Breastfeeding experiences of women with perinatal mental health problems: a systematic review and thematic synthesis | BMC Pregnancy and Childbirth

The study selection process is outlined on the PRISMA [20] flow diagram (Fig. 1). A total of 5510 studies were retrieved. After removing duplicates (n = 2604) and excluding articles which were not relevant following screening of title and abstract (n = 2878), full text of the remaining 28 studies were screened. Of these, 11 studies were excluded, resulting in 17 studies being included in this review.

PRISMA flow diagram detailing study selection [20]. CINAHL – Cumulative Index to Nursing and Allied Health Literature. PRISMA flow diagram- Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372(71). DOI: https://doi.org/10.1136/bmj.n71

Characteristics of the studies

From the 17 included studies, four used thematic analysis, two in a qualitative study [25, 26] and two within a mixed methods secondary analysis of existing data [27, 28]. Six studies used phenomenological methods [29,30,31,32,33,34], two used an ethnographic approach [35, 36] and three undertook a Grounded Theory approach [37,38,39]. One study used a psychoanalytically informed analysis [40] and one used comparative analysis [41].

Following CASP quality appraisal, the methodological quality of included papers was ranked as either low (n = 3), moderate (n = 2) or high (n = 12), (Table 2).

Of the included studies, seven focused on PND, four included patients with PND and/or emotional difficulties, postnatal blues or mental distress, two focused on mood disorders, four included women previously diagnosed with severe mental illnesses, eating disorders, obsessive compulsive disorder, and/or traumatic childbirth/PTSD.

There were a total of 551 participants across the studies. Of these, 456 were married/cohabiting, 18 were single/separated, and 77 did not specify. For educational attainment, 321 participants identified as either ‘well educated’ or having studied beyond high school level. A total of 86 participants received a school education (high school or below), 14 participants had no schooling and 130 did not specify. Of the 17 studies, 15 were carried out in high-income countries and two in low-income countries (Table 3).

Themes

Through in-depth analysis of the data, three overarching themes: Vulnerabilities, Positive outcomes, and Challenges, emerged. These themes and associated sub themes are shown in Table 4. The interplay among these major domains within the context of themes and subthemes are summarised in Fig. 2.

Illustration of the interplay of themes and subthemes of the breastfeeding experiences of women with perinatal mental health problems PMH – Perinatal mental health

Theme: vulnerabilities

Expectations versus reality

For some new mothers the reality of breastfeeding did not meet their expectations of being easy and ‘natural’, leaving them feeling unprepared and disillusioned when they experienced difficulties.

“You think you’re a completely useless mother and, you know, you should be able to know how to do this instinctively [breastfeeding] and in fact it’s probably the hardest thing I’ve ever done.” (25, p255).

Limited availability of antenatal breastfeeding advice led to mothers being unaware of the potential complexities of breastfeeding during the early days and weeks.

“Everyone make it seem like it’s natural because your body produces [milk]. It’s just something that should frequently come to you as soon as you have the baby., but it’s not like that. You had to hold the baby a certain way, you got to adjust your thing a certain way, you got to put the nipple in far enough for the baby to get it. There’s a lot to it. It’s really complicated.” (26, p5).

Self-perception as a mother

To be perceived as a ‘good mother’, by themselves and others, some women felt they must breastfeed at all costs. This perceived association of breastfeeding as the representation of ‘good mothering’, appeared to result in self-imposed pressure.

“I was so desperate to breastfeed him and I felt as if it was my, I felt as if I had some moral obligation as a mother and if I didn’t breast feed him I was badly letting him down.” (25, p255).

If these women were then unable to breastfeed, or if they faced significant breastfeeding difficulties, this sometimes led to feelings of guilt or inadequacy.

“There’s so much pressure on you to breastfeed. so you’re told that breast is best and you should do it and so when you don’t you think you are a failure and it’s what you should be doing.” (39, p322).

The opinions of family, friends and health professionals also played a significant part in the woman’s perception of her status as a ‘good mother’.

“The approval thing was a big factor. Everyone was telling me how well I’d done to keep breastfeeding. All that approval made me feel really good about myself, and that I was being a good mother to (baby). I wasn’t thinking negative thoughts about myself, I was feeling very positive really.” (35, p114).

However, for some mothers, this resulted in added pressure, causing them to hide their feelings and maintain an outward display of happiness.

“I didn’t want to talk with anybody about it, I always had to pretend that I was doing just great … I thought that wasn’t normal, that I was a bad mom who felt that way.” (37, p264).

Finding the right support could be very beneficial but some women had negative experiences of clinics or groups, undermining their self-belief.

“Daggers are drawn and everybody’s acting as if they can rule the world and the trouble is, when you’re depressed you just see that image and you think, I’m never going to be as good as this.” (39, p323).

Isolation

Feelings of isolation felt by breastfeeding women were exacerbated by mental health issues, with Homewood et al. (39, p325) suggesting that breastfeeding could contribute to depression by increasing the sense of being trapped by the infant’s dependency.

“abandoned and alone … .scared all the time that something would happen to the baby…” (37, p264).

The sense of isolation was increased by the fact that seeking help could be difficult for women who were distressed because they were reluctant to reveal their negative feelings.

“I was feeling like really sad and just really isolated and really stuck!. . I just thought. . “How am I going to take care of this baby? And I am feeling so crappy!” I found it to be really hard just to reach out and admit that I was feeling the way that I was. I don’t know why I was so worried about being stigmatized, but I was. I just didn’t want that label of being a person with postpartum depression.” (32, p12) “.

Theme: positive outcomes

Bonding and closeness

Whilst struggling with mental health issues, the experience of breastfeeding successfully could increase mothers’ positive feelings toward the baby, allowing them to enjoy time spent together and enhance their confidence.

“I used to feed her and it was the time I got a little lump in my throat and thought, oh, perhaps she’s not that bad, and I thought, this is perhaps how people feel a bit more of the time than I feel it.” (39, p323).

Some women reported that the physical aspect of breastfeeding allowed a connection that could compensate, to a degree, for the mental withdrawal caused by the depressive symptoms.

“I think [breastfeeding] helps because even if I feel like some days I’m not very connected emotionally, I know that at least I’m providing the baby with physical touch and bonding and all that. Even if I’m not mentally 100% there. So, I think it makes me feel better about myself as a mom.” (33, p641).

One mother noted that breastfeeding could reduce feelings of stress.

‘‘When I’m nursing her, I’m able to just hold her. And that just alleviates any worries, any stress that I’ve had through the day, just knowing that she needs me, that she’s finding comfort in me, that I’m able to comfort her. She’s comforting me at the same time.” (26, p5).

Sense of achievement

Achieving success with breastfeeding was a factor in mitigating some of the guilt that women with eating disorders might feel about the possible effects of their eating disorder on the baby, positively affecting their self-esteem.

“It wasn’t my instinct to want to breastfeed him but in the end I did. In some ways it made up for all the damage I thought I’d done to him because of my eating disorder.” (35, p113).

Some women who had experienced a traumatic birth perceived breastfeeding as having the potential to heal and reinforced their self-perception as a good mother.

“I would cover her up to feed her and hide her little head in the clothing. Not because of dignity, but because I did not want anyone else to see the magic and healing that was happening between us. Being able to breastfeed my daughter, despite all the odds, is my proudest achievement in life. I wear it in my soul as a badge of honor.” (29, p233).

Women described how breastfeeding was within their sphere of control whereas other aspects of motherhood were not.

“[Breastfeeding] was the one thing that I could control. . I think that it made me feel better because it was the one thing that I was successful at, as a mom, because my birth went so shitty, and everything just kind of spiraled down and my mood and everything. . .I lean on [breastfeeding] a lot. It is my thing with her that no one can take away. . .I don’t like other people doing it. I don’t even like the suggestion of other people doing it.” (32, p12).

Theme: challenges

Striving for control

Some women with eating disorders perceived stopping breastfeeding as the only way to allow them to resume control over their body and their eating.

“I wanted my body back and I knew I wouldn’t get it back until I’d stopped breastfeeding. I knew the minute that stopped feeding him I could control my food again and that’s what I wanted. When I was feeding I needed to eat properly because he needs the nutrients.” (35, p114).

For women with obsessive compulsive disorder [30], some responded to contamination fears by breastfeeding, sometimes for much longer than planned.

“I forced myself to breastfeed for the whole of the first year because I was convinced that formula would be contaminating his body.” (30, p317).

Other women with eating disorders chose not to breastfeed in order to allow themselves to return to purging and undertaking strenuous exercise in order to lose their pregnancy weight rapidly [35].

Some still struggled between eating a ‘good’ diet to produce ‘healthy’ milk and the desire to return to their usual strategies such as restricted eating or purging.

“I didn’t need to make myself sick so often [when breastfeeding] but that wasn’t because I didn’t want to! [Laughs] I had to fight with myself all the time to control the urge. I thought breastfeeding would take that urge away but it didn’t. It eased a bit but I was still vomiting all the time I was breastfeeding.” (35, p112).

Inconsistent advice and lack of support

Women’s difficulties and lack of confidence with breastfeeding were increased by inconsistent advice from both professionals and family [25]. Mothers frequently made reference to seeking advice from healthcare professionals during the early weeks of breastfeeding but felt they were often left unsupported.

“I was alone and . the nurse often didn’t answer the buzzer, my buzzer when I was trying to breast feed and things. Again I felt so kind of, incredibly sensitive about everything, and anxious about everything, and they just weren’t there, were never there for me.” (25, p256).

Mothers described feeling pressurised by healthcare professionals to continue breastfeeding [35] and, without adequate support, women would often turn to friends or relatives for infant feeding advice [25].

Concerns over medication safety

Concerns regarding medication safety and breastfeeding [26, 27, 34] led some women to discount breastfeeding as an option for them.

“….I could try and breastfeed, but yeah, I decided that wasn’t—a good idea. Because it’s too hard and I wouldn’t be able to go back on my medication—right away after the baby was born. You have to wait two months, or something like that. So I thought that was dangerous— for both of us.” (34, p383).

Whilst others discontinued breastfeeding due to health concerns for the baby.

“And I had to get my wisdom teeth pulled out, so I decided to stop because they put you on antibiotics and stuff like that. So I just stopped.”(26, p5).

Some women with severe mental illness felt that due to the complexities of their mental health, breastfeeding was not considered relevant and was “de-prioritized” for other aspects of acute care [27]. Despite many mothers expressing strong preferences to continue breastfeeding, the mothers often felt that their preferences were ignored.

“Medication was an issue as I was initially given medication that specified it should not be taken while breastfeeding, when I had made my wish to breastfeed very clear.” (27, p7).

Some women felt that they needed to prompt staff to consider whether the medication they were prescribed would allow breastfeeding, or, alternatively, be given the choice to cease breastfeeding to allow them to have the most suitable medication to treat their mental health condition.

“I wish they had told me to stop breastfeeding rather than give me diluted medication.” (27, p6).

Others described being given contradictory information from health professionals about breastfeeding whilst taking psychotropic medication:

“Early in pregnancy, the mental health midwife said not to take fluoxetine if breastfeeding and to change to sertraline or citalopram. Next time I saw her later on and she said I could stay on fluoxetine if I was happy on it.” (27, p6).

Such conflicting advice made mothers confused and distressed. A resultant lack of confidence in healthcare professionals “prompted some women to conduct their own research or to disregard medical advice” (27, p6).

Perceived impact on milk quality and supply

There was a perception that women with PMH conditions would be unable to produce a sufficient quality and/or volume of breastmilk to sustain their baby nutritionally. This concern could potentially generate feelings of depression for women [26].

Some mothers perceived that their own poor nutrition could potentially cause problems with breastfeeding. This concern was often associated with eating disorders [26], food unavailability or lack of appetite due to mental ill health [38, 41]. For women with eating disorders there was a belief that frequent cycles of binging and purging were not compatible with producing sufficient good quality breast milk. This caused some women to discount breastfeeding, and some received pressure from partners to bottle feed in the belief that the child would not receive the necessary nutrition.

“He (husband) didn’t want me to breastfeed because he thought I wasn’t eating enough to feed her (baby) properly. [.] He was on and on about me giving her the bottle. He even dragged my sister in to try and get her to talk me round.” (35, p111).

Some women with eating disorders did wish to breastfeed and commented on needing to change their eating patterns to achieve this.

“I had to eat properly when I was breastfeeding because I had a baby to think about. The baby needs nutrition. I thought whatever I eat the baby is going to get it. So I had to eat properly. Like when I was pregnant I made myself eat properly.” (35, p112).