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ORIGINAL ARTICLE
Aim: Depressive and anxiety symptoms are common in new mothers. The aim of this study is to explore the link between postpartum
psychological adjustment and feeding preferences of the mothers.
Methods: Sixty mothers and newborns were enrolled in this prospective, longitudinal study. Maternal depressive symptoms were screened
by the Edinburgh Postpartum Depression Scale (EPDS), and maternal anxiety level was assessed by the State-Trait Anxiety Inventory at 1 month
postpartum. The Multidimensional Scale of Perceived Social Support was used for the assessment of maternal social support. The Adult
Attachment Scale was used to determine the attachment style of the mother. Infants were examined and evaluated at 1 and 4 months of life.
Results: All mothers started breastfeeding their infants postpartum; 91% and 68.1% continued exclusive breastfeeding at 1 and 4 months,
respectively. The rst-month median EPDS score of mothers who breastfeed at the fourth month was statistically signicantly lower than those
who were not breastfeeding (6 and 12, respectively) (P = 0001). The rst-month median EPDS score of mothers with secure attachment was
lower than the median score of mothers with insecure attachment (5 and 9, respectively) (P < 0001). Exclusive breastfeeding rate was not
statistically different among mothers with secure and insecure attachment styles. The median state and trait anxiety scores and social support
scores of mothers were not different between groups according to breastfeeding status.
Conclusions: This study has shown an association between higher EPDS scores and breastfeeding cessation by 4 months after delivery.
The World Health Organization recommends exclusive breast- mild mood changes while they are trying to adapt to their new
feeding for the first 6 months of life because of the numerous roles as main care givers. These symptoms often do not reach to
benefits of breastfeeding for the mother and the child.1 a clinical significance and most of the time, require no specific
However, previous studies have reported that young maternal treatment other than maternal education and support. However,
age, lower educational attainment, low social class and maternal high levels of depressive symptoms may contribute to poor child
depressive disorder increase the risk of early termination of outcomes from infancy to adolescence. Compared with well
breastfeeding.2,3 After adjustment of confounding factors, early women, depressed mothers were found to be less sensitively
cessation of breastfeeding was found to be significantly associ- attuned to their infants and were less affirming.11 Therefore,
ated with postnatal depression.2,46 there is a need for resources devoted to supporting new mothers
Postpartum depressive or anxiety symptoms are common and routine screening and treatment for postpartum depression.
maternal experiences effecting 1020% of new mothers.79 It is Attachment styles are emotional patterns that reflect mother
often under diagnosed causing significant morbidity for the and infant reciprocal relationship. Adult attachment styles are a
entire family and deleterious effects on child care.10 In the post- prominent marker of personal construction of early childhood
partum period, mothers might often feel anxious and present experiences, which are closely related to the caregiving content.12
In an earlier meta-analysis, it was demonstrated that if mothers
Key Points attachment styles were secure, the caregiving behaviours were
more responsive and positive.13 Mothers anxiety level, maternal
1 There is an association between higher EPDS scores and breast-
attachment style and enviromental psychological (marital dissat-
feeding cessation by 4 months after delivery.
isfaction, etc.) or non-psychological factors can contribute to
2 There is an association with insecure adult attachment style and
maternal psychological adoptation and create a contextual risk
postpartum depression.
for motherinfant diad in the early postpartum period.
3 There is a tendency of exclusive breastfeeding in mothers
In this study, we aimed to examine the psychological adjust-
who had a secure attachment style but this is not statistically
ment of the mothers during early postpartum months and
signicant.
describe the effect of maternal depressive symptoms, anxiety
levels, availability of social support and maternal attachment
Correspondence: Dr Ipek Akman, evre Sok, 54/6 06680 ankaya, Ankara, styles on breastfeeding discontinuation for the first 4 months of
Turkey. Fax: 090 216 3250323; email: ipekakman@yahoo.com life.
Materials and Methods translated into Turkish and validated by Alp (IE Alp, unpub-
lished data, 1998). Because of the response rates in Turkish
The study population comprised a cohort of 60 mothers who population, avoidant and ambivalent styles were clustered as
gave birth at Marmara University Hospital between June and insecure attachment style in this study.
December 2005 and their infants who had an uneventful pre-
natal, perinatal and postnatal course. Mothers and newborns
State-Trait Anxiety Inventory
with medical problems that needed hospitalisation were
excluded from the study. None of the mothers had any obstetric The STAI is a 40-item questionnaire measuring state (20 items)
complications in their previous pregnancies. Mothers were and trait (20 items) anxiety.18 The STAI assesses how respon-
asked to sign an informed consent before participation in the dents feel right now (state) and how respondents generally feel
study. The study was approved by Marmara University Ethical (trait) on a 4-point Likert scale, indicating experience of a sig-
Committee. nificant amount of anxiety symptom. The total score for trait
Perinatal records were reviewed and newborns were exam- and state anxiety ranges from 20 to 80. The STAI has good
ined in the first week, the first and fourth months of life. All internal consistency and testretest reliability.19
mothers received short introductory information and encour-
agement to breastfeed from doctors and nurses during initial
Multidimensional Scale of Perceived
hospital stay and subsequent follow-up appointments. A com-
Social Support
plete dietary history was obtained and growth parameters of
infants were assessed during these visits. For analysis of data, we The MSPSS is a self-report measure of perceived social support
grouped mothers into two according to the status of exclusively which is composed of 12 items, with four items comprising each
breastfeeding at the fourth month. of three sources of social support (family, friends and significant
Maternal evaluations were done by two research assistants others).20 It was translated into Turkish and its validity and
from psychiatry department. Each interview was evaluated with reliability was provided by Eker and Arkar.21
a consultant psychiatrist. An initial assessment interview was
developed to assess the context of pregnancy and postpartum
Statistical analysis
experience of caregiving in the first week of postpartum period.
The interview included questions about the demographic char- The SPSS 10.0 for Windows (SPSS Inc., Chicago, IL, USA) was
acteristics of mothers, medical and personal adversity before and used for data analysis. The differences in dichotomous variables
after childbirth, quality of living circumstances, quality and were analysed by c2 test, and the differences in continues vari-
quantity of social support network, problems and life events ables were analysed by independent t-test when the sample was
related to pregnancy, daily life including instrumental, personal distributed normally and by MannWhitney U-test when the
and family life, and life adversity before the childbirth. The distribution was not normal.
initial interviews were carried out in a separate room in the
inpatient newborn unit. In the first month of the follow-up,
mothers were instructed to fill the Edinburgh Postpartum
Results
Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI), Demographic characteristics of the study group are shown in
Adult Attachment Scale (AAS) and Multidimensional Scale of Table 1. There was no statistically significant difference among
Perceived Social Support (MSPSS) during their visits to infant and maternal characteristics. All mothers had uneventful
newborn outpatient clinic. Mothers who had difficulties under- prenatal and postnatal course. None of them were on any medi-
standing the content of the questionnaires were assisted by cation that would require discontinuation of breastfeeding.
research assistants. Mothers who had an EPDS score >13 were Thirty-seven of 60 mothers were multiparous and 32 mothers
evaluated with a semistructured interview on postpartum had breastfed their infants before. The median duration of
depression to confirm the postpartum depression. Mothers who breastfeeding was 12 months (interquartile range (IQR) 618)
experienced a postpartum depression were invited to the psy- in the previous pregnancies.
chiatry clinic for further intervention and follow-up. All mothers, enrolled to the study, started breastfeeding their
infants postpartum; 91% and 68.1% continued breastfeeding
Edinburgh Postpartum Depression Scale at first and fourth months, respectively. The EPDS scores of
mothers who discontinued breastfeeding before 4 months were
The EPDS is a 10-item scale developed to measure the depres- statistically significantly higher than those who were not. The
sive symptoms during postpartum period.14 The scale focuses on state and trait anxiety scores and social support scores were not
specific depressive symptoms of postpartum period. The Turkish different between groups (Table 2).
validation is done by Engindeniz et al.15 It was found that 13.6% of mothers were at high risk for
depression (EPDS 13). Among mothers who had an EPDS
Adult Attachment Scale score of 13 (n = 8), 87.5% (n = 7) have discontinued breast-
feeding at 4 months. There was a statistically significant differ-
The AAS is a Likert-type 18-item self-report scale developed by ence between the feeding preferences of mothers at high risk
Collins and Read based on Hazan and Shavers Attachment of depression (P < 0.01). The median EPDS score of mothers
Style Measure.16,17 It assesses three adult attachment styles, with secure attachment 538 was lower than the median EPDS
namely secure, avoidant and ambivalent styles. The AAS was score of mothers with insecure attachment 9,512 and this was
Table 2 Postpartum psychological state of mothers and feeding preference at the fourth month
statistically significant (Table 3). Mothers with secure attach- this condition may contribute to breastfeeding continuation and
ment style seemed to have higher exclusive breastfeeding rate, prevention of adverse effects on mothers and infants.
but this pattern showed no statistical significance (Table 4). The promotion and support of beastfeeding should be a
national public health priority especially in developing coun-
Discussion tries. Most mothers initiate breastfeeding in hospital, but the
rate of exclusive breastfeeding at 6 months is relatively low in
This study has shown an association between higher maternal many countries. Henderson et al. have reported that 57% of the
EPDS scores and cessation of exclusive breastfeeding by patients were breastfeeding at 6 months and there is a signifi-
4 months after delivery. Postpartum depression is a serious, cant negative impact of postpartum depression on breastfeed-
common and treatable condition, and clinicians recognition of ing duration.22 Ertem et al. have shown that only 59.3% of a
13 van Ijzendoorn M. Adult attachment representations, parental 21 Eker D, Arkar H. ok Boyutlu Alglanan Sosyal Destek leginin faktr
responsiveness, and infant attachment: a meta-analysis on the yaps, geerlik ve gvenirligi. Trk Psikoloji Dergisi. 1995; 34: 4555.
predictive validity of the Adult Attachment Interview. Psychol. Bull. 22 Henderson JJ, Evans SF, Straton JA, Priest SR, Hagan R. Impact of
1995; 117: 387403. postnatal depression on breastfeeding duration. Birth. 2003; 30:
14 Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: 17580.
development of the Edinburgh Postnatal Depression Scale. Br. J. 23 Ertem IO, Aknc Z, Ulukol B, Baskan-Gulnar S. Socioeconomically
Psychiatry 1987; 150: 7826. advantaged infants attending university well-child clinic in Ankara: are
15 Engindeniz AN, Kuey L, Kultur S. Edinburg post-partum depression they breast-feeding optimally? Turk J Pediatr 2001; 43: 22330.
inventory. Study of validity and reliability in Turkish sample. In: 24 Losch M, Dungy CI, Russell D, Dusdieker LB. Impact of attitudes on
Psychiatric Spring Symposiums Book. Ankara: Psychiatry Association maternal decisions regarding infant feeding. J. Pediatr 1995; 126:
Publication, 1997; 512. 50714.
16 Collins NL, Feeney BC. A safe haven: An attachment theory 25 Piper S, Parks PL. Predicting the duration of lactation: evidence from a
perspective on support seeking and caregiving in intimate national survey. Birth 1996; 23: 712.
relationships. J. Pers. Soc. Psychol. 2000; 78: 105373. 26 Ertem IO, Votto N, Leventhal JM. The timing and predictors of the
17 Hazan C, Shaver P. Romantic love conceptualized as an attachment early termination of breastfeeding. Pediatrics 2001; 107: 5438.
process. J. Pers. Soc. Psychol. 1987; 52: 51124. 27 Forman DN, Videbech P, Hedegaard M, Salvig JD, Secher NJ.
18 Spielberger CD, Gorsuch RC, Lushene RE, Vagg PR, Jacobs GA. Postpartum depression: identication of women at risk. BJOG 2000;
Manual for the State Trait Anxiety Inventory. Palo Alto, CA: Consulting 107: 121017.
Psychologists Press, 1983. 28 Belsky J, Fearon RM. Infantmother security, contextual risk, and early
19 Barnes LLB, Harp D, Jung WS. Reliability generalization of scores on development: a moderational analysis. Dev Psychopathol. 2002; 14:
the Spielberger State-Trait Anxiety Inventory. Edu. Psychol. Meas. 293310.
2002; 62: 60318.
20 Zimet GD, Dahlen NW, Zimet SG, Farley GK. The multidimensional
scale of perceived social support. J. Pers. Assess. 1988; 52: 3041.