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Meta-Analysis
. 2025 Feb 18;2(2):CD014833.
doi: 10.1002/14651858.CD014833.pub2.

Breastfeeding interventions for preventing postpartum depression

Mikaela Lenells  1   2 , Eleonora Uphoff  3 , David Marshall  3 , Emilija Wilson  1 , Anna Gustafsson  1   4   5 , Michael B Wells  1 , Ewa Andersson  1 , Cindy-Lee Dennis  6
Affiliations
Meta-Analysis

Breastfeeding interventions for preventing postpartum depression

Mikaela Lenells et al. Cochrane Database Syst Rev. .

Abstract

Background: Postpartum depression is a debilitating mental health disorder, which occurs in approximately 6% to 13% of women who give birth in high-income countries. It is a cause of great suffering for women and can have long-term consequences for child development. Postpartum depression can also negatively influence breastfeeding duration and breastfeeding exclusivity (i.e. feeding the infant only breast milk). However, a positive early, and continued, breastfeeding experience may reduce the risk of having postpartum depression. Breastfeeding interventions that increase the duration and exclusivity of breastfeeding may help prevent or reduce postpartum depressive symptoms.

Objectives: The primary objective of this review was to assess the effect (benefits and harms) of breastfeeding support interventions, in comparison to standard perinatal care, on maternal postpartum depression. The secondary objective was to assess whether breastfeeding support interventions had an effect on depression symptoms, and whether the effect was dependent on the duration and exclusivity of breastfeeding.

Search methods: We searched CENTRAL (Wiley), MEDLINE ALL (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL Complete (Ebsco) and several other bibliographic databases and trial registers. The most recent search was conducted in June 2024.

Selection criteria: Randomised controlled trials (RCTs) that evaluated educational, psychosocial, pharmacological, alternative (any breastfeeding support intervention that promotes relaxation and reduces stress) or herbal breastfeeding support interventions targeting the prevention or reduction of postpartum depression were eligible for inclusion.

Data collection and analysis: Each title and abstract we identified was screened by two authors independently. Two review authors then independently examined full-text manuscripts to decide if the study met the inclusion criteria. If so, they extracted data from included studies using Covidence software. Two review authors also independently conducted a risk of bias assessment of each study using the RoB 2 tool. We contacted study authors when necessary for more information. We conducted meta-analyses using a random-effects model.

Main results: We included 10 RCTs with 1573 participants in this review. Depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) in all studies, where scores range between 0 and 30 (higher scores indicating more depressive symptoms). The studies used a score of over 10 as the cut-off for a diagnosis of depression. Primary outcome It is very uncertain whether psychosocial breastfeeding interventions had any effect on the incidence of postpartum depression immediately post-intervention (RR 0.78, 95% CI 0.23 to 2.70; 1 study, 30 participants), but we found low-certainty evidence that psychosocial breastfeeding interventions may prevent the incidence of postpartum depression in the short term (one to three months) post-intervention (risk ratio (RR) 0.37, 95% confidence interval (CI) 0.14 to 0.93; 1 study, 82 participants). It is very uncertain whether alternative breastfeeding interventions had any effect in preventing the incidence of postpartum depression immediately post-intervention (RR 0.64, 95% CI 0.27 to 1.54; 1 study, 60 participants). The short-term time point was not measured. Secondary outcomes It is very uncertain whether psychosocial breastfeeding interventions had any effect on reducing depressive symptoms immediately post-intervention (mean difference (MD) -0.67, 95% CI -1.63 to 0.28; 4 studies, 512 participants). There is very low-certainty evidence that psychosocial breastfeeding interventions could reduce symptoms of anxiety immediately post-intervention as measured with the Zung Self-rating Anxiety Scale (SAS), where scores between 45 and 59 out of 80 on the SAS indicate mild to moderate anxiety, scores between 60 and 74 marked severe anxiety levels and > 75 extreme anxiety levels (MD -2.30, 95% CI -4.36 to -0.24; 1 study, 100 participants). There was no difference in rates of exclusive breastfeeding immediately post-intervention between those offered a psychosocial breastfeeding intervention and those receiving standard care, but the evidence is very uncertain (RR 1.20, 95% CI 0.96 to 1.51; I2 = 29%; 571 participants; very low-certainty evidence). We found low-certainty evidence that a psychosocial breastfeeding intervention may increase the duration of breastfeeding in the long term (RR 1.64, 95% CI 1.08 to 2.50; 129 participants; low-certainty evidence). For the comparison of alternative breastfeeding intervention versus standard care (which was evaluated in only one study), there was no difference between groups immediately post-intervention in anxiety measured with the State-Trait Anxiety Inventory (STAI); range 20 to 80; higher scores indicate more severe anxiety symptoms (MD 1.80, 95% CI -9.41 to 13.01; 60 participants; very low-certainty evidence), or in stress measured with the Perceived Stress Scale (PSS)-NICE; range 1 to 230, higher scores indicate higher levels of stress (MD 1.90, 95% CI -10.28 to 14.08; 60 participants; very low-certainty evidence), but the evidence is very uncertain. No adverse events connected to the intervention itself were stated in any of the trials, but for most studies, we do not know if this is because there were none or because they were not measured or reported.

Authors' conclusions: There is low-certainty evidence that psychosocial breastfeeding interventions may prevent postpartum depression in the short term and increase the duration of breastfeeding in the long-term. The evidence is very uncertain about the effect of psychosocial breastfeeding interventions on other outcomes. The evidence is very uncertain about the effect of alternative breastfeeding interventions on postpartum depression or other outcomes. The included studies did not report any adverse events directly related to the interventions, but it is not clear if this outcome was measured in most studies. Future trials of breastfeeding interventions should be conducted carefully to reduce their risk of bias, and they should be large enough to detect differences between mothers in their mental health.

PubMed Disclaimer

Conflict of interest statement

Mikaela Lenells: none known

Eleonora Uphoff: none known

David Marshall: David Marshall was an Editor for Cochrane Common Mental Disorders (closed March 2023) but had no role in the editorial process for this review.

Ewa Andersson: none known

Anna Gustafsson: none known

Michael Wells: none known

Cindy‐Lee Dennis: none known

Emilija Wilson: none known

Update of

References

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    1. NCT03511508. Pregnancy and chronic disease: the effect of a multimodal maternity care intervention (ChroPreg). https://clinicaltrials.gov/ct2/show/NCT03511508 (first received 27 April 2018).
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    1. IRCT201105093706N6. Effect of telephone counseling on exclusive breastfeeding and postpartum depression. https://irct.behdasht.gov.ir/trial/3799 (first registered 2 July 2011).
IRCT2013060313565N1 {published data only}
    1. IRCT2013060313565N1. Presenting a pattern of postpartum care at home and its effects on the health of the mother and the suckling. https://irct.behdasht.gov.ir/trial/13379 (first received 7 December 2013).
IRCT2013123010746N3 {published data only}
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IRCT201408318801N9 {published data only}
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IRCT20160521027994N9 {published data only}
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IRCT20171209037794N2 {published data only}
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IRCT20180715040477N1 {published data only}
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IRCT20210510051245N1 {published data only}
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    1. NCT01312883. Mothers Avoiding Depression Through Empowerment Intervention Trial (MADE IT). https://clinicaltrials.gov/study/NCT01312883 (first received 8 March 2011).
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NCT03807726 {published data only}
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NCT03922334 {published data only}
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NCT05729854 {published data only}
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NCT06148831 {published data only}
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NCT06315127 {published data only}
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NTR6065 {published data only}
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Olenick 2006 {published data only}
    1. Olenick PL. The Effect of Structured Group Prenatal Education on Breastfeeding Confidence, Duration and Exclusivity to Twelve Weeks Postpartum [PhD thesis]. Ann Arbor, USA: Touro University International, 2006.
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Petrozzi 2016 {published data only}
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RBR‐6gbzw6 {published data only}
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    1. RBR‐6gbzw6. Omega-3 supplementation during pregnancy to prevent postpartum depressive symptoms and possible effect on breastfeeding, child growth and development. https://trialsearch.who.int/Trial2.aspx?TrialID=RBR-6gbzw6 (first received 19 June 2018).
Rotheram Fuller 2017 {published data only}
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    1. Shiau SH. Randomized Controlled Trial of Kangaroo Care with Fullterm Infants: Effects on Maternal Anxiety, Breastmilk Maturation, Breast Engorgement, and Breastfeeding Status [PhD thesis]. Cleveland, USA: Case Western Reserve University, 1997.
Shields 1997 {published data only}
    1. Shields N, Reid M, Cheyne H, Holmes A, McGinley M, Turnbull D, et al. Impact of midwife-managed care in the postnatal period: an exploration of psychosocial outcomes. Journal of Reproductive and Infant Psychology 1997;15(2):91-108. [DOI: 10.1080/02646839708404537] - DOI
Sikander 2015 {published data only}
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Sinha 2021 {published data only}
    1. Sinha B, Sommerfelt H, Ashorn P, Mazumder S, Taneja S, More D, et al. Effect of community-initiated kangaroo mother care on postpartum depressive symptoms and stress among mothers of low-birth-weight infants: a randomized clinical trial. JAMA Network 2021;4(4):e216040. [DOI: 10.1001/jamanetworkopen.2021.6040] - DOI - PMC - PubMed
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Taneja 2020 {published data only}
    1. NCT02631343. Community kangaroo mother care for improving child survival and brain development in low birth weight newborns. https://clinicaltrials.gov/ct2/show/NCT02631343 (first received 16 December 2015).
    1. Taneja S, Sinha B, Upadhyay RP, Mazumder S, Sommerfelt H, Martines J, et al. Community initiated kangaroo mother care and early child development in low birth weight infants in India - a randomized controlled trial. BMC Pediatrics 2020;20(1):150. [DOI: 10.1186/s12887-020-02046-4] - DOI - PMC - PubMed
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TCTR20230910004 {published data only}
    1. TCTR20230910004. Effect of domperidone on the breast milk volume of mothers of preterm newborn at prapokklao hospital; a randomized controlled trial. https://trialsearch.who.int/Trial2.aspx?TrialID=TCTR20230910004 (first received 10 September 2023).
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References to studies awaiting assessment

Rodriguez‐Gallego 2024 {published data only}
    1. Rodríguez-Gallego I, Vila-Candel R, Corrales-Gutierrez I, Gomez-Baya D, Leon-Larios F. Evaluation of the impact of a midwife-led breastfeeding group intervention on prevention of postpartum depression: a multicentre randomised clinical trial. Nutrients 2024;16:227. [DOI: 10.3390/nu16020227] - DOI - PMC - PubMed
Şimsek‐Çetinkaya 2024 {published data only}
    1. NCT05781477. Effect of breastfeeding training program and system (BMUM) for mothers. www.clinicaltrials.gov/ct2/show/NCT05781477 (first received 23 March 2023).
    1. Şimsek-Çetinkaya Ş, Gümüş Çaliş G, Kibris Ş. Effect of breastfeeding education program and nurse-led breastfeeding online counseling system (BMUM) for mothers: a randomized controlled study. Journal of Human Lactation 2023;40(1):101-12. [DOI: 10.1177/08903344231210813] - DOI - PubMed
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References to ongoing studies

Dib 2018 {published data only}
    1. Dib S, Wells J, Fewtrell M. Identification of the most effective relaxation tool for use in a trial to improve breastfeeding outcomes in mothers of late preterm infants. Breastfeeding Medicine 2018;13(7):A30-1. [DOI: 10.1089/bfm.2018.29100.abstracts C2 - 624936209]
    1. NCT03791749. Mother and late preterm lactation study. https://www.clinicaltrials.gov/ct2/show/NCT03791749 (first received 3 January 2019).
Huang 2023 {published data only}
    1. ChiCTR2300069648. Effect of co-parenting intervention on improving breastfeeding rate and alleviating depression in new parents. https://trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR2300069648 (first received 22nd March 2023).
Kuo 2021 {published data only}
    1. NCT04798872. Web-based educational intervention on breastfeeding self-efficacy and breastfeeding outcome. https://www.clinicaltrials.gov/ct2/show/NCT04798872 (first received 15 March 2021).
Lok 2020 {published data only}
    1. NCT04621266. Home based peer support program for mothers with low breastfeeding self-efficacy. https://www.clinicaltrials.gov/ct2/show/NCT04621266 (first received 9 November 2020).
Lucas 2019 {published data only}
    1. Lucas R, Bernier K, Perry M, Evans H, Ramesh D, Young E, et al. Promoting self‐management of breast and nipple pain in breastfeeding women: protocol of a pilot randomized controlled trial. Research in Nursing & Health 2019;42(3):176‐88. [DOI: 10.1002/nur.21938] - DOI - PMC - PubMed
    1. Lucas R, Evans H, Starkweather A. Promoting self-management of breast and nipple pain in breastfeeding women. Maternal and Child Nutrition 2017;14(Supplement 2):40. [DOI: 10.1111/mcn.12587] - DOI
    1. Lucas R, Starkweather A, Evans H. Promoting self-management of breast and nipple pain in breastfeeding women. Breastfeeding Medicine 2018;13(7):A-45. [DOI: 10.1089/bfm.2018.29100.abstracts C2 - 624935897]
Na 2022 {published data only}
    1. ChiCTR2200063722. Research on the construction and application of family-based breastfeeding health education intervention model based on self-efficacy theory. https://trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR2200063722 (first received 15 September 2022).
NCT05301309 {published data only}
    1. Integrative early breastfeeding support in NICU. www.clinicaltrials.gov/ct2/show/NCT05301309 (first received 29 March 2022).
NCT05657886 {published data only}
    1. Half swaddle and kangaroo care in preterm on breastfeeding, infant attachment, sleep quality and depression of mothers. www.clinicaltrials.gov/ct2/show/NCT05657886 (first received 20 December 2022).
NCT06250933 {published data only}
    1. NCT06250933. The Meleis theory on postpartum depression, breastfeeding, and maternal self-efficacy in women experiencing preterm birth. https://clinicaltrials.gov/study/NCT06250933 (first received 8 January 2024).
Ngai 2021 {published data only}
    1. NCT05109988. Father-involvement telephone support intervention on breastfeeding: RCT. https://clinicaltrials.gov/ct2/show/NCT05109988 (first received 5 November 2021).
Taloyan 2023 {published data only}
    1. NCT06044636. Early digi-physical support during breastfeeding initiation. https://clinicaltrials.gov/study/NCT06044636 (first received 18 January 2023).
Yaohua 2023 {published data only}
    1. ChiCTR2200065220. A randomized controlled trial on intervention of improving breastfeeding by mHealth. https://www.chictr.org.cn/showproj.html?proj=182939 (first received 24 October 2022).

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