Maternal Mental Health

by Dr Louise Santhanam, General Practitioner

When it comes to breastfeeding, wish my GP had accurate information on drugs which are safe, particularly anti-depressants.

AP, Mother

I was told to stop (breastfeeding) and not offered any further support as I got PND.

HP, Mother

The Importance of Maternal Mental Health

Approximately 1 in 5 women will suffer from perinatal mental health problems (during pregnancy and in the year after birth) and currently only 50% of these will be diagnosed1, 2. The range of conditions in the perinatal period include antenatal and postnatal depression, anxiety, obsessive compulsive disorder, post-traumatic stress disorder and postpartum psychosis, as well as pre-existing mental health problems and substance misuse. Additionally, research is emerging to highlight the importance of paternal mental health, with estimates that approximately 10% of fathers will suffer from prenatal or postnatal depression, more commonly if their partner is suffering from depression3.

holding-hands

In recent years significant reports have highlighted the importance of improving the quality of UK perinatal mental health care in order to save maternal and infant lives, improve quality of life for the family, protect infant mental health and reduce the economic cost of perinatal mental illness. Early diagnosis and access to peer support, psychological therapies, medication, specialist care and admission if necessary, can facilitate the best possible outcomes. 

Familiarisation with local perinatal mental health service provision, health visiting contacts and infant feeding support is important in the management of perinatal mental health problems and supporting maternal wellbeing.

NSPCC: Infographic of the Estimated Numbers of Women Affected by Perinatal Mental Illness in England Each Year

LSE and Centre for Mental Health: The Costs of Perinatal Mental Health Problems (2014)

RCGP & The Centre for Mental Health: Falling Through the Gaps – Perinatal Mental Health and General Practice (2015)


The Significance of Infant Feeding for Maternal Mental Health

The relationship between infant feeding and maternal wellbeing should not be underestimated. Very young babies require feeding approximately 8-12 times a day and feeding becomes a major part of the new routine.  Feeding provides comfort to the infant and an opportunity for bonding, and feeding difficulties (including reflux, allergies, tongue-tie and colic) can be very distressing and can impact on parents’ mental health.  Equally, maternal mental illness may impact on a mother’s ability to pursue her own feeding goals, and may impact on feeding choices.

Infant Feeding Wellbeing and Mental Health Article written by Dr Louise Santhanam for the RCGP Perinatal Mental Health Toolkit, July 2016

This page of our website is not intended to be a comprehensive guide to perinatal mental health, but serves to illustrate links between infant feeding issues and maternal wellbeing. 


Breastfeeding and Lowering of Depression Risk

Mothers who meet their personal goals for breastfeeding duration have been shown to be at lower risk of postnatal depression, while mothers who plan to breastfeed but do not go on to do so are at higher risk4. Higher depression scores have been demonstrated in mothers who stop breastfeeding due to physical difficulty and pain, rather than personal choice5.

The 2010 UK Infant Feeding Survey6 demonstrated:

  • While 69% of mothers were exclusively breastfeeding at birth, this figure had dropped to 23% by 6 weeks postnatal.
    • 80% of mothers who stopped breastfeeding within the first week reported they would have like to continue for longer.
    • 85% of mothers who had stopped breastfeeding between one and two weeks reported they would have like to continue for longer.
    • 63% of mothers who had stopped breastfeeding by 8-10 months reported that they would have liked to continue for longer.
  • Many women who initiate breastfeeding stop before they had planned to do so due to problems with attachment at the breast (the ‘latch’), problems with milk supply (real or perceived) and pain.
  • The main factors that mothers who breastfed for less than one week indicated could have helped them continue for longer were:
    • More support and guidance from hospital staff, midwives and family (23%)
    • If the baby could have latched on the breast easier (19%)
    • Less pain (14%)

Good quality breastfeeding support to prevent and correct reversible problems, aftercare for mothers who stop breastfeeding before they planned to and accurate advice from healthcare professionals therefore play a role in protecting maternal mental health4, 5, 7.  Furthermore, to reduce the risk to those who face difficulties breastfeeding, breastfeeding promotion should be accompanied by ongoing support from healthcare professionals, family and friends, and society in general. The responsibility for healthy infant feeding should be viewed as a collective one, rather than that of an individual with the potential for personal ‘failure’8.


Tips for the GP Supporting Maternal Wellbeing & Infant Feeding

  • Acknowledge the ongoing value of breastfeeding to mother and infant for as long as they are both comfortable.
  • Support a mother’s personal feeding goals wherever possible, alongside prescribing, planning investigations and making referrals.
  • Appreciate that breastfeeding problems need prompt attention and know how to refer for a specialist lactation assessment and breastfeeding support locally.
  • If treatment for mental health problems is required, offer options that enable the mother to commence or continue breastfeeding if she wishes- Remember that untreated depression conveys risk.
  • Provide accurate medical advice on the safety of drugs in breastmilk, referring to specialist information and advice as necessary.
  • Avoid unprompted recommendations to interrupt or cease breastfeeding.  Only advise cessation of breastfeeding when there are no treatment options that would allow breastfeeding to continue or if the benefits of stopping breastfeeding will outweigh the benefits to mother and baby of continuing.
  • Provide sensitive aftercare, if required, to mothers who have been unable to commence breastfeeding and mothers who have had to cease breastfeeding before they had planned to.
  • If parents seek advice on whether to continue breastfeeding, offer evidence based information on feeding methods and signpost to support services if required.  Enable an non-directive informed parental decision based on their personal circumstances.
  • Provide impartial evidence-based information on infant formula milk and safe preparation of bottle feeds for those who need to or who choose to use these.
  • Support the family to make informed infant feeding decisions based on evidence, not opinion.

The RCGP ’10 Top Tips’ Summary of NICE Guidance CG192 (2014) is a useful guide to diagnosis and management of a woman experiencing mental health problems in the perinatal period. Exploring the impact of any infant feeding problems may also be pertinent in postnatal consultations. If it becomes clear that a woman who had planned to breastfeed was unable to commence, or experienced difficulties that led to early cessation of breastfeeding, a useful question might be:

How do you feel about that now?

It is important to appreciate that a stressful labour and delivery, unplanned caesarean birth, and psychosocial stress and pain related to childbirth are risk factors for delayed lactogenesis, and so birth trauma and breastfeeding difficulties may co-exist9 (see also below).

If a difficult infant feeding experience has impacted on a woman’s mental health, options including a local ‘birth reflections’ clinic, mental health peer support group, psychological therapy or medication might be explored, according to need. Trained breastfeeding supporters can also assist women to discuss difficult breastfeeding experiences if this is suitable for the mother.

If not breastfeeding or no longer breastfeeding, parents can be informed that responsive feeding and responding to an infants cues for close contact have been shown to assist the development of secure infant-mother attachment10.  There is evidence that frequent skin-to-skin contact can help to reduce maternal depressive symptoms and psychological stress in the early postpartum period11.

RCGP Perinatal Mental Health Clinical Toolkit Is a resource to assist GPs to managing maternal mental health problems.  The section on ‘Clinical Resources for Professionals’ contains information on perinatal mental health in general and prescribing for breastfeeding mothers. The section on ‘Supporting Parenting’ includes information on infant feeding and ‘Resources for Women and their Families’ lists a number of UK organisations that can support women in the perinatal period.


Breastfeeding & Medication for Perinatal Mental Health

NICE Guideline CG192 (Updated June 2015)12 recommends discussing breastfeeding with all women who may need to take psychotropic medication in pregnancy or in the postnatal period. Clinicians should aim to enable informed decision making by the mother, and if necessary seek further specialist advice, ideally from the Perinatal Mental Health Team. Good practice includes:

  • Discussing the ‘benefits of breastfeeding, the potential risks associated with taking psychotropic medication when breastfeeding and with stopping some medications in order to breastfeed’
  • Treatment options that enable a woman to breastfeed if she wishes
  • Support for women who choose not to breastfeed after a discussion of this information

NICE Guideline PH11 (Updated November 2014)13 states that sources of information for prescribing other than the British National Formulary (BNF) should be used to discuss the safety of drugs in breastmilk. See our webpage on ‘Prescribing Information‘ for useful sources of specialist prescribing information. 

Where a woman of reproductive age has a pre-existing mental health problem the GP should be mindful of the possibility of pregnancy and subsequent lactation. If drug treatment is required, wherever possible patients should be counselled with this in mind and a careful choice of drug made. If pregnancy is being planned, or medications are required during lactation, specialist advice should be considered12, 13.

NICE Guideline CG192 Antenatal and postnatal mental health: clinical management and service guidance  Updated June 2015, Section 1.4 highlights relevant issues for infant feeding.

NICE Guidelines PH11 Maternal and Child Nutrition Updated November 2014, Refers to prescribing issues.


Birth Trauma, Preterm Infants, the Unwell Baby and Infant Feeding

For me breastfeeding kept me alive, on the days when I had no idea if I would make it, I lived to express for my baby. When I went home, when I was battling flashbacks and nightmares from the birth, when I was scared and worried about my baby, breastfeeding was my lifeline. When I held her to my breast I felt calm, and safe. The terror went away and the fear eased.

E, Mother

Following a traumatic birth breastfeeding can either have therapeutic benefit or be associated with further distress9. The opportunity if desired to discuss the birth experience and non-judgmental, respectful breastfeeding support are important.

Enabling breastfeeding or the feeding of maternal expressed breastmilk for a baby on the NICU may be beneficial for mothers as it can facilitate involvement in the treatment of their baby, (due to the benefits of breastmilk in reducing the risk of necrotising enterocolitis)14. If a mother is breastfeeding, this should be taken into consideration when initiating treatment for birth trauma or PTSD, and the impact of the feeding experience considered in all cases.

I learned that you do not have to breastfeed to bond with your baby. All that is required for bonding is that the caregiver loves the child and is free to express that love.

L, Mother

Infant Feeding on Psychiatric Inpatient Mother and Baby Units (MBUs) 

Access to MBU beds nationwide is important to enable mothers with severe mental illness who wish to breastfeed as well as to encourage positive attachment, increase the mother’s confidence in her maternal role and provide support for the family in all cases15.  Healthcare professionals should be aware that a breastfeeding mother and baby need to remain physically close as responsive feeding establishes and maintains good milk supply.


Dysphoric Milk Ejection Reflex (D-MER) 

D-MER is a physiological phenomenon, recently described in case studies as a brief period of intense negative emotions, occurring seconds before a milk let-down with normal mood between episodes. Symptoms range from mild (anxiety, a sense of dread) to severe (anger and suicidal thoughts) and can result in discontinuation of breastfeeding due to the distress caused. D-MER should not be confused with depression and is not a psychological condition. Some cases reportedly improve with understanding the condition and simple lifestyle changes, but in the case of severe symptoms specialist advice may be required16.


Further Reading

  • A Breastfeeding Friendly Approach to Postpartum Depression Kendall-Tackett K, Praeclarus Press (2015) ISBN-13: 978-1939807298 Covers the evidence for the relationship between breastfeeding and maternal wellbeing, and how the clinician can support new mothers experiencing mental ill health.
  • Healing Breastfeeding Grief Jacobson H, Rosalind Press (2016) ISBN-13: 978-0979599521 Addresses mothers’ feelings and healing from difficult breastfeeding experiences.

References

  1. LSE and Centre for Mental Health: The Costs of Perinatal Mental Health Problems 2014
  2. RCGP & The Centre for Mental Health: Falling Through the Gaps – Perinatal Mental Health and General Practice 2015
  3. Paulson J, Bazemore S. Prenatal and Postpartum Depression in Fathers and Its Association With Maternal Depression. JAMA. 2010;303(19):1961.
  4. Borra C, Iacovou M, Sevilla A. New Evidence on Breastfeeding and Postpartum Depression: The Importance of Understanding Women’s Intentions. Maternal and Child Health Journal. 2014;19(4):897-907.
  5. Brown A, Rance J, Bennett P. Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing. 2015;72(2):273-282.
  6. UK Infant Feeding Survey 2010
  7. Chaput K, Nettel-Aguirre A, Musto R, Adair C, Tough S. Breastfeeding difficulties and supports and risk of postpartum depression in a cohort of womenwho have given birth in Calgary: a prospective cohort study. Canadian Medical Association Journal Open. 2016;4(1):E103-E109.
  8. Ashmore S. Changing the conversation around breastfeeding 2016
  9. Beck C, Watson S. Impact of Birth Trauma on Breast-feeding. Nursing Research. 2008;57(4):228-236.
  10. Ainsworth M, Bowlby J. An ethological approach to personality development. American Psychologist. 1991;46(4):333-341
  11. Bigelow A, Power M, MacLellan‐Peters J, Alex M, McDonald C. Effect of Mother/Infant Skin‐to‐Skin Contact on Postpartum Depressive Symptoms and Maternal Physiological Stress. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2012;41(3):369-382.
  12. NICE Guideline CG192 Antenatal and postnatal mental health: clinical management and service guidance Updated June 2015 – specifically section 1.4
  13. NICE Guidelines PH11 Maternal and Child Nutrition (Updated November 2014)
  14. Lucas A, Cole T. Breast milk and neonatal necrotising enterocolitis. Lancet. 1990;336(8730-8731):1519-1523.
  15. NICE CKS Depression Antenatal and Postnatal- Scenario Postnatal: new episode Revised September 2015
  16. D-MER Website

Published April 2017, Updated September 29th 2017