Abstract
Associations between depressive symptoms and breastfeeding are well documented. However, evidence is lacking for subdivisions of feeding styles, namely exclusive breastfeeding, exclusive formula feeding and a mixed feeding style (breastfeeding and formula feeding). In addition, studies examining associations between mother-child-bonding and breastfeeding have yielded mixed results. The aim of this study is to provide a more profound understanding of the different feeding styles and their associations with maternal mental health and mother-child-bonding. Data from 307 women were collected longitudinally in person (prenatally) and by telephone (3 months postnatally) using validated self-report measures, and analyzed using correlational analyses, unpaired group comparisons and regression analyses. Our results from a multinomial regression analysis revealed that impaired mother-child-bonding was positively associated with mixed feeding style (p = .003) and depressive symptoms prenatal were positively associated with exclusive formula feeding (p = .013). Further studies could investigate whether information about the underlying reasons we found for mixed feeding, such as insufficient weight gain of the child or the feeling that the child is unsatiated, could help prevent impaired mother-child-bonding. Overall, the results of this study have promising new implications for research and practice, regarding at-risk populations and implications for preventive measures regarding postpartum depression and an impaired mother-child-bonding.
Similar content being viewed by others
Introduction
Pregnancy and the birth of a child is an extraordinary and overwhelming event for many women. It is accompanied by intense positive emotions1,2. However, the birth of a child is associated with several changes and can cause intense stress2,3. Peri- and postpartum depression is defined as an episode of major depression that is associated with childbirth4. With a prevalence ranging from 10 to 15%—or even higher in lower- and middle-income countries—postpartum depression (PPD) is a widespread illness5,6,7,8. Its effects on maternal and the infant’s health, is a well-recognized issue9. Several studies have examined developmental disturbances in children of (severely) depressed mothers10,11,12,13,14,15,16,17, such as behavioral problems, lower math scores, or a sevenfold risk of depression during adolescence16. PPD is furthermore associated with an impaired mother-child-bonding14,18,19,20,21,22,23,24, which poses an increased risk of impaired emotional, social and cognitive development in the child25,26. Mother-child-bonding is described as a general tendency in the first weeks and months after birth to engage in social interaction with each other27. It is conceived as the maternal bond towards the child and the child's attachment towards the mother28. Disruption of this process has a long history in research29 and has been described as a disorder of mother-child-bonding19,30. The mother’s emotional response to the child is considered an essential symptom of bonding disorder and may reach the level of hatred and rage29. Mother-child-bonding disorders include a lack of maternal emotion to the extent that it can cause distress, irritability, hostile and aggressive impulses, pathological ideas, and outright rejection of the child19. Numerous further studies provide evidence for an association between PPD and mother–child bonding disorders14,18,19,20,24,31.
A possibility to prevent adverse outcomes such as PPD and an impaired mother-child-bonding might be breastfeeding. Previous studies found supportive evidence that (exclusive) breastfeeding prevents PPD and a poor mother-child-bonding32,33,34,35,36,37,38,39,40,41 and vice versa, as PPD is associated with early cessation of breastfeeding42,43,44. Numerous other studies provide evidence of an association between weaning and maternal depression45,46,47,48,49,50. In addition, 60% to 90% of women indicate breastfeeding difficulties, which may be an additional source of stress51,52. This can lead to a vicious cycle, as breastfeeding difficulties are an additional stressor for the mother and may promote depression53,54,55.
Studies examining associations between mother-child-bonding and breastfeeding, as well as attachment—which focuses more on how the infant builds up a relationship with its primary caregiver56—and breastfeeding, have found mixed results37,38,57,58,59,60,61. Keller et al. (2016) found that the Postpartum Bonding Questionnaire (PBQ) factor “anxiety about care” negatively predicted breastfeeding duration beyond six months62. Besides the educational level of the mothers, this was found to be the most important influential factor on the duration of breastfeeding in a regression analysis. Systematic reviews of the associations between breastfeeding and mother-child-bonding found that maternal sensitivity and secure attachment were the aspects of mother-child-bonding most often associated with breastfeeding63,64. Regarding the associations between breastfeeding difficulties and mother-child-bonding, emotional availability was found to be negatively correlated with objective (e.g. cracked nipples) as well as subjective breastfeeding difficulties (e.g. perceived insufficiency of milk supply65). In another study, secure attachment also appears to play an important role in breastfeeding continuation when breastfeeding difficulties occur66. In addition, breastfeeding confidence was found to be positively associated with higher levels of maternal attachment67. A study by Smith and Ellwood (2011) reported a descending pattern from exclusive to mixed to no breastfeeding and receipt of emotional care from the mother. The authors suggest that the time invested in breastfeeding and the associated close contact between mother and child strengthens the bond between the two. More time may also improve breastfeeding itself68. However, to our knowledge, no study so far differentiated exclusive, mixed and no breastfeeding patterns with regard to mother-child-bonding in particular.
Further research on the association of breastfeeding on PPD and mother-child-bonding may contribute in a meaningful way to the prevention of subsequent disorders and the reduction of long-term consequences for mother and child. The aforementioned influence of mother-child-bonding on breastfeeding behavior led us to include bonding as an independent variable in the study. The study design explained below led us to examine the influence of depressive symptoms in pregnant women and the influence of depressive symptoms in postpartum mothers, also as independent variables, in relation to the different feeding practices. The aim of this study is to examine whether PPD and poor mother-child-bonding are associated with different feeding practices (exclusive, mixed and no breastfeeding) in order to gain a better understanding of the associations between feeding practices and adverse psychological outcomes, such as PPD. In addition, to better understand such associations, we investigated the reasons for non-breastfeeding or adding formula in our study. We hypothesized that mothers who breastfed (exclusively) at the time point of three months postpartum would show significantly less symptoms of PPD and would report a better bonding towards their child, than mothers who did not breastfeed at that time.
Methods
Study design and procedure
The present work was embedded in a larger research project “Baby-Friendly and Breastfeeding” (in the following BaSti-study) and is a longitudinal observational cohort design. We recruited women between December 2017 and November 2019 vis-a-a-vis prenatal (participants were at least in their 16th week of pregnancy) as well as postpartum (three months after birth) via phone after the participants gave their informed consent. Recruitment took place before and after midwife consultations and gynecological examinations, delivery room information evenings and, for only postpartum surveys, through the hospital staff at the neonatal wards. Four pilot surveys were conducted prior to actual implementation. The participating hospitals were two university teaching hospitals in Germany. Inclusion criteria were delivery in one of the participating hospitals, a minimum age of 18 years and sufficient German language skills. Stillbirths or early postnatal death led to an exclusion of the study. The final study sample comprised N = 307. Of the total sample, 90 women (29.3%) were surveyed during pregnancy. To ensure that the conditions of the surveys were as comparable as possible, the procedure was always as follows: participants received (1) an information sheet, (2) the consent form, (3) a questionnaire on sociodemographic data and the test battery. Prior to the introduction of the EPDS, the following standardized introduction was presented to the participants by the person conducting the survey: " I would like to move on to topics that may be uncomfortable for you. If you do not wish to answer a question, you are of course free to do so. It is important for me to emphasize at this point that negative thoughts and feelings about yourself and the child can be common during and after pregnancy and are, to a certain extent, quite normal. However, it is possible for these feelings to persist for several days or weeks, leading to what is known as PPD. It is important to us that this topic receives more attention and recognition in the future and is not made taboo, as this leaves those affected alone with it". We filled in the answers given in the postpartum telephone survey in the questionnaire and sent it to the participants upon request.
Approval
All research was performed in accordance with relevant guidelines. The participants proved written informed consent to participate in the study. This study was conducted in accordance with the Declaration of Helsinki. The Ethics Committee of the University Witten/Herdecke approved all components of the project 86/2017.
Instruments
Edinburgh Postnatal Depression Scale (EPDS)
To assess the occurrence of depressive symptoms we used the German version69 of the 10-item self-report scale EPDS70 as a screening tool. The EPDS was originally developed as a screening instrument for the postnatal period71, but because it has been validated in numerous studies as an applicable tool for both pre- and postpartum assessment72, we included it in both settings. Each item is scored on a 4-point scale ranging from 0 to 3—with a higher sum score indicating more depressive symptoms20,69. Responses are based on the mental state over the past seven days69. The data revealed a Cronbach’s α of 0.82 (prepartum) and 0.79 (postpartum) in our sample.
Postpartum Bonding Questionnaire (PBQ)
To investigate mother–infant bonding, we used the German version of the self-report PBQ19,23, which assesses a mother’s feelings or behaviors toward her infant73. In contrast to the original version, which consists of 25 items and proposes a four factor solution, the German version of the screening instrument consists of 16 Items and proposes a solution with only one general factor “impaired bonding”23. The Likert scaling of the PBQ ranges from 0 (always) to 5 (never), with a higher sum score indicating impaired bonding20. In our sample, the internal consistency was α = 0.80.
Questionnaire “Feeling Comfortable During Pregnancy” (original: Schwanger Wohlfühlen)
To assess possible covariates such as subjective mental and physical well-being, coping during pregnancy and partner relationship/social support, we administered the questionnaire “Feeling Comfortable During Pregnancy”74 during pregnancy. The questionnaire was originally developed in German and consists of 38 items. They reflect the dimensions “affective well-being”, “physical well-being” and “coping during pregnancy”. Responses are given on a Likert scale ranging from 1 (does not apply at all) to 7 (fully applicable). In our sample, the overall internal consistency reached Cronbach’s α = 0.82 and for the three underlying dimensions affective well-being α = 0.82, physical well-being α = 0.42 and coping during pregnancy α = 0.66.
Statistical analysis
All analyses were performed using IBM SPSS Statistics 27.0 (IBM Corp 2020). Decisions regarding the use of parametric or non-parametric tests are, besides the scale levels of the variables, based on the examination of outliers and the following assumptions: additivity and linearity, homoscedasticity, independence of residual terms and multicollinearity75. We tested normality with regard to sample sizes ˂ 3075,76. To use either parametric or non-parametric tests was decided for each test individually.
Hypothesis testing was conducted in two steps. First, unpaired group comparisons and correlational analyses were performed. All significant interactions with more than two groups were analyzed with post hoc tests. Due to different sample sizes, we chose to use Hochberg’s GT2 as a post hoc test75. Second, logistic regression analyses containing the significant results out of step one were performed. Because the regression analyses were hierarchical75, we focused primarily on the Akaike information criterion (AIC) to decide on a model. The final model of the regression analyses was bootstrapped (N = 1000 samples, 95% confidence interval), to ensure its explanatory value.
Potential covariates
Given previous research on the EPDS postpartum, the PBQ and the success of breastfeeding20,23,77,78,79,80,81, we included the following covariates (see Table 1) to minimize potential confounding.
Results
Descriptive statistics
Women were aged between 19 and 57 years (M = 32.93, SD = 4.50) and 87.6% of the women were born in Germany. 10.1% of the women have previously had a psychological illness. 12.7% of the children had to be transferred to the pediatric clinic after birth. See Table 2 for additional demographic characteristics.
Feeding styles and its associations with PPD and mother–child-bonding
A t-test did not reveal significant differences between the breastfeeding (n = 263) and the non-breastfeeding group (n = 43) concerning the postpartum EPDS, t(304) = 1.695, p = 0.09. Due to an outlier we found, we additionally performed a Mann–Whitney U-Test, which confirmed our results, U(43,263) = 4647.00, Z = −1.881, p = 0.060. However, a tendency was evident here. No significant difference could be shown with respect to PBQ scores either, t(304) = −1.320, p = 0.188.
Examining exclusive breastfeeding vs. mixed feeding vs. non-breastfeeding, an ANOVA revealed significant differences in EPDS scores postpartum, F(2, 304) = 3.323, p = 0.037, r = 0.145, with a small effect size82, as well as in PBQ scores, F(2, 304) = 4.689, p = 0.010, r = 0.173. For EPDS scores, post hoc tests did not reveal significant differences between the groups. For PBQ scores, post hoc tests showed significant differences between the breastfeeding group and the mixed feeding group, MDiff = −2.801, 95% CI [− 5.24, − 0.37], p = 0.018, with d = 0.551, indicating a medium effect size82, as well as between the non-breastfeeding group and the mixed feeding group, MDiff = −3.610, 95% CI [− 6.57, − 0.65], p = 0.011, with d = 0.677, also indicating a medium effect size82.
Based on these findings, we conducted multinomial regression analyses. Table 3 shows all correlations of potential variables relevant to exclusive breastfeeding. Significant correlations were included in the regression analyses. In order to obtain a feasibly parsimonious model, we decided to use a hierarchical method75.
Our final regression model (Table 4) included the PBQ score and EPDS score prenatal as significant variables relevant to the different breastfeeding states (AIC = 148.514). The Likelihood Ratio test was significant, χ2(4, N = 86) = 17.647, p ˂ 0.001, and Nagelkerke’s R2 = 0.221 (Cox and Snell’s R2 = 0.184) can be considered as acceptable83. Both, Pearson test (p = 0.554) and deviance (p = 0.954), indicated that the model was a good fit to the data75. Bootstrapped regression weights (Table 5) confirm our results.
We furthermore investigated partner relationship/social support for breastfeeding and reasons for non-breastfeeding or adding formula as well as associations with breastfeeding difficulties. Regarding partner relationship/social support, no significant difference was found between the groups, χ2(2, N = 200) = 3.293, p = 0.193. Table 6 shows the reasons given by the groups. Mothers who added formula reported more often than mothers who did not breastfeed, that they were unsure whether the infant was satiated/were sure that they were not satiated, and that the infant did not gain enough weight. In terms of any breastfeeding difficulties, correlations with the EPDS postpartum, η = 0.033, p = 0.568, and the PBQ, η = 0.077, p = 0.181, were both not significant. Regarding the quantity of breastfeeding difficulties no significant correlation was found with the EPDS postpartum, r(307) = 0.058, p = 0.311, 95% CI [− 0.054, 0.169], nor with the PBQ, r(307) = 0.080, p = 0.160, 95% CI [− 0.032, 0.191], either.
Discussion
The aim of this study was to investigate associations between depressive symptoms, mother–child-bonding and different feeding practices (exclusive, mixed, and no breastfeeding). We found that higher EPDS scores prepartum were associated with non-breastfeeding rather than with exclusive breastfeeding three months after birth. The association with the postpartum EPDS score was less clear. Nevertheless, an association between depressive symptoms occurring around pregnancy and birth and non-breastfeeding at three months after delivery was, as hypothesized, definitely reflected in our results and supports previous studies which found similar relations36,40,46,47,48. Another study that focused on the factor of a "breastfeeding method" found that exclusive or non-exclusive breastfeeding did not significantly affect depression, anxiety, or mother–child-bonding in the early postpartum period nor vice versa84. However the authors attributed these results to the short observation period of one month after birth, among other factors.
Considerations that PPD could be triggered by breastfeeding difficulties54,55 as a common source of stress51,52, are not supported by our results. According to Roth et al. (2021) breastfeeding difficulties are associated with lower bonding while postpartum depression has a negative impact on bonding quality regardless of breastfeeding difficulties: “The effect of breastfeeding difficulties on bonding persists over and above the effect of postnatal depressive symptoms”85. The authors concluded that postpartum depression and breastfeeding difficulties provide unique pathways for understanding bonding. A better understanding of bonding is relevant because studies have confirmed its importance, especially the importance of maternal sensitivity, for child development86. Furthermore, we found that with a higher PBQ score, mothers were signficantly more likely to report adding formula at the time point of three months than to exclusively breastfeed. To our knowledge, no study so far differentiated exclusive, mixed and formula feeding patterns with regard to mother-child-bonding in particular. Higher oxytocin levels may be of explanatory value for differences between exclusive and mixed breastfeeding. The quality of mother–child interrelations and maternal oxytocin levels appear to be positively correlated87,88,89,90. Oxytocin has also been found to be lower in patients with major depression91 and with higher depression symptoms postpartum47,92.
However, following the argument of oxytocin levels and breastfeeding, it remains unclear why mothers who had not breastfed also reported a better bonding quality than mothers who practiced mixed feeding, which is different from our hypothesis. Mothers who added formula reported reasons such as insufficient weight gain and non-satiation of the infant for doing so significantly more often than mothers who did not breastfed. Clayton et al. (2013) already found that infant hunger was a predominant reason for mixed feeding, rather than bottle-feeding alone93. In addition, no mother who added formula cited self-referred reasons, such as convenience, less dependency, stress or simply “not feeling like it” for their decision, whereas mothers who did not breastfeed did report such reasons. These results indicate that the underlying impulses and prior experiences that lead to the decision whether to add formula or to wean differ. First, women who decide to wean seem to be more likely to make decisions in their own favor, as the postpartum period has negative effects on their quality of life94. Second, these women may have more self-confidence to face potential stigmas associated with the role of the mother and (discontinued) breastfeeding. Hence, they may be able to see their bond with their child as unaffected by less successful breastfeeding. The relationship between self-confidence, self-care and bonding has been well investigated95,96,97 and may be of important explanatory value for our findings. Third, thinking that the child is not gaining enough weight or might be hungry could lead to feelings of guilt and cause stress. Postpartum stress decreases maternal self-confidence and affects the relationship between mother and child98. The decision to wean might be a relief for some women and reduce one source of postpartum stress. Symon et al. (2013) furthermore found the antenatal breastfeeding intention to be an important factor regarding satisfaction99. Maternal satisfaction scores were highest, when breastfeeding goals were reached, regardless of whether the goal was to breastfeed or intentionally not to do so99. Subsequently, regarding the given reasons to add formula, a possible explanation for higher PBQ scores of mixed feeding mothers in our sample could be, that they did not reach their breastfeeding goal, which subsequently resulted in a poorer rating of the bonding to their infant. However, more research is needed to prove our findings and conclusions, as the breastfeeding patterns, as distributed by us, and their association to mother–child-bonding, are to our knowledge still unexplored.
Our findings can be highly beneficial in terms of designing and disassembling preventive programs. They support for example indications to provide universal screening of previous depressive symptoms during pregnancy. It should be noted that screening in itself does not mean that depression can be definitively identified in an individual. Screening aims to identify as accurately as possible subpopulations with a high prevalence. A full diagnostic evaluation can only be made based on gold-standard clinical criteria100. Furthermore, peripartum maternal mental health is complex, as it comprises a variety of possible mental health problems1.
Screening should also be conducted postpartum, comprehensively, and with a special focus on at-risk populations. Especially reasons and impacts concerning a mixed feeding-style should be addressed in future research, to enable drawing more profound conclusions. Breastfeeding mothers with infants that do not gain enough weight or are not being sufficiently satiated, should especially be supported postpartum, as they tend to characterize their bonding as poorer, respectively. Education over these problems and possible solutions for them should get more attention during hospitalization and antepartum. According to our findings, mother–child-bonding seems to be an important variable in the issue of different feeding practices (exclusive, mixed, and non-breastfeeding). Depressive symptoms prepartum also seem to be an important variable in this context. We have not investigated to what extent the two are related. Although breastfeeding has many benefits for both the mother and the infant, the relationship between maternal mental health and breastfeeding is complex. It should be taken into consideration that breastfeeding may not be the most effective or viable option for all mothers101.
Limitations
Several points limiting our findings should be considered. Although we included several possible covariates in our analyses, confounding factors might remain. We also did not impute the missing values (this refers especially to the prepartum data). When recruiting participants for the study, we were aware that this was a sensitive issue and that we did not want to commit to the sample size initially. We did not perform a power analysis prior to recruitment. Besides that, we did not evaluate our data with respect to dropouts. Hence, we cannot completely rule out an attrition bias. Future studies should collect data concerning information over their dropouts, as previous studies already reported for example higher depression rates in groups with missing data16. However, inclusion in our study was not very restrictive and data collection took place in different in-hospital environments. This led to a large sample that is representative of the facilities in which they were collected. The reliability of the subscales physical well-being and coping during pregnancy of the Questionnaire "Feeling Comfortable During Pregnancy" was lower than expected and not significant in the correlations (Table 3) and thus excluded from the regression analyses, which needs to be addressed here. Even though all screening tools used in our study were established and validated, it should be noted that we exclusively used self-report measures. These can cause biases, for example through answering in a socially desirable manner102,103,104, which could be crucial for our findings regarding associations between poor bonding and high education23,81. Reck et al. (2006) reported similar findings and hypothesized that higher educated mothers would have a greater tendency to answer in a less socially desirable manner, rather than actually suffering from poorer bonding to their infants23. Mixed-measure designs could prevent such biases. Future studies should for example consider including structured diagnostic interviews, video observations of maternal behavior or biochemical analyses. Depressed women furthermore tend to rate themselves as worse parents than they are, due to a low self-esteem and negative thoughts105,106, which could have affected some of the associations we found.
Conclusion
Our findings provide important implications for future directions. These concern information regarding populations that may be at higher risk of developing PPD or a poor mother-child-bonding, such as antenatal depressive symptoms, or, representing to our knowledge a new finding, a mixed feeding style. However, more research is needed to get a more profound understanding of associations between mother–child-bonding and a mixed feeding style. Especially information about underlying reasons we found for performing mixed feeding, such as insufficient weight gain of the child or the feeling that the child was unsatiated, could contribute in a meaningful way to prevent impaired mother–child-bonding. We suggest implementing more measures supporting aspects such as self-efficacy and postpartum well-being of the mother in preventive programs.
Data availability
Due to the strict European General Data Protection Regulation the dataset generated in this study can not be deposited in a public repository. A request for access to the pseudonymized data for researchers who meet the criteria for access to confidential data must be submitted to the author: Clara Carvalho Hilje, email: Clara.CarvalhoHilje@uni-wh.de.
References
Jomeen, J. in Mayes’ Midwifery, edited by S. Macdonald & G. Johnson (Elsevier, 2017), Vol. 15 186–199.
Razurel, C., Bruchon-Schweitzer, M., Dupanloup, A., Irion, O. & Epiney, M. Stressful events, social support and coping strategies of primiparous women during the postpartum period: a qualitative study. Midwifery 27, 237–242 (2011).
Razurel, C., Kaiser, B., Sellenet, C. & Epiney, M. Relation between perceived stress, social support, and coping strategies and maternal well-being: A review of the literature. Women Health 53, 74–99 (2013).
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-5, 5th ed (American Psychiatric Publishing, 2013).
Dorn, A. & Mautner, C. Postpartale depression. Interdisziplinäre Behandlung. Die Gynäkologie 51, 94–101 (2018).
Gaynes B. N. et al. in AHRQ Evidence Report Summaries, edited by B. N. Gaynes, et al. (Agency for Healthcare Research and Quality (US), 2005).
Howard, L. M. et al. Non-psychotic mental disorders in the perinatal period. Lancet 384, 1775–1788 (2014).
Munk-Olsen, T., Laursen, T. M., Pedersen, C. B., Mors, O. & Mortensen, P. B. New parents and mental disorders: A population-based register study. JAMA 296, 2582–2589 (2006).
Grigoriadis, S. et al. The impact of maternal depression during pregnancy on perinatal outcomes: A systematic review and meta-analysis. J. Clin. Psychiatry 74, e321–e341 (2013).
DiPietro, J. A., Novak, M. F. S. X., Costigan, K. A., Atella, L. D. & Reusing, S. P. Maternal psychological distress during pregnancy in relation to child development at age two. Child Dev. 77, 573–587 (2006).
Field, T. Prenatal depression risk factors, developmental effects and interventions: A review. J. Pregnancy Child Health 4, 66 (2017).
Gelaye, B., Rondon, M. B., Araya, R. & Williams, M. A. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry 3, 973–982 (2016).
Kim-Cohen, J., Caspi, A., Rutter, M., Tomás, M. P. & Moffitt, T. E. The caregiving environments provided to children by depressed mothers with or without an antisocial history. Am. J. Psychiatry 163, 1009–1018 (2006).
Moehler, E., Brunner, R., Wiebel, A., Reck, C. & Resch, F. Maternal depressive symptoms in the postnatal period are associated with long-term impairment of mother–child bonding. Arch. Womens Ment. Health 9, 273–278 (2006).
Murray, L., Halligan, S. L., Goodyer, I. & Herbert, J. Disturbances in early parenting of depressed mothers and cortisol secretion in offspring: A preliminary study. J. Aff. Disord. 122, 218–223 (2010).
Netsi, E. et al. Association of persistent and severe postnatal depression with child outcomes. JAMA Psychiatry 75, 247–253 (2018).
Öztop, D. & Uslu, R. Behavioral, interactional and developmental symptomatology in toddlers of depressed mothers: A preliminary clinical study within the DC:0–3 framework. Turk. J. Pediatr. 49, 171–178 (2007).
Behrendt, H. F. et al. Postnatal mother-to-infant attachment in subclinically depressed mothers: Dyads at risk?. Psychopathology 49, 269–276 (2016).
Brockington, I. F. et al. A screening questionnaire for mother–infant bonding disorders. Arch. Womens Ment. Health 3, 133–140 (2001).
Dubber, S., Reck, C., Müller, M. & Gawlik, S. Postpartum bonding: The role of perinatal depression, anxiety and maternal-fetal bonding during pregnancy. Arch. Womens Ment. Health 18, 187–195 (2015).
Friedman, S. H. & Resnick, P. J. Postpartum depression: An update. Women’s Health 5, 287–295 (2009).
Nonnenmacher, N., Noe, D., Ehrenthal, J. C. & Reck, C. Postpartum bonding: The impact of maternal depression and adult attachment style. Arch. Womens Ment. Health 19, 927–935 (2016).
Reck, C. et al. The German version of the postpartum bonding instrument: Psychometric properties and association with postpartum depression. Arch. Womens Ment. Health 9, 265–271 (2006).
Song, M. et al. Maternal depression and mother-to-infant bonding: The association of delivery mode, general health and stress markers. OJOG 07, 155–166 (2017).
Fitzsimons, E. & Vera-Hernández, M. Breastfeeding and child development. Am. Econ. J. Appl. Econ. 14, 329–366 (2022).
Smith-Nielsen, J., Tharner, A., Krogh, M. T. & Vaever, M. S. Effects of maternal postpartum depression in a well-resourced sample: Early concurrent and long-term effects on infant cognitive, language, and motor development. Scand. J. Psychol. 57, 571–583 (2016).
Bowlby, J. Attachment and Loss (Basic Books, 1980).
Jansen, J., de Weerth, C. & Riksen-Walraven, J. M. Breastfeeding and the mother–infant relationship—A review. Dev. Rev. 28, 503–521 (2008).
Brockington, I. F., Aucamp, H. M. & Fraser, C. Severe disorders of the mother–infant relationship: Definitions and frequency. Arch. Womens Ment Health 9, 243–251 (2006).
Kumar, R. C. “Anybody’s child”: Severe disorders of mother-to-infant bonding. Br. J. Psychiatry 171, 175–181 (1997).
Field, T., Healy, B. T., Goldstein, S. & Guthertz, M. Behavior-state matching and synchrony in mother–infant interactions of nondepressed versus depressed dyads. Dev. Psychol. 26, 7–14 (1990).
Alimi, R., Azmoude, E., Moradi, M. & Zamani, M. The association of breastfeeding with a reduced risk of postpartum depression: A systematic review and meta-analysis. Breastfeed Med. 17, 290–296 (2022).
Figueiredo, B., Canário, C. & Field, T. Breastfeeding is negatively affected by prenatal depression and reduces postpartum depression. Psychol. Med. 44, 927–936 (2014).
Govoni, L. et al. Breastfeeding pathologies: Analysis of prevalence, risk and protective factors. Acta Biomed. 90, 56–62 (2019).
Ip, S. et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid. Rep. Technol. Assess 66, 1–186 (2007).
McCoy, S. J. B., Beal, M. J., Shipman, S. B. M., Payton, M. E. & Watson, G. H. Risk factors for postpartum depression: A retrospective investigation at 4-weeks postnatal and a review of the literature. Int. J. Osteopath. Med. 106, 193–198 (2006).
Mezzacappa, E. S. & Katlin, E. S. Breast-feeding is associated with reduced perceived stress and negative mood in mothers. Health Psychol. 21, 187–193 (2002).
Strathearn, L., Mamun, A. A., Najman, J. M. & O’Callaghan, M. J. Does breastfeeding protect against substantiated child abuse and neglect? A 15-year cohort study. Pediatrics 123, 483–493 (2009).
Weaver, J. M., Schofield, T. J. & Papp, L. M. Breastfeeding duration predicts greater maternal sensitivity over the next decade. Dev. Psychol. 54, 220–227 (2018).
Webber, E. & Benedict, J. Postpartum depression: A multi-disciplinary approach to screening, management and breastfeeding support. Arch. Psychiatr. Nurs. 33, 284–289 (2019).
Xia, M., Luo, J., Wang, J. & Liang, Y. Association between breastfeeding and postpartum depression: A meta-analysis. J. Aff. Disord. 308, 512–519 (2022).
Dias, C. C. & Figueiredo, B. Breastfeeding and depression: A systematic review of the literature. J. Aff. Disord. 171, 142–154 (2015).
Seimyr, L., Edhborg, M., Lundh, W. & Sjögren, B. In the shadow of maternal depressed mood: Experiences of parenthood during the first year after childbirth. J. Psychosom. Obstet. Gynaecol. 25, 23–34 (2004).
Silva, C. S. et al. Association between postpartum depression and the practice of exclusive breastfeeding in the first three months of life. Jornal de Pediatria 93, 356–364 (2017).
Dennis, C.-L. & McQueen, K. The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics 123, e736–e751 (2009).
Kendall-Tackett, K., Cong, Z. & Hale, T. W. The effect of feeding method on sleep duration, maternal well-being, and postpartum depression. Clin. Lactation 2, 22–26 (2011).
Lara-Cinisomo, S., McKenney, K., Di Florio, A. & Meltzer-Brody, S. Associations between postpartum depression, breastfeeding, and oxytocin levels in latina mothers. Breastfeed Med. 12, 436–442 (2017).
Nishioka, E. et al. A prospective study of the relationship between breastfeeding and postpartum depressive symptoms appearing at 1–5 months after delivery. J. Aff. Disord. 133, 553–559 (2011).
Taveras, E. M. et al. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics 112, 108–115 (2003).
Watkins, S., Meltzer-Brody, S., Zolnoun, D. & Stuebe, A. Early breastfeeding experiences and postpartum depression. Obstet. Gynecol. 118, 214–221 (2011).
Brown, A., Rance, J. & Bennett, P. Understanding the relationship between breastfeeding and postnatal depression: The role of pain and physical difficulties. J. Adv. Nurs. 72, 273–282 (2016).
Chaput, K. H., Nettel-Aguirre, A., Musto, R., Adair, C. E. & Tough, S. C. Breastfeeding difficulties and supports and risk of postpartum depression in a cohort of women who have given birth in Calgary: A prospective cohort study. CMAJ Open 4, E103–E109 (2016).
Borra, C., Iacovou, M. & Sevilla, A. New evidence on breastfeeding and postpartum depression: The importance of understanding women’s intentions. Matern. Child Health J. 19, 897–907 (2015).
Henshaw, E. J., Fried, R., Siskind, E., Newhouse, L. & Cooper, M. Breastfeeding self-efficacy, mood, and breastfeeding outcomes among primiparous women. J. Hum. Lact. 31, 511–518 (2015).
Lion, C. Ph.D. (Walden University, 2011).
Ettenberger, M., Bieleninik, Ł, Epstein, S. & Elefant, C. Defining attachment and bonding: Overlaps, Differences and implications for music therapy clinical practice and research in the neonatal intensive care unit (NICU). Int. J. Environ. Res. Public Health 18, 66 (2021).
Davis, A. M. B. & Sclafani, V. Birth experiences, breastfeeding, and the mother–child relationship: Evidence from a large sample of mothers. Can. J. Nurs. Res. 54, 518–529 (2022).
Else-Quest, N. M., Hyde, J. S. & Clark, R. Breastfeeding, bonding, and the mother–infant relationship. Merrill Palmer Q 49, 495–517 (2003).
Hairston, I. S., Handelzalts, J. E., Lehman-Inbar, T. & Kovo, M. Mother–infant bonding is not associated with feeding type: a community study sample. BMC Pregnancy Childb. 19, 125 (2019).
Minamida, T. et al. Do postpartum anxiety and breastfeeding self-efficacy and bonding at early postpartum predict postpartum depression and the breastfeeding method?. Infant Ment. Health J. 41, 662–676 (2020).
Papp, L. M. Longitudinal associations between breastfeeding and observed mother–child interaction qualities in early childhood. Child Care Health Dev. 40, 740–746 (2014).
Keller, N., Medved, V. & Armano, G. The influence of maternal personality and risk factors for impaired mother–infant bonding on breastfeeding duration. Breastfeed Med. 11, 532–537 (2016).
Linde, K., Lehnig, F., Nagl, M. & Kersting, A. The association between breastfeeding and attachment: A systematic review. Midwifery 81, 102592 (2020).
Peñacoba, C. & Catala, P. Associations between breastfeeding and mother–infant relationships: A systematic review. Breastfeed Med. 14, 616–629 (2019).
Whittingham, K. & Mitchell, A. E. Birth, breastfeeding, psychological flexibility and self-compassion as predictors of mother–infant emotional availability in a cross-sectional study. Infant Ment. Health J. 42, 718–730 (2021).
Scharfe, E. Maternal attachment representations and initiation and duration of breastfeeding. J. Hum. Lact. 28, 218–225 (2012).
Kim, S.-H. Factors associated with maternal attachment of breastfeeding mothers. Child Health Nurs. Res. 25, 65–73 (2019).
Smith, J. P. & Ellwood, M. Feeding patterns and emotional care in breastfed infants. Soc. Indic. Res. 101, 227–231 (2011).
Bergant, A. M., Nguyen, T., Heim, K., Ulmer, H. & Dapunt, O. Deutschsprachige Fassung und Validierung der “Edinburgh postnatal depression scale”. Dtsch Med Wochenschr 123, 35–40 (1998).
Cox, J. L., Holden, J. M. & Sagovsky, R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br. J. Psychiatry 150, 782–786 (1987).
Cox, J. L., Chapman, G., Murray, D. & Jones, P. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in non-postnatal women. J. Aff. Disord. 39, 185–189 (1996).
Matthey, S., Henshaw, C., Elliott, S. & Barnett, B. Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale: Implications for clinical and research practice. Arch. Womens Ment. Health 9, 309–315 (2006).
Wittkowski, A., Wieck, A. & Mann, S. An evaluation of two bonding questionnaires: A comparison of the Mother-to-Infant Bonding Scale with the Postpartum Bonding Questionnaire in a sample of primiparous mothers. Arch. Womens Ment. Health 10, 171–175 (2007).
Ayerle, G. & Gross, M. Psychometric assessment of subjective well-being and coping in pregnancy. Z. Med. Psychol. 19, 12–20 (2010).
Field, A. Discovering Statistics Using IBM SPSS Statistics. And Sex and Drugs and Rock 'n' Roll 4th ed. (Sage, 2013).
Lumley, T., Diehr, P., Emerson, S. & Chen, L. The importance of the normality assumption in large public health data sets. Annu. Rev. Public Health 23, 151–169 (2002).
Declercq, E., Labbok, M. H., Sakala, C. & O’Hara, M. Hospital practices and women’s likelihood of fulfilling their intention to exclusively breastfeed. Am. J. Public Health 99, 929–935 (2009).
Goecke, T. W. et al. The association of prenatal attachment and perinatal factors with pre- and postpartum depression in first-time mothers. Arch. Gynecol. Obstet. 286, 309–316 (2012).
Handelzalts, J. E. et al. Associations of rooming-in with maternal postpartum bonding: The impact of mothers’ pre-delivery intentions. Midwifery 95, 102942 (2021).
Hawkins, S. S., Stern, A. D., Baum, C. F. & Gillman, M. W. Compliance with the baby-friendly hospital initiative and impact on breastfeeding rates. Arch. Dis. Child Fetal. Neonatal Ed. 99, F138–F143 (2014).
van Bussel, J. C. H., Spitz, B. & Demyttenaere, K. Three self-report questionnaires of the early mother-to-infant bond: Reliability and validity of the Dutch version of the MPAS, PBQ and MIBS. Arch. Womens Ment. Health 13, 373–384 (2010).
Cohen, J. Statistical Power Analysis for the Behavioral Sciences 2nd ed. (Erlbaum, 1988).
Backhaus, K., Erichson, B., Plinke, W. & Weiber, Rs. Multivariate Analysemethoden. Eine anwendungsorientierte Einführung, 13th ed. (Springer, 2011).
Fukui, N. et al. Exclusive breastfeeding is not associated with maternal–infant bonding in early postpartum, considering depression, anxiety, and parity. Nutrients 13, 66 (2021).
Roth, M. C., Humphreys, K. L., King, L. S., Gotlib, I. H. & Robakis, T. K. Breastfeeding difficulties predict mothers’ bonding with their infants from birth to age six months. Matern. Child Health J. 25, 777–785 (2021).
Soares, H., Barbieri-Figueiredo, M., Pereira, S., Silva, M. & Fuertes, M. Parents attending to nurse visits and birth age contribute to infant development: A study about the determinants of infant development. Early Hum. Dev. 122, 15–21 (2018).
Galbally, M., Lewis, A. J., van Ijzendoorn, M. & Permezel, M. The role of oxytocin in mother–infant relations: A systematic review of human studies. Harv. Rev. Psychiatry 19, 1–14 (2011).
Levine, A., Zagoory-Sharon, O., Feldman, R. & Weller, A. Oxytocin during pregnancy and early postpartum: Individual patterns and maternal-fetal attachment. Peptides 28, 1162–1169 (2007).
McErlean, R. & Eape, V. in Perinatal Depression, edited by M. Graciela Rojas Castillo 39–54 (IntechOpen, 2012).
Meyer-Lindenberg, A., Domes, G., Kirsch, P. & Heinrichs, M. Oxytocin and vasopressin in the human brain: Social neuropeptides for translational medicine. Nat. Rev. Neurosci. 12, 524–538 (2011).
Scantamburlo, G. et al. Plasma oxytocin levels and anxiety in patients with major depression. Psychoneuroendocrinology 32, 407–410 (2007).
Stuebe, A. M., Grewen, K. & Meltzer-Brody, S. Association between maternal mood and oxytocin response to breastfeeding. J. Womens Health 22, 352–361 (2013).
Clayton, H. B., Li, R., Perrine, C. G. & Scanlon, K. S. Prevalence and reasons for introducing infants early to solid foods: Variations by milk feeding type. Pediatrics 131, e1108–e1114 (2013).
Özdemir, F., Öztürk, A., Karabulutlu, Ö. & Tezel, A. Determination of the life quality and self-care ability of the mothers in post-partum period. J. Pak. Med. Assoc. 68, 210–215 (2018).
Barbosa, E. M. G. et al. Educational technologies to encourage (self) care in postpartum women. Rev. Bras Enferm 69, 582–590 (2016).
Kadiroğlu, T. & Güdücü Tüfekci, F. Effect of infant care training on maternal bonding, motherhood self-efficacy, and self-confidence in mothers of preterm newborns. Matern. Child Health J. 26, 131–138 (2022).
Zietlow, A.-L., Schlüter, M. K., Nonnenmacher, N., Müller, M. & Reck, C. Maternal self-confidence postpartum and at pre-school age: The role of depression, anxiety disorders, maternal attachment insecurity. Matern. Child Health J. 18, 1873–1880 (2014).
Moghaddam Tabrizi, F. & Nournezhad, H. The effect of family support based counselling on postnatal perceived stress and mother–child bonding in nulliparous women to health centers in Urmia in 2016–2017. Nurs. Midwif. J. 16, 109–121 (2018).
Symon, A. G., Whitford, H. & Dalzell, J. Infant feeding in Eastern Scotland: A longitudinal mixed methods evaluation of antenatal intentions and postnatal satisfaction—The Feeding Your Baby study. Midwifery 29, e49-56 (2013).
Fisher, J., Rahman, A., Cabral de Mello, M., Chandra, P. S. & Herrman, H. in Parenthood and Mental Health, edited by S. Tyano, M. Keren, H. Herrman & J. Cox 429–442 (Wiley, 2010).
Vanderkruik, R., Lemon, E. & Dimidjian, S. Breastfeeding support and messaging: A call to integrate public health and psychological perspectives. Matern. Child Health J. 19, 2545–2547 (2015).
Cuixia, L., Jian, X. & Zhongfang, Y. A compromise between self-enhancement and honesty: Chinese self-evaluations on social desirability scales. Psychol. Rep. 92, 291–298 (2003).
Tourangeau, R., Rips, L. J. & Rasinski, K. The Psychology of Survey Response (Cambridge University Press, 2000).
Wlömert, N., Pellenwessel, D., Fox, J.-P. & Clement, M. Multidimensional assessment of social desirability bias: An application of multiscale item randomized response theory to measure academic misconduct. J. Surv. Stat. Methodol. 7, 365–397 (2019).
Frankel, K. A. & Harmon, R. J. Depressed mothers: They don’t always look as bad as they feel. J. Am. Acad. Child Adolesc. Psychiatry 35, 289–298 (1996).
Hornstein, C., Schenk, S., Wortmann-Fleischer, S., Downing, G. & Schwarz, M. Videotherapie bei postpartalen Störungen. Psychotherapeut 51, 363–368 (2006).
Acknowledgements
We would like to thank the women who were willing to participate in this study. Furthermore, we would like to thank the Gerhard-Kienle-Foundation for supporting the study.
Funding
Open Access funding enabled and organized by Projekt DEAL.
Author information
Authors and Affiliations
Contributions
C.C.H., F.V., N.B., C.K. and A.L. conceived and designed the idea for the study and the manuscript, while C.K. was mainly supporting the data collection. C.C.H. wrote the manuscript of the paper and created together with D.R. the tables. C.C.H., N.B., D.R., C.K., T.O., F.V. and A.L. reviewed and edited the draft of the paper independently until consensus was reached on the final version. All authors have read and agreed to the published version of the manuscript.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Additional information
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Carvalho Hilje, C., Bauer, N.H., Reis, D. et al. The role of breastfeeding and formula feeding regarding depressive symptoms and an impaired mother child bonding. Sci Rep 14, 11417 (2024). https://doi.org/10.1038/s41598-024-62168-y
Received:
Accepted:
Published:
DOI: https://doi.org/10.1038/s41598-024-62168-y
Comments
By submitting a comment you agree to abide by our Terms and Community Guidelines. If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.
