Short report

Symptoms of maternal depression immediately after delivery predict unsuccessful breast feeding
Luigi Gagliardi,1 Angela Petrozzi,1,2 Franca Rusconi3
of Woman and Child Health, Ospedale Versilia, Lido di Camaiore, Italy 2Division of Psychology, Ospedale Versilia, Lido di Camaiore, Italy 3Unit of Epidemiology, Anna Meyer Childrens University Hospital, Florence, Italy Correspondence to Dr Luigi Gagliardi, Department of Woman and Child Health, Ospedale Versilia, Via Aurelia 335, I-55043 Lido di Camaiore (LU), Italy; l.gagliardi@neonatalnet.org These data were presented in part at the 48th meeting of the European Society for Paediatric Research, Prague, Czech Republic, 68 October 2007. Accepted 27 October 2010 Published Online First 1 December 2010
1Department

ABSTRACT Objective Postnatal depression may interfere with breast feeding. This study tested the ability of the Edinburgh Postnatal Depression Scale (EPDS) to predict later breast feeding problems, hypothesising that risk of unsuccessful breast feeding increased with increasing EPDS scores, even at low values. Design The authors administered the EPDS on days 23 after delivery to 592 mothers of a healthy baby. Feeding method was recorded at 1214 weeks. Results Median EPDS score was 5 (IQR 2 -8); 15.7% of women scored >9. At 1214 weeks, 50.7% of infants received full breast feeding, 21.0% mixed breast feeding and 28.4% bottle feeding. Mothers with higher EPDS scores were more likely to bottle feed at 3 months; the odds of bottle feeding increased with EPDS result, even at low scores (OR 1.06, 95% CI 1.01 to 1.11). Conclusions Higher EPDS scores immediately after delivery were associated with later breast feeding failure. INTRODUCTION
T he importance of breast feeding for infant health is widely recognised, and its implementation should be supported by a wide range of strategies at both the society and individual level.1 Several papers have examined the depressive symptoms experienced by women after delivery as potential risk factors for not initiating or continuing breast feeding; the results have been summarised in two qualitative systematic reviews2 3 that, while recognising that depression in the postpartum period might increase the risk of poor breast feeding, found methodological issues in published studies, and concluded that the results were quite variable and that more investigation was needed. Most of the studies used the Edinburgh Postnatal Depression Scale (EPDS) to screen for postnatal depression.4 This is a 10-item selfadministered scale; depression is suspected when a mother scores higher than a cut-off value (usually >9 or >12). Recent data suggest that mothers with high EPDS scores (>12) tend to breast feed less in the rst 2 months, 5 but it is not known if mothers with mild depressive symptoms and with normal scores are at increased risk. In fact, depression does not come in an all-or-none way, and represents the end of a continuum of severity of symptoms In light of the high prevalence of maternal depressive symptoms in the postnatal period, we analysed the results of a cohort study (carried out to investigate the feasibility of screening for depression at delivery) where we administered

What is already known on this topic

The psychological characteristics of mothers might inuence breast feeding. Postnatal depression is very frequent, and there are limited data suggesting that mothers with overt signs of depression breast feed less.

What this study adds

Mothers who have a higher Edinburgh Postnatal Depression Scale (EPDS) score immediately after delivery breast feed less at 3 months. The risk of bottle feeding increases dosedependently even at low EPDS scores, making mildly anxious/depressed mothers a target for intervention.

the EPDS on the 2nd day after delivery, with the following aims: (1) to con rm that mothers scoring high on the EPDS have a lower breast feeding rate; and (2) to test the hypothesis that the risk of unsuccessful breast feeding increases with increasing EPDS scores, even if below the cut-off value.

METHODS Study design

All mothers who delivered a healthy baby (ie, not admitted to a special care baby unit) at Versilia Hospital, Lido di Camaiore, Tuscany from December 2005 to November 2006 and could speak Italian were eligible. Mothers of twins and those taking antidepressive drugs were excluded. The study was approved by the ethics committee of the hospital. Written informed consent was obtained from mothers. Of 1050 mothers, 969 agreed to participate and completed the Italian version6 of the EPDS on day 2 or 3 after delivery while still in hospital. Of these women, 175 could not be traced due to incorrect contact details and 202 refused, leaving 592 mothers available after 1214 weeks for a telephone interview enquiring about the feeding method of their infant at that time. Breast feeding was categorised according to the WHO, as complete breast feeding (breast milk only), predominant breast feeding (breast milk+water or vitamins), mixed breast feeding (breast milk+articial milk) and no breast feeding
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(only articial milk). Since vitamin D supplementation was recommended for all neonates, complete and predominant breast feeding were grouped together as full breast feeding. Statistical analysis was carried out using Stata 10, employing linear and multinomial logistic models. feeding group, and 5.90 (SD 4.2) in the bottle feeding group, the difference between the full breast feeding and bottlefeeding groups (0.89, 95% CI 0.13 to 1.66) being statistically signicant (p=0.02). Figure 1 also shows the odds of bottle feeding at 1214 weeks plotted against the EPDS score. Although the pattern is irregular due to small numbers, an increasing trend is clearly evident, starting at very low scores. There was no cut-off under which no risk increase was seen. In a multinomial logistic regression, the OR of bottle feeding associated with an increase of one point in the EPDS score was 1.06 (95% CI 1.01 to 1.11; p=0.02), and it remained the same after adjusting for parity, mode of delivery, age and nationality (Italian/foreigner) of the mother and sex of the infant.

RESULTS
We studied 592 mothers; their mean age was 32.3 years, 64% were primiparae and 93% of Italian origin. Four hundred and twenty-nine women (72.5%) had a vaginal delivery and 163 (27.5%) a caesarean delivery. These gures were not signicantly different from those of the whole cohort of women who delivered a baby in our hospital in 2006 (data from birth certicates): mean age 31.6 years, 60.0% primiparae, 88% of Italian origin and 29.3% caesarean section. The babies in our study were born at 35.543 weeks gestation (median 40 weeks), and birth weight was 22304850 g (median 3310 g). The infants did not need any special care, their hospital stay (4872 h as customary in our region) was uneventful and they were discharged home with their mothers. Mean EPDS score was 5.39 (median 5, SD 4.1, IQR 28). These values did not differ from those of mothers lling in the questionnaire at birth but not followed up at 1214 weeks (n=377; mean EPDS score 5.32, median 5, SD 4.2, IQR 28). Overall, 15.7% of women had a score >9, and 6.8% a score >12. The frequency distribution of EPDS scores is shown in gure 1; a unimodal distribution was seen. The absence of two distinct peaks is consistent with the literature and with our hypothesis that postnatal depression represents a tail of the distribution in the population. Mode of delivery, parity, birth weight, gestation, sex and being Italian or a foreigner did not inuence scores, probably because of the homogeneity of the sample of infants and mothers. At 1214 weeks, 300 (50.7%) infants received full breast feeding, 124 (21.0%) mixed breast feeding and 168 (28.4%) bottle feeding. Mean EPDS scores were 5.01 (SD 3.9) in mothers in the full breast feeding group, 5.59 (SD 4.2) in the mixed breast

DISCUSSION
T his study shows that mothers who had higher EPDS scores immediately after delivery were more likely to bottle feed at 3 months, and that even mild depressive symptoms were associated with a dose-dependent increase in the risk of unsuccessful breast feeding. An increase in one point in the EPDS score at birth increased the odds of bottle feeding at 1214 weeks by 6%. The relationship between breast feeding and depression is complex and not completely understood, and is perhaps bidirectional (ie, maternal depression might causally interfere with breast feeding and unsuccessful breast feeding might contribute to depression 2 3). In most studies there is no clear de nition of the time-course of events, so it is unclear if it is depression that inuences breast feeding, or breast feeding that causes depression. 2 3 Our study design clearly assessed exposure (EPDS) before outcome (breast feeding), thus allowing us to draw clear time-oriented conclusions. We demonstrate that there is no threshold to the detrimental effect of depressive symptoms on breast feeding. Clinicians tend to focus their attention on sick people and on individuals at high risk who would benet most from their intervention. As Rose7 pointed out, the strategy of preventive medicine should be different and pay attention to average and not just clearly abnormal people. Usually, a large number of people at small risk may generate many more cases of disease than a small number of people at high risk. Examples are hypertension and stroke, or cholesterol and coronary heart disease, or depression and related disability.7 Even if we could prevent all cases arising from high risk individuals (very high blood pressure, very high cholesterol, overt depression), we would prevent only a minority of events. T his is also the situation with this sample, where 38.7% of bottle fed babies had mothers who scored 59 on the EPDS, while only 17.3% of bottle fed babies had mothers who scored >9. This study had some limitations. First, we did not con rm the diagnosis of depression in our sample. The EPDS has been validated as a screening tool at high scores, not as a diagnostic tool, and there is no guarantee that a mother scoring say, 6, is more depressed than another scoring 3. (Quotes are necessary, because obviously a mother scoring 3 is not affected by depression.) However, EPDS scores increase with increasing severity of depression as already noted by Cox et al in the original description of the scale.4 Second, we studied a self-selected sample of mothers willing to participate. However, this should not invalidate our results, because the general demographic variables in the studied sample were similar to those of the whole population of mothers
Arch Dis Child 2012;97:355357. doi:10.1136/adc.2009.179697

Figure 1 Distribution of Edinburgh Postnatal Depression Scale (EPDS) scores (bars, left-hand scale), and the odds of bottle feeding at each score (dots, right-hand scale). The linear regression line is shown.
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delivering at our hospital; furthermore, EPDS scores were not different between women who were and were not followed up at 1214 weeks. Regarding the outcome (type of feeding), data from a small previous survey (158 women) carried out in our local health authority before a campaign to support breast feeding was launched, demonstrated a similar distribution of feeding practices (full breast feeding: 46.0%, mixed breast feeding: 17.2%). On a more general level, an observational study such as this cannot guarantee that the observed relationships represent causal factors, that is, it cannot guarantee that depression causes discontinuation of breast feeding, as opposed to both being associated with an unknown true cause. On the other hand, a randomised controlled trial (attributing depression at random and observing the outcome) is clearly impossible, so an observational study is the only option. In any case, our study demonstrates that the EPDS detects psychological distress around delivery, making it useful for prediction and indicating that this mechanism is involved in breast feeding cessation.8 In conclusion, this study shows that even low levels of depressive symptoms detected by the EPDS are negatively associated with breast feeding. Although our study concerns the effect of postnatal depression on breast feeding, we speculate that the same might also hold true for other harmful effects that have been ascribed to postnatal depression (eg, child cognitive disorders, behavioural disturbance).9
Acknowledgements The authors wish to thank the nurses in the Division of Neonatology at Ospedale Versilia for their invaluable support for the project. Funding This study was supported by a grant from Piccole Stelle Onlus to AP. Competing interests None. Ethics approval This study was conducted with the approval of the ethics committee of Ospedale Versilia. Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES
1. 2. Britton C, McCormick FM, Renfrew MJ, et al. Support for breastfeeding mothers. Cochrane Database Syst Rev 2007;1:CD001141. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment No. 153. AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare Research and Quality, April 2007. Dennis CL, McQueen K. The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics 2009;123:e736 51. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782 6. Dennis CL, McQueen K. Does maternal postpartum depressive symptomatology inuence infant feeding outcomes? Acta Paediatr 2007;96:590 4. Benvenuti P, Ferrara M, Niccolai C, et al. The Edinburgh Postnatal Depression Scale: validation for an Italian sample. J Affect Disord 1999;53:137 41. Rose G. The Strategy of Preventive Medicine. Oxford University Press, Oxford, 1992:227. Gagliardi L. Prediction and causal inference. Acta Paediatr 2009;98:1890 2. Cooper P, Murray L. Prediction, detection, and treatment of postnatal depression. Arch Dis Child 1997;77:97 9.

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