Background

During pregnancy, a woman goes through different hormonal, physical, physiological, and emotional changes, and even after childbirth, she experiences diverse and mixed emotions, from joy and excitement to sadness, fear, lamentation, and anxiety [1]. Many mothers who just delivered a baby can experience ‘baby blues’, which usually do not affect a mother’s capability to take care of a newly born baby and include symptoms like mood swings, worry, sadness, and tiredness that commonly begin within the first 2 to 3 days and resolve in two weeks [1]. However, the persistence and intensity of these symptoms can lead to postpartum depression, which affects the mother’s ability to perform her daily routines and take proper care of the child [2]. Postpartum depression occurs after giving birth to an infant, starts soon after the baby’s delivery, and lasts up to a year [1]. It influences how mothers feel, act, and think [3, 4]. The clinical symptoms of postpartum depression are feelings of sadness, hopelessness, restlessness, anxiety, irritation, excessive concern, sleep difficulties, problematic decision-making, and suicidal thoughts [2, 3, 5].

Globally, postpartum depression is a common yet serious problem that affects around 15% of women [6]. In the United States (US), 13% of mothers experience postpartum depression after giving birth [2]. Postpartum depression has a critical impact on mothers and poses a long-term risk to their mental health and well-being. Furthermore, it negatively influences the physical, social, and cognitive development of their children [7]. Postpartum depression also impacts the parenting and relationship between the mother and the infant, which eventually affects breastfeeding practices [1, 8].

Breast milk is one of the best sources of nutrition for infants [9]. There is strong evidence that breastfeeding positively impacts the physical, cognitive, and neurological health and well-being of infants, as well as mothers, which translates into economic benefits for society as a whole [10–12]. The American Academy of Pediatrics (AAP) and the World Health Organization (WHO) recommend exclusively breastfeeding an infant for six months and continuing breastfeeding for at least two years or longer if desired [13]. However, less than half of the world’s infants are being breastfed as recommended [14], which represents a loss of more than $300 billion each year in unintended benefits from breastfeeding to health and human development [15], when estimating the premature deaths of children due to diarrhea, pneumonia, the occurrence of obesity [16, 17], and other negative outcomes for mothers’ health that are demonstrably prevented by breastfeeding [16, 18].

Early breastfeeding cessation refers to a mother who interrupts any type of breastfeeding before an infant completes six months old. On average, the prevalence of any breastfeeding cessation at 6 months in the US is 44.2% [19]. Similarly, sixty percent of the mothers who initiated breastfeeding do not continue breastfeeding as recommended. The common reasons for early cessation are having latching issues, concerns about infant nutrition and weight, illness or using medication, issues with pumping milk, unsupportive work and hospital policies, lack of adequate maternal leave, lack of family support, and cultural barriers [20, 21]. Other risk factors that diminish breastfeeding practices include low education, first-time pregnancy, lack of prenatal care visits, lack of social support, and postpartum depression [22].

The causal pathways between breastfeeding and postpartum depression can be bidirectional and are still not fully understood [23, 24]. On the one hand, postpartum depression is linked with a greater risk for early breastfeeding cessation [25]. Mothers who experience postpartum depression can face breastfeeding difficulties due to emotional distress and may be less responsive to their infant’s feeding cues [26]. As a result, breastfeeding difficulties can lead the mother to feel frustrated and guilty, which exacerbates the risk for postpartum depression symptoms [27]. On the other hand, breastfeeding cessation is linked with a higher risk of postpartum depression [5, 27]. However, the psychological benefits of breastfeeding for the mother are not widely explored and require more research [5, 23, 27].

Better understanding of the factors that impact maternal mental health and depression is important for the health and wellness of mothers and children. Thus, determining factors that are protective against postpartum depression is a high research priority. Our hypothesis is that practicing breastfeeding is associated with maternal mental health. Therefore, the aim of this study is to identify whether breastfeeding cessation is associated with postpartum depressive symptoms.

Methods

Results

A total of 305 mother-infant dyads were included in the analytical sample. Among them, 9.2% of the mothers reported postpartum depressive symptoms. The prevalence of breastfeeding cessation was 26.2%. The majority of the mothers were between 25 and 34 years old (n = 183, 60.0%), had bachelor’s or graduate degrees (n = 223, 73.1%), and were not enrolled in the WIC (n = 262, 85.9%). Likewise, most mothers were multiparous (n = 167, 55.1%), had a vaginal delivery (n = 204, 70.6%), and infants were breastfed within the first hour (n = 225, 78.1%) (Table 1).

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Table 1. Descriptive analysis of maternal sociodemographic, environmental, and obstetric characteristics, 2021 (n = 305).

https://doi.org/10.1371/journal.pone.0297218.t001

Young mothers of 18–24 years (n = 8, 24.2%) had a greater prevalence of postpartum depressive symptoms than mothers of the older age group. Similarly, mothers with some college-level education without a degree (n = 10, 20.8%) were more likely to experience postpartum depressive symptoms compared to mothers with primary, secondary or vocational education, and a degree. Mothers without a partner presented a higher frequency of experiencing postpartum depressive symptoms (n = 4, 25.0%) compared to those with partners. Mothers with an unplanned pregnancy (n = 14, 12.7%) and having their first child (primiparous) (n = 18, 13.2%) had a higher frequency of experiencing postpartum depressive symptoms compared to mothers with a planned pregnancy and having more than one child (multiparous). In addition, mothers who ceased breastfeeding (n = 13, 16.2%) and those who got less than 5 hours of sleep (n = 9, 13.2%) were more likely to present postpartum depressive symptoms compared to the reference group. Finally, mothers whose infants were admitted to the neonatal unit (n = 6, 17.1%) and not breastfed within the first hour (n = 9, 14.3%) also showed a greater frequency of postpartum depressive symptoms (Table 2).

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Table 2. Prevalence of postpartum depressive symptoms by maternal sociodemographic, environmental, and obstetric characteristics, 2021 (n = 305).

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https://doi.org/10.1371/journal.pone.0297218.t002

Multivariate logistic regression revealed that postpartum depressive symptoms are independently associated with early cessation of breastfeeding (AOR = 3.30, 95% CI: 1.16–9.32) after controlling for maternal sociodemographic, environmental, and obstetric characteristic (Table 3).

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Table 3. Multivariate logistic regression on the association between postpartum depressive symptoms and selected maternal sociodemographic, environmental, and obstetric characteristics, 2021.

https://doi.org/10.1371/journal.pone.0297218.t003

Discussion

To our knowledge, this is one of the first studies to assess factors associated with postpartum depressive symptoms in Clark County, Nevada. We found a significant relationship between postpartum depressive symptoms and breastfeeding cessation among six-month-old infants. Mothers who ceased breastfeeding had 3.30 times higher odds of postpartum depressive symptoms compared to mothers who were breastfeeding. Our results are consistent with prior studies that showed an association between breastfeeding and the mental health of mothers, in which non-breastfeeding mothers were at greater risk of depression [8, 22, 36, 38, 39]. A similar study in the United States also concluded that breastfeeding mothers (AOR = 0.87, p = 0.001) had significantly lower risks for depression than non-breastfeeding mothers [40]. Correspondingly, a recent meta-analysis revealed that breastfeeding mothers have a 14% reduced risk of depression compared to mothers who were not breastfeeding [8]. This might be because breastfeeding mothers are more likely to regulate negative moods and perceived stress, which ultimately prevents them from developing depressive symptoms [41, 42]. Breastfeeding can promote hormonal processes that protect mothers against postpartum depressive symptoms by attenuating cortisol response to stress [22]. Breastfeeding mothers are also more likely to produce calm reactions to stress, which fosters their nurturing behavior [43]. Moreover, evidence indicates that if a mother is unable to breastfeed, it may increase anxiety and depressive symptoms [43]. This is because the social culture of mandatory breastfeeding can make a mother feel responsible for its success or unsuccess [44]. Even though the current study presented strong support for such a relationship, more research is needed to determine the relationship between breastfeeding and postpartum depression outcomes.

Our study did not find an association between postpartum depressive symptoms and maternal characteristics such as planned pregnancy, mother sleep hours, and parity. Corroborating our findings, a longitudinal study in the Netherlands found that women with an unplanned pregnancy reported persistently higher levels of depressive symptoms compared to women with a planned pregnancy [45]. Concerning maternal sleeping hours, similarly to our study researchers found that depressive symptoms during postpartum were associated with poorer sleep, and poorer sleep quality increased postpartum depression symptom severity [46]. On the other hand, the lack of association between parity and postpartum depressive symptoms found in our study differed from the findings from other studies [47, 48]. Martnez-Galiano and colleagues showed that first-time mothers (primiparous) had greater postnatal depressive symptoms and that such mothers were more likely to have issues related to lactation, sadness, and anxiety [47]. On the other hand, Hartmann and colleagues observed an association between having more than one child (multiparous) and greater depression [48]. Overall, it can be inferred that giving birth to a baby, either for the first time or multiple times, can be stressful, and mothers can easily be anxious about how to handle new responsibilities related to their infant. Additionally, the influence of parity on a mother’s mental health is poorly studied, and the results are incongruous, highlighting the need to critically analyze and do extensive research on this aspect in the near future.

Infant characteristics such as infant breastfed within the first hour and infant admitted in the neonatal unit were also not associated with postpartum depressive symptoms. Corroborating our findings, in Sweden, pregnant women reported depressive symptoms when they could not accomplish the first breastfeeding session within two hours after birth [49]. Regarding infants admitted to the neonatal intensive unit, a study in Australia showed that postpartum depression was reported within the first 2 weeks after their baby was admitted to the neonatal intensive care unit [50]. Despite the lack of association with postpartum depressive symptoms almost half of the infants were routinely separated from their mothers during the first 24 hours after birth even though very low admission to the neonatal unit was reported. Evidence has demonstrated that routine maternity ward procedures such as early skin-to-skin contact and breastfeeding within the first hours promoted by Baby-Friendly Hospital are protective factors for immediate postpartum depression [51] as well as support maternal role competence [52].

Our results showed that the prevalence of postpartum depressive symptoms (9.2%) among mothers living in Clark County, Nevada, was slightly below the US average (13%) [2]. A recent meta-analysis found increased postpartum depressive symptoms at 6 months postpartum and reported that the prevalence of postpartum depression varied according to country (from 5.0% to 26.32%) [53]. According to their findings, the prevalence of postpartum depression was 8.6% in the US, which is similar to our findings [53]. Our study is the first to date to report the prevalence of postpartum depressive symptoms in Nevada, which is critical to determine the resources and support needed as well as to tailor existing interventions to the needs of the population.

Our findings emphasize the importance of universal mental health screening for postpartum women and appropriate treatment for those with depressive symptoms. Similarly, supportive and evidence-based interventions that address and encourage both breastfeeding and maternal mental well-being should be formulated and implemented. Evidence shows that providing support for mental health well-being may increase breastfeeding practices [54]. Moreover, breastfeeding may protect against or ameliorate depressive symptoms [55]. A systematic review found twelve interventions with a significant positive effect on both maternal mental health and breastfeeding outcomes, including psychoeducational group programs, relaxation therapy, skin-to-skin contact between mother and infant, psychological nursing, motivational interviewing, a health and infant care education program, stepped-care psychological treatment, peer support with home visits, breastfeeding training with home visits, and risk-based treatment with home visits [54]. Thus, health and mental health professionals should inform, educate, and advocate for breastfeeding as it can positively impact mothers’ mental health. Most importantly, when delivering these interventions, professionals should take a holistic, integrative approach considering that the impact of depressive symptoms, medication, sleep arrangements, and social support is critical to maternal-child well-being and breastfeeding promotion.

Our study has some limitations that should be considered when interpreting the findings. We surveyed a convenience sample of mothers with infants under six months old in Clark County, Nevada. Data collection efforts across birth, lactation, and pediatric care centers were made to recruit a diverse population of mothers; however, due to the COVID-19 pandemic, most participants were recruited through a paid advertisement on social media. The survey was provided in both English and Spanish, allowing participants to respond to the survey in their preferred language. A comparison of our data to the demographic data (i.e., ethnicity, educational attainment, and household income) in Clark County showed similar trends. Nevertheless, our findings may only be generalized to areas in the US with a similarly high proportion of urban populations as Clark County. Another limitation is that we did not collect the age of the infant at the time of the survey. We acknowledge that some care practices are influenced by the infant’s age, and some associations may not be found or weakened due to the lack of the infant age information. Also, we adopted the 24-hour diet recall method as recommended by the WHO to measure breastfeeding cessation to avoid the recall bias. However, if an infant was breastfed before 24 hours or only a couple of days a week, or even never breastfed, it would be classified as breastfeeding cessation. Our questionnaire did not include questions about previous medical diagnosis of depression or other types of psychiatric disorder, and the use of medications such as antidepressants, mood stabilizers, etc. We acknowledge that the lack of this information may underestimate the prevalence of depression symptoms. Finally, because this study was cross-sectional, the causal relationship between postpartum depressive symptoms and breastfeeding cannot be established. In fact, as there was no data regarding postpartum depression in Nevada, our cross-sectional study may establish a baseline for future longitudinal research to clarify this causal relationship. Collectively, our findings contribute to Nevada context-specific hypotheses and support transferability for future public health research exploring the relationship between postpartum depression and breastfeeding [56].

Conclusion

Our study showed a significant association between postpartum depressive symptoms and breastfeeding cessation. Early identification of postpartum depressive symptoms and the promotion of breastfeeding can create a positive feedback loop to foster the well-being of mothers and infants. More research is needed to clarify the bidirectional causal relationship between postpartum depressive symptoms and breastfeeding cessation.

Supporting information