.
Overall, I really appreciated the researchers’ nuanced approach to this topic. They explicitly stated that one of their aims for publishing this work was to reduce the stigma around feeding choices. They acknowledge the stigma surrounding the choice to not breastfeed and suggest practical clinical recommendations for providers, including to ask parents “How are you feeding or planning to feed your baby?” (vs. directly asking if they are breastfeeding), discussing feeding intentions with parents alongside other perinatal mental health assessments, informing parents about common feeding challenges, and refraining from presenting “all-or-nothing” scenarios when it comes to feeding choices.
There are so many reasons to choose to breastfeed, or not to breastfeed, or to do some combination of both. Maternal mental health is one that should not be overlooked. Parents should feel empowered to make individual choices for themselves and their well-being without shame or stigma. Of course we should fight for structural solutions to support those who want to breastfeed to make it as easy and painless as possible. But even if someone can breastfeed, it doesn’t mean that they should. Our aim should be to create a world where the choice to breastfeed actually feels like a choice for everyone.
Unrelated to the above review, I wanted to note the existence of Dysphoric Milk Ejection Reflex (D-MER), the experience of abrupt negative emotion just before milk release that usually lasts a few minutes. It was first identified by a mother and lactation consultant and appears to be related to a drop in dopamine in some women during milk release. It’s unclear how common this experience is, but I wanted you to be aware of it when thinking about breastfeeding and mental health.
This is the language the authors used, based on the language used in the studies they reviewed. However, they (admirably) called out in their review that not all people who breastfeed identify as women and that more research is necessary to understand the full spectrum of experiences of individuals who breastfeed.