Carnival of Evidence-Based Parenting: What the science says (and, more importantly, doesn’t say) about breastfeeding issues, bonding, and postpartum adjustment

As I sat down to write a piece for this month’s Carnival of Evidence-Based Parenting on the connection between breastfeeding problems and postpartum depression and adjustment issues, I realized something: everything I wanted to say in the post, I already said in my book. So, the following post is actually an adapted excerpt.

Before we get into it, though, I’d like to add that I think breastfeeding difficulties can also affect women in far less dramatic ways. Nearly every mother I know says that the early postpartum period is all about nursing – learning to latch, worrying about weight gain, and soldiering on through cracked nipples and marathon cluster feeds. And nearly every mother I know also tells me that after 4-6 weeks, it got infinitely better; that she and her baby got the hang of things, and breastfeeding became the wonderful, easy, pleasant experience people promise it will be. I think we need to be honest with women about this adjustment period – 6 weeks can feel like an eternity, and to tell new moms just to “hang in there” isn’t going to cut it. Not all of us have adequate maternity leave, familial support, and the money to pay for private lactation consultants. If we are serious about raising the breastfeeding rates in this country, we need to think more critically about how to help women handle these first 6 weeks, and get them through the “learning curve”. Otherwise, I believe we will be causing two things to happen – more mothers will suffer from stress-induced depression and anxiety, and more women will quit nursing way before they had planned or desired to do so. Neither of these are outcomes are beneficial to anyone. 

 

A few years ago, a study published in the aptly titled journal Medical Hypotheses claimed that the cessation of breastfeeding simulates child loss. According to the authors, from a biological, anthropological perspective, “the decision to bottle feed unwittingly mimics conditions associated with the death of an infant.” And since “child loss is a well documented trigger for depression particularly in mothers,” the findings of the study joined the “growing evidence [that] shows that bottle feeding is a risk factor for postpartum depression.”(1) The ominous takeaway message rang out over the Internet. “Does bottle feeding cause postpartum depression?” asked one natural parenting website’s headline;(2) “Mothers who bottle feed their infants in lieu of breastfeeding put themselves at risk of developing postpartum depression,” warned another site, directed at general consumer healthcare.(3)

Two years later, a different study examining the same issues offered a less evolutionary-based (and less daunting) explanation for why not breastfeeding seems to be linked with postpartum depression. Dr. Alison Stuebe, a respected member of the Academy of Breastfeeding Medicine, found that women who reported trouble breastfeeding in the first weeks after giving birth had a 42 percent higher risk of developing postpartum depression than those who enjoyed nursing their babies. Stuebe told Time that although it was important to advocate for breastfeeding, clinicians should “look not just at baby’s mouth and the boob but to also look at mom’s brain” and urged providers to take a more personal approach to infant feeding recommendations: “If, for this mother, and this baby, extracting milk and delivering it to her infant have overshadowed all other aspects of their relationship, it may be that exclusive breast-feeding is not best for them—in fact, it may not even be good for them.” (4)

Back in the 1960s and 1970s, theories on infant “attachment” and the “maternal/infant bond” posited that there was a “critical period” when babies formed either secure or insecure attachments to a primary caregiver—in most cases, for obvious reasons, the mother. Based on the work of John Bowlby, it was thought that a securely attached infant would use his mother as a sort of “home base”; he could explore the world, depending on his mother for comfort and security when things got too intense. If a kid was insecurely attached, the mom-as-safety-net concept didn’t hold; an insecurely attached baby would actually avoid physical contact with his mom and take longer to recover from periods of distress. (5)

By the 1980s, most experts had officially dismissed this “attachment theory,” especially the idea of a critical period beyond which there is no hope of correcting problems, because the original studies that formed the basis for this theory were flawed. (6) But the ideas behind attachment theory still permeate breastfeeding literature, which is chock-full of references to the “maternal-infant bond” and “attachment.” (Ironically, Bowlby himself believed that attachment was formed through the inter- actions of the primary caregiver and the child, rather than the act of feeding in and of itself, or “individual differences in feeding, such as breast or bottle.”) (7)

Later research into attachment discovered that “sensitively and consistently” responding to our infants’ cues—cues like crying, smiling, and eye contact—creates that coveted secure attachment; being unresponsive, unpredictable, disengaged, or, on the other end of the spectrum, overly intrusive results in insecure attachment (8)… and a hefty bill from the child psychiatrist somewhere down the line.

Interestingly, the behaviors blamed for causing insecure attachment not only are related to postpartum depression but could also be attributed to breastfeeding problems. Extreme nipple pain, clogged ducts, or mastitis can cause feedings to be unbearably painful; insufficient milk can be anxiety-provoking. Is it too much of a stretch to suggest that physical pain and anxiety could cause a mom to act “overly intrusive,” “unpredictable,” or “disengaged”? Sociologist and researcher Stephanie Knaak says that despite numerous claims in parenting literature that breastfeeding leads to better bonding, “It’s not going to be the same for all women. For some women, it’s not at all about closeness and bonding, because they don’t actually enjoy breastfeeding. They don’t enjoy the physical aspect of it.” (9)

Many of the moms featured in the FFF Friday posts here on this blog talk about formula allowing them to “finally be a mom”; about how all their energy had gone into breastfeeding, a process that often took so much out of them physically and mentally that they had nothing left to give to their babies. For those of us who have had extreme physical difficulty or emotional discomfort with breastfeeding, formula may allow us to stay calm, connected, and responsive to our children in a way that breastfeeding can’t. Some women have also told me that they believed their breastfeeding struggles made them better mothers, leading them to focus more intensely on meeting their babies’ needs in other ways. Irvin Leon, of the University of Michigan, argues a similar point regarding the benefits of adoptive parenting:

Biological parents may be inclined to believe that their genetic connection with their offspring will inevitably solidify the emotional bond with their young. It may feel a bit less important to parent when one is so assured of being the parent. Adoptive parents, not having that genetic connection, must rely on the actual parent- child bond as the principal determinant of parenthood. Attachment theory . . . make[s] it clear that in the eyes of a child the sense of Mommy and Daddy is based on who takes care of that child, meeting that child’s needs, and knowing that child’s uniqueness and individuality in moment-by-moment daily interactions.(10)

Yet, we are forced to balance our desire to connect and bond with our children in a way that actually works for us with what society – and parenting research- tells us is the “proper” way to bond.  In a review of breastfeeding’s impact on the mother-infant relationship, Norwegian behavioral scientists found that out of forty-one papers discussing breastfeeding and the maternal bond, twenty-two of them made “general statements on the positive effect of breastfeeding on either facet of the mother-infant relationship without a reference to empirical studies supporting this claim.” (11) The study authors then examined the papers which did provide evidence backing these claims, and came to the conclusion that “breastfeeding may promote the maternal bond, but mothers who bond better with their infants may also be more likely to choose to breastfeed over bottle-feeding.”

Think about it—a mother who is already nervous, depressed, or stressed may have a tougher time bonding with a newborn. This mother may ultimately turn to bottle-feeding to control at least one aspect of her new, overwhelming life. Or consider how a baby having trouble feeding may act on a daily basis. A hungry, frustrated baby does not a happy baby make (or a happy mother, for that matter). In both cases, the maternal bond may be affected and bottles may replace breastfeeding. So although it is true that the mothers of these bottle-feeding babies may exhibit less positive, “bonded” behavior toward their children, is it the fault of the bottle? Or was it the situation that led the mom to the bottle that also caused difficulty bonding?

The same question holds for the connection between breastfeeding and postpartum depression. Some researchers have found a correlation between lack of breastfeeding and higher incidence of depression; however, the majority of these studies don’t factor in why the mother isn’t breastfeeding in the first place. A 2009 study found that women who exhibited pregnancy-related anxiety or prenatal depressive symptoms were roughly two times more likely than women without these mood disorders to plan to formula feed. (12) “Prenatal mood disorders may affect a woman’s plans to breastfeed and may be early risk factors for failure to breastfeed,” the researchers point out. And even if the intention to breastfeed is there, multiple factors inform infant-feeding choices once a woman leaves the hospital.

Feeling like a failure, dealing with pain, frustration, and exhaustion, and having a baby who screams at the sight of her, could make any mother feel overwhelmed, let alone one who’s already on the brink of actual PPD. Maybe for those of us more prone to anxiety or depression, the stress of breastfeeding struggles is just the camel’s dreaded straw.

(Excerpted from “Of Human Bonding” in Bottled Up: How the Way We Feed Babies Has Come to Define Motherhood, and Why It Shouldn’t. University of California Press, 2012.) 

Want to read more on the topic of new parenthood from people far smarter than I am? Check out this post from Jessica at School of Smock, who is hosting this months’s carnival – she will link you to the contributions from the rest of the Carnival of Evidence-Based Parenting bloggers:

Introduction to this month’s carnival: http://www.schoolofsmock.com/2013/05/13/evidencebasedparenting

The Transition to New Motherhood (Momma, PhD)

Bonding in Early Motherhood:  When Angels Don’t Sing and the Earth Doesn’t Stand Still (Red Wine and Applesauce)

The Connection Between Poor Labour, Analgesia, and PTSD (The Adequate Mother)

For Love or Money:  What Makes Men Ready for New Fatherhood (Matt Shipman)

No, Swaddling  Will Not Kill Your Baby (Melinda Wenner Moyer,  Slate)

Sleep Deprivation:  The Dark Side of Parenting (Science of Mom)

The Parenting Media and You (Momma Data)

Reassessing Happiness Research:  Are New Parents Really That Miserable?(Jessica Smock)

40 Long Days and Nights (Six Forty Nine)

Also, “like” us on Facebook – we’re trying to bring fresh perspective and research-based insight to the parenting blogosphere. Plus we’re all really nice. It’s really a no-brainer.

 

Sources

(1) Gallup, Gordon G., Jr., R. Nathan Pipitone, Kelly J. Carrone, and Kevin L. Leadholm. 2010. Bottle feeding simulates child loss: Postpartum depression and evolutionary medicine. Medical Hypotheses 74 (1): 174–176.

(2) Nelson, Cate. 2009. Does bottle-feeding cause postpartum depression? August17.http://ecochildsplay.com/2009/08/17/does-bottle-feeding- cause-postpartum-depression/

(3) Harutyunyan, Ruzanna. 2009. Bottle-feeding mimics child loss. Emax Health. August 15. www.emaxhealth.com/2/84/32867/bottle- feeding-mimics-child-loss.html

(4)Rochman, Bonnie. 2011. Time Healthland: Is breast always best? Examining the link between breastfeeding and postpartum depression. August 5. http://healthland.time.com/2011/08/05/do-depression-and-difficulty-breast-feeding-go-hand-in-hand/

(5) Sonkin, Daniel. 2005. Attachment theory and psychotherapy. California Therapist 17 (1): 69–77.

(6) (8) (11) Jansen, J., C. D. Weerth, and J. M. Riksen-Walraven. 2008. Breastfeeding and the mother-infant relationship—A review. Developmental Review 28 (4): 503–521.

(7) Britton, Cathryn. 2003. Breastfeeding: A natural phenomenon or a cul- tural construct? In The Social Context of Birth, edited by Catherine Squire, 305–317. Milton Keynes, United Kingdom: Radcliffe Publishing.

(9) Knaak, Stephanie J. Telephone interview – September 10, 2010.

(10) Leon, Irving. 1998. Nature in adoptive parenting. Parenting in America. 1998. http://parenthood.library.wisc.edu/Leon/Leon.html

(12) Fairlie, Tarayn G., Matthew W. Gillman, and Janet Rich-Edwards. 2009. High pregnancy-related anxiety and prenatal depressive symptoms as predictors of intention to breastfeed and breastfeeding initation. Journal of Women’s Health (Larchmont) 18 (7): 945–953.

 

 

 

 

 

 

 

 

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