Clinical practice

Can hormones in breastfeeding

protect against postnatal depression?
Abstract
The benefits of breastfeeding are widely accepted; however, one of the
likely advantages of breastfeeding is often overlooked: breastfeeding
may help protect against postnatal depression. An earlier article
(Donaldson-Myles, 2011) reviewed the evidence of the beneficial effects
of breastfeeding against postnatal depression. This article now examines
the hormonal changes engendered by human suckling and lactation
which appear to reduce the incidence of depression. It explores the role
of stress and inflammation in depression together with the attenuating
effects of the hormones of lactation. Prolactin and oxytocin are shown
to have an inhibitory influence on the hypothalamic-pituitary-adrenal
axis which is activated at times of stress. In addition, evidence that
oxytocin has a central calming effect on the brain is discussed. An
understanding of the moderating effects of the lactational hormones on
postnatal depression could assist midwives in encouraging vulnerable
women to breastfeed and help combat this devastating condition. Using
this evidence-based information, midwives can utilize their valuable and
limited time to encourage and support breastfeeding in women who are
prone to depression to help improve their mental wellbeing.

Fiona Donaldson-Myles
Supervisor of Midwives,
The Soldiers, Sailors,
Airmen and Families
Association - Forces
Help (SSAFA),
The Princess Marys
Hospital, RAF Akrotiri,
BFPO 57

88

ostnatal depression (PND) is a devastating

condition affecting the mental health of
an increasing number of women following
birth (Royal College of Midwives (RCM), 2007).
Prevalence rates vary between studies but an
average prevalence of 13% can be suggested
(Dennis, 2005; National Institute for Health and
Clinical Excellence (NICE), 2006; Horowitz et al,
2009). Symptoms include tearfulness, persistent
low mood and fatigue, lack of drive and insomnia
with most cases starting in the first 3 months postpartum (Dennis, 2005).
The evidence for the benefits of breastfeeding
in helping to reduce PND has previously been
considered (Donaldson-Myles, 2011), and found
the evidence to be inconclusive, with study results
confounded by unclear definitions of breastfeeding. However, it is generally accepted that
formula feeding mothers experience more
depressive symptoms than their breastfeeding
counterparts (Dennis and McQueen, 2009). The
question is whether this is because depressed
mothers are less likely to succeed in their attempts
to breastfeed, thereby compounding depressive
mood, or whether breastfeeding in itself confers
some protection against depression? This article

explores the possible psycho-protective role of

the hormones specifically related to lactation and
reviews the evidence which helps explain why
breastfeeding mothers appear to be at a lower
risk of PND.

Do hormonal changes cause PND?

During pregnancy and the puerperium major
hormonal changes take place in the body as a
result of alterations to the hypothalamic-pituitaryadrenal (HPA) axis. These include the placenta
producing the hormones progesterone and
oestrogen which maintain and nurture the pregnant state. Levels of these hormones fall sharply
at birth, reaching pre-pregnancy levels at around
the fifth postpartum day (Dalton, 1989; Hendrick
et al, 1998).
The possibility of a biological link between the
hormonal environment of the puerperium and
depression has been suggested since the time
of Hippocrates (Hanley, 2009); however, many
authors explored this relationship by looking
at how hormonal changes may cause PND. It is
known, for example, that a steep fall in progesterone after delivery has an association with
the baby blues (Harris et al, 1994; GlangeaudFreudenthal et al, 1999) Recent research,
however, suggests that certain endocrine changes
present in breastfeeding women may actually
help prevent PND (Abou-Saleh et al, 1998; Klier
et al, 2007).

What is the role of prolactin?

It is known that the secretion of the lactogenic
hormone prolactin increases during pregnancy,
rising steadily until delivery. Production is then
further stimulated by the baby suckling at the
breast. It is produced by the adenohypophysis (the
anterior lobe of the pituitary gland), situated at the
base of the skull (Box 1). It is the main stimulant
for milk production. Its secretion is influenced by
biochemical circadian rhythms being produced
in larger quantities when the woman is asleep.
Following birth, prolactin levels remain high if
the woman is breastfeeding on demand and this
stimulates milk production further. The raised
prolactin inhibits the production of oestrogen,
progesterone and follicle-stimulating hormone
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Clinical practice
in a negative feedback mechanism and ovulation is initially suppressed. In this way exclusively
breastfeeding women differ from formula feeding
women in that they have high serum prolactin
levels and are generally anovulatory. In non-breastfeeding women prolactin levels return to normal
within 34 weeks post-delivery (Alder et al, 1986;
Hendrick et al, 1998).
Various studies have pointed to the possibility
that raised prolactin levels protect against PND.
Abou-Saleh et al (1998) undertook an investigation into 70 postpartum women in Dubai who
were assessed at 7 days using the Edinburgh
Postnatal Depression Score (EPDS). Blood
samples for a range of hormones were taken twice
on the day of the mental health assessment.
Unfortunately, only 34 postpartum participants agreed to the venepuncture, limiting the
studys strength, but it did involve two comparison groups: 23 women still pregnant and 38
non-pregnant women. The findings showed that
postpartum women had significantly higher levels
of prolactin than the controls and that those who
breastfed had significantly higher levels than nonbreastfeeders with significantly lower EPDS scores.
When a statistical analysis of all the variables
was made, decreased prolactin was found to be
one of the accurate predictors of depression, as
was non-breastfeeding, increased progesterone
and increased maternal age. This was a very small
study but the findings were supported by Harris
et al (1989) whose extensive research into the role
of hormones in PND found that a low plasma
prolactin is associated with depression irrespective of the method of feeding. Asher et al (1995)
found that the only hormonal change consistently associated with a raised EPDS score was low
prolactin.
Maureen Gror (2005), in her research into 138
mothers feeding method and hormone status
during the first 4 weeks after delivery, found the
most significant finding in relation to prolactin
was that the low levels found in formula feeding
mothers correlated with an increase in stress and
low mood. Gror et al (2005) came to the same
conclusion when they assessed endocrine and
immune relationships with postpartum fatigue.
They found that the higher levels of prolactin in
breastfeeding women seemed to buffer the effects
of stress. Gror describes how stress in the postpartum period activates the HPA axis, normally
leading to increased release of cortisol, the stress
hormone, but prolactin and oxytocin inhibit this
response. She has called this protective mechanism the lactational stress resistance model
(Gror, 2005: 108).
British Journal of Midwifery February 2012 Vol 20, No 2

Box 1. Prolactin
ll Prolactin, the lactional hormone, is produced in the anterior lobe of the
pituitary gland
ll Production is circadian and increases during sleep
ll Levels rise throughout pregnancy and are highest in breastfeeding women
ll Low prolactin is associated with depression
ll High levels of prolactin seem to buffer stress responses by opposing
the effect of cortisol

Box 2. Oxytocin
ll Oxytocin is a neuro-hormone which is present in the peripheral
circulation, the cerebrospinal fluid and the brain
ll It has a short half-life and its release is pulsatile, making accurate
measurement difficult
ll Levels rise in pregnancy and are high in breastfeeding women as it is
the hormone of uterine contractibility and milk ejection
ll It is strongly associated with successful mother-baby bonding and pair
bonding in mammals
ll In humans oxytocin has been shown to reduce stress, have a calming
effect and improve mood by moderating the effects of adrenocorticotropic hormone (ACTH) and cortisol

What is the role of oxytocin?

Oxytocin is a neuro-hormone that plays an important part in the physiology of lactation. Oxytocin
found in the peripheral circulation is synthesized
in the hypothalamus and stored in the posterior pituitary gland before being released into
the bloodstream (Box 2). Plasma levels increase
during pregnancy and rise further at birth.
Oxytocin has long been known to have an effect
on uterine contractibility and milk ejection from
the breast and is released into the blood during
breastfeeding, resulting in much higher levels of
oxytocin in breastfeeding women than in women
who are formula feeding. It is widely thought that
oxytocin moderates stress responses by reducing
the secretion of adrenocorticotropic hormone
(ACTH) and cortisol (Windle et al, 1997; Boutet
et al, 2006; Jolley et al, 2007). In addition to being
released into the bloodstream under the influence
of the hypothalamus, oxytocin is also produced
by pariocellular neurones in the brain and can be
released centrally where it acts as a neuro-peptide
hormonea neuro-signalling moleculeacting
on the central nervous system (Cyranowski et al,
2008). Special pathways for the passage of oxytocin
exist in the brain and there are significant levels
of oxytocin in cerebrospinal fluid (Argiolas and
Gessa, 1991). This suggests that oxytocin production and release is a complex biochemical process
that cannot be measured by plasma levels alone.
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Clinical practice

Prolactin and oxytocin have been shown to have

an inhibitory influence on the hypothalamicpituitary-adrenal axis activated at times of stress.
Since the early 1960s oxytocin has been thought
to play a complex and multi-role function in
maternal behaviour and stress. It is strongly implicated in mother-baby bonding and pair-bonding
success in mammals (Turner et al, 2002). Animal
research has shown that oxytocin production
increases when female mammals are under stress
and that when this happens the females exhibit
more serene behaviour (Windle et al, 1997). In
mouse experiments, Arletti and Bertolini (1987)
described oxytocin working as an anti-depressant
and demonstrated that reduced oxytocin levels led
to poor maternal behaviour and increased anxiety.
Grippo et al (2007) found that when they subjected
female prairie voles to social isolation, the voles
displayed characteristics of depression such as
reduced self-interest, but when their levels of
plasma oxytocin rose, there were positive changes
in behaviour such as increased grooming, feeding
and care for their young. They postulated that
these raised oxytocin levels were a biochemical
response to stress and had a soothing effect which
promoted social engagement. Several studies have
also shown that oxytocin has an amnesic effect
on animals (Argiolas and Gessa, 1991; de Wied
et al, 1993) which could possibly be useful in
helping to forget stressful experiences or pain. The
evidence from these animal studies strongly points
to oxytocin having an inhibiting role on cortisol.
90

Extrapolation from animal studies to humans

should of course be treated with caution. It is
known that oxytocin is released into the human
circulation in a pulsatile fashion, making assessment through blood sampling at timed intervals
potentially inaccurate. In addition, human
oxytocin is thought to have a short half-life, making
assessment even more difficult (Amico et al, 1987;
Boutet at al, 2006). Animals allow unrestricted
access to the breast whereas humans may feed in
a set pattern or mix mechanical expression with
breast suckling and we do not know how different
feeding behaviour might affect oxytocin production. Thus these factors make the application of
animal research to the human situation complex.
However, the potential for further research into
the relationship between oxytocin and enhanced
maternal mood is tremendous and begs the question do women who have high oxytocin levels
benefit from a natural anxiolytic?
Turner et al (2002) looked at the effect strong
emotions such as aggression and anxiety might
have on plasma oxytocin levels in women by
inducing these feelings in the research setting and
measuring serum concentrations. They found that
those participants who showed a rise in oxytocin
exhibited less feelings of anxiety but overall the
findings were not statistically significant. The
authors acknowledged that problems with studying oxytocin release includes its episodic and
pulsatile secretion, its tendency to be affected by
circadian rhythms and the inaccessibility of measuring oxytocin in cerebrospinal fluid.
However, Uvns-Mobcrg et al (1990) found that
oxytocin levels in lactating women did show a
negative correlation with the emotions of aggression, guilt and suspicion and that women felt calm
and less anxious during breastfeeding when their
oxytocin levels were highest. Boutet et al (2006)
found that the first hour of breastfeeding, when
plasma oxytocin concentration is greatest, seemed
to protect women from psychological distress.
Mezzacappa and Katlin (2002) also investigated
this link by studying the immediate effect of breastfeeding or bottle feeding on the same mother.
Women who were both breast and formula feeding
had their feelings and reactions assessed before
and after feeding their baby. Participants were
blind to which method of feeding they were about
to give the baby and were asked to score their
mood on a self-report scale before and after the
feed. Physiological responses were also measured.
The results showed that mood became significantly less positive from pre- to post-feed when the
mother gave a formula feed compared to when she
breast fed. The mood then became significantly
British Journal of Midwifery February 2012 Vol 20, No 2

less negative after breastfeeding sessions. This

finding indicated that, in the same mother, the act
of breastfeeding by itself decreased negative mood
compared to giving a feed by bottle. Albeit a small
study, this research was unique in this field in that
by using the same mothers there was no difference
in the characteristics of the two groups. There was
something about the breastfeeding that appeared
to reduce feelings of stress despite all other parameters remaining the same.
The researchers speculated that the surge of
oxytocin at suckling might be responsible for this
effect, acting as an endogenous anti-depressant
and went on to suggest that, in line with research
on oxytocin improving mother-infant bonding,
the positive feeling achieved following suckling
may become a self-fulfilling prophecy enhancing
positive perceptions of the baby. However, alternate explanations for these differences should
not be discounted.

Breastfeeding, depression and

inflammation
Inflammation is a process which occurs in the
body in response to both physical and psychological stress. In response to insults of stress the
sympathetic nervous system releases catecholamines such as dopamine, epinephrine, serotonin
and angiotensin and the HPA axis is stimulated to
produce ACTH and cortisol (Raison et al, 2006)
(Box 3).
The psycho-neuro-immunological response
to the release of these stress hormones is an
increase in the production of pro-inflammatory
cytokinesmessenger molecules which stimulate inflammation and are involved in wound
healing, allergic responses, and auto-immune
diseases (Gror and Davis, 2006; Kendall-Tackett,
2007). Cytokines require a receptor T-cell to
cause a response. It is thought that the release
of cortisol and cytokines in particular initiate an
acute phase reaction (APR) which results in an
increased production of T-cells, mast cells, platelets, lymphocytes, APR proteins, such as C-reactive
protein, and lipids. The result is that the body is in
a neuro-inflammatory state with an altered endocrine and immunological profile. When cytokines
are within normal response levels they are protective against infection and strengthen the immune
system. However, if the level becomes abnormally
high, as in cases of severe or chronic inflammation, they become dysfunctional and ineffective
and their presence contributes to the effects of the
other abnormal endocrine secretions resulting in
alterations in sleep patterns, appetite and mood
(Raison et al, 2006).
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Clinical practice

Recent and robust studies

have largely supported the
proposition that breastfeeding
can help protect women from
the effects of stress.

In 2003 a comprehensive literature review

showed that over 150 studies demonstrated a link
between depression and inflammatory responses
in the body (Padgett and Glaser, 2003). In 2007,
in her review of the literature on inflammation
and maternal mental health, Kendall-Tackett
argued that as inflammation is a key factor in
depression, postpartum women are at increased
risk because their inflammation levels are naturally elevated due to the immune system already
being altered due to pregnancy, with postpartum
women experiencing some of the known proinflammatory stimulators such as fatigue, pain
and trauma (Kendall-Hackett, 2007).
Kendall-Tackett (2007) advocated exclusive
breastfeeding as a positive natural intervention
to reduce the risk of PND by attenuating stress
responses and reducing the inf lammatory
response of the body. In her assessment of the
impact of pain as a trigger for inflammation
she highlights how common nipple pain is in
breastfeeding and stresses that breastfeeding
difficulties should be dealt with promptly to halt
the cascade of stress hormones and pro-inflammatory cytokines, decreasing their risk [sic] for
depression (Kendall-Tackett, 2007: 8). Maureen
Gror (2005) has also concluded that stress,
inflammation and fatigue reduce immunity to
infection in postpartum women and that breastfeeding seems to moderate the effect. She found
that immunity was decreased and susceptibility
to infection was increased in depressed bottle
feeding women but not in depressed breastfeeding women.

Box 3. Depression and chronic inflammation

ll Depression can lead to neuro-inflammatory changes which reduce
immunity
ll Inflammatory responses are partly provoked by adrenocorticotropic
hormone (ACTH) and cortisol released from the hypothalamicpituitary-adrenal (HPA) axis
ll The hormones of breastfeeding counter the effects ACTH and cortisol
ll Breastfeeding women may experience less inflammation and be less
susceptible to infection

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Clinical practice

Key points
ll The sudden drop in oestrogen and progesterone following birth
arguably play a role in baby blues, but not postnatal depression
ll Low prolactin is an accurate predictor of depression
ll Oxytocin protects against stress in animals and humans
ll Oxytocin is likely to have a soothing and amnesic effect and to
encourage positive mood
ll The levels of both prolactin and oxytocin are greatly increased by
breastfeeding
ll Parturition results in a physiological inflammatory response
associated with depression
ll Breastfeeding hormones may moderate the inflammatory process,
reducing the risk of depression
ll These hormones may also increase the immunoglobulin levels in
breast milk helping to protect the baby against infection

Gror et al (2004) also established that when a

lactating mother was under psychological stress
there was an increase in immunoglobulin A (IgA)
secreted in breast milk. Only exclusively breastfeeding women were included in this study. The
authors assessed womens mood state and infection symptoms at 46 weeks post-delivery. Samples
of hindmilk, foremilk and blood were collected.
Raised breast milk IgA was positively associated
with raised maternal serum cortisol suggesting
that stress in the postpartum woman stimulates
the HPA axis and this is turn affects the content of
the milk. The finding that the content of human
milk can alter in response to maternal stress
and that the alteration is an increased production of immunoglobulins, improving protection
from infection for the child, is a profound finding.
This is strong evidence to support the theory
that a two-way psycho-neuro-hormonal pathway
concerning mood and lactation exists; mood being
capable of influencing serum and breast milk
content and the act of breastfeeding influencing
secretions, in turn affecting mood.

Conclusions
This review explored the hormones related to
breastfeeding and the positive influence they have
on maternal mood. The stress-related inflammatory process and its effect on mood was also
described with particular reference to the postnatal state and breastfeeding
The likely psycho-protective effects of breastfeeding are often overlooked or put down to
folklore, but recent and robust studies have
largely supported the proposition that breastfeeding can help protect women from the effects
of stress. Research on the hormones of lactation
has established that their role, although not fully
92

understood in humans, is fundamental to the

link between breastfeeding and PND. Prolactin,
oestrogen and progesterone are easier to study
than oxytocin. Despite the importance of the relationship between oxytocin and maternal mental
health, research into the full role of oxytocin is
not likely to expand in the near future due to
the difficulty in quantifying such an elusive and
shifting neuro-hormone and to the ethical issues
involved in studying vulnerable groups such as
pregnant and postpartum women.
This review shows there is credible scientific
evidence to support the proposition that breastfeeding helps protect against PND. It is important
that midwives understand the physiology and
neuro-endocrinology of breastfeeding in order
to give well-informed and effective advice on
the links between breastfeeding and improved
BJM
maternal mental health.

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