BREASTFEEDING MEDICINE Volume 10, Number 6, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2015.0069
Clinical Research
Antenatal Depressive Symptoms and Breastfeeding: A Prospective Cohort Study Aza Sherin Mohamad Yusuff,1 Li Tang,2,3 Colin W. Binns,3 and Andy H. Lee 3
Abstract
Introduction: Globally many women suffer from depression during pregnancy. This study investigated the impact of antenatal depressive symptoms on the duration of breastfeeding up to 6 months among women in Sabah, Malaysia. Subjects and Methods: A prospective cohort study of 2,072 women was conducted in Sabah during 2009–2010. Participants were recruited at 36–38 weeks of gestation and followed up at 1, 3, and 6 months postpartum. Depressive symptoms were assessed using the validated Malay version of the Edinburgh Postnatal Depression Scale (EPDS). Cox regression analyses were performed to determine the relationship between antenatal EPDS scores and cessation of breastfeeding before 6 months postpartum. Results: In total, 1,078 (52%) women with complete information on breastfeeding duration were included in the final sample. Approximately 99% of mothers were breastfeeding at discharge, and 87% of them continued to breastfeed at 6 months postpartum. Women with an antenatal EPDS score of 8 or above were twice more likely to stop breastfeeding before 6 months (adjusted hazards ratio = 1.95; 95% confidence interval, 1.26, 3.01) than those who scored less than 4 on the EPDS. Conclusions: Depressive symptoms during pregnancy appeared to be associated with early breastfeeding cessation for mothers residing in Sabah.
Introduction
D
epression has become the leading cause of disease burden for women of reproductive age.1,2 It is estimated that between 9% and 24% of women worldwide experience a depressive disorder while pregnant.3 When left untreated, antenatal depression may lead to serious consequences for both the mother and the infant. Women struggling with depressive symptoms during pregnancy tend to receive poor prenatal care and have increased incidence of obstetric complications and preterm delivery,4,5 and their infants may experience impaired physical, social, psychological, and cognitive development.6 After birth, breastfeeding plays an important role in preventing mortality and achieving optimal nutrition and health outcomes for the newborn.7 Studies from a variety of societies have examined factors that influence mothers at risk of a short breastfeeding duration.8–10 Only a few have investigated the effects of antenatal depression on breastfeeding practices, but their findings remain inconclusive. For instance, a study of two maternal cohorts in Britain found no association between 1 2 3
antenatal depression and early cessation of breastfeeding,11 yet a recent longitudinal study of American primiparous mothers reported that those with fewer depressive symptoms during pregnancy breastfed for a longer period.12 In Malaysia, the available data suggested a range of 8.6– 30.2% of mothers suffering from antenatal depression.13–15 According to the most recent nationwide survey, the prevalence of ‘‘ever breastfeeding’’ was 94.7%, and about 37% of children were breastfed for at least 2 years.16 However, there has been no published report on the relationship between depression during pregnancy and infant feeding practices in Malaysia or South East Asia. The present study thus aimed to determine whether antenatal depressive symptoms could increase the risk of lactation cessation within 6 months postpartum in Sabah, Malaysia. Subjects and Methods Study design and participants
A prospective cohort study of maternal depression was undertaken at five maternal and child health clinics in the
School of Medicine, University Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia. Department of Management Sciences, City University of Hong Kong, Kowloon, Hong Kong. School of Public Health, Curtin University, Perth, Western Australia, Australia.
300
ANTENATAL DEPRESSIVE SYMPTOMS AND BREASTFEEDING
Kota Kinabalu and Penampang Districts of Sabah, Malaysia, between 2009 and 2010. Sabah, with a population of 3.5 million, is situated on the Island of Borneo in East Malaysia. Estimates from the Department of Statistics Malaysia showed that the Gross Domestic Product per capita in Sabah was 18,603 Ringgit (approximately 5,200 USD) in 2013, well below the national average of 32,984 Ringgit (approximately 9,100 USD). Pregnant women who attended the clinics for their routine antenatal care at 36–38 weeks were approached and invited to participate in this study. Women were excluded if they had a multiple pregnancy, were illiterate, or were deemed unsuitable as advised by health professionals. A minimum sample size of 570 mothers at 6 months postpartum was required, calculated by assuming a prevalence of any breastfeeding between 82% and 88%. In total, 2,072 eligible women consented to participate (response rate, 92.2%). They were asked to complete a selfadministered questionnaire in a private space. Trained nurses were available for clarification if required. Information collected from the baseline questionnaire included demographic, socioeconomic, and health characteristics, as well as depressive symptoms during pregnancy. Mothers were then followed up at 1, 3, and 6 months postpartum when they returned to the clinics for immunization and routine examination of the infants. Detailed information on infant feeding methods was obtained at each follow-up. The content validity of the questionnaire was verified through a pilot study involving 50 pregnant women from the same catchment area. At the end of 6 months postpartum, 979 participants (47.2%) remained in the cohort. Measurements
The presence of depressive symptoms was measured using the Edinburgh Postnatal Depression Scale (EPDS), which has been widely used in antenatal and postnatal depression research.17 The EPDS consists of 10 items rated on a 4-point scale (from 0 to 3). The total score thus ranges from 0 to 30, with higher scores indicating more severe depressive symptoms. The reliability and validity of the Malay version of the EPDS have been verified.18 In this study, ‘‘any breastfeeding’’ was defined as feeding with breastmilk (direct from the breast or expressed) with or without other drinks, formula, or other infant food.19 Statistical analysis
Descriptive statistics were first applied to profile the characteristics of participants. In addition to univariate statistics, a full Cox regression analysis was performed to ascertain the effects of antenatal depressive symptoms on discontinuation of ‘‘any breastfeeding’’ before 6 months. The antenatal EPDS score was categorized according to the tertiles of its distribution, with the lowest level being the reference group. Confounding variables considered in the regression model included maternal age (in years), ethnicity (indigenous; nonindigenous), education level (primary; secondary or above), monthly household income (
Clinical Research
Antenatal Depressive Symptoms and Breastfeeding: A Prospective Cohort Study Aza Sherin Mohamad Yusuff,1 Li Tang,2,3 Colin W. Binns,3 and Andy H. Lee 3
Abstract
Introduction: Globally many women suffer from depression during pregnancy. This study investigated the impact of antenatal depressive symptoms on the duration of breastfeeding up to 6 months among women in Sabah, Malaysia. Subjects and Methods: A prospective cohort study of 2,072 women was conducted in Sabah during 2009–2010. Participants were recruited at 36–38 weeks of gestation and followed up at 1, 3, and 6 months postpartum. Depressive symptoms were assessed using the validated Malay version of the Edinburgh Postnatal Depression Scale (EPDS). Cox regression analyses were performed to determine the relationship between antenatal EPDS scores and cessation of breastfeeding before 6 months postpartum. Results: In total, 1,078 (52%) women with complete information on breastfeeding duration were included in the final sample. Approximately 99% of mothers were breastfeeding at discharge, and 87% of them continued to breastfeed at 6 months postpartum. Women with an antenatal EPDS score of 8 or above were twice more likely to stop breastfeeding before 6 months (adjusted hazards ratio = 1.95; 95% confidence interval, 1.26, 3.01) than those who scored less than 4 on the EPDS. Conclusions: Depressive symptoms during pregnancy appeared to be associated with early breastfeeding cessation for mothers residing in Sabah.
Introduction
D
epression has become the leading cause of disease burden for women of reproductive age.1,2 It is estimated that between 9% and 24% of women worldwide experience a depressive disorder while pregnant.3 When left untreated, antenatal depression may lead to serious consequences for both the mother and the infant. Women struggling with depressive symptoms during pregnancy tend to receive poor prenatal care and have increased incidence of obstetric complications and preterm delivery,4,5 and their infants may experience impaired physical, social, psychological, and cognitive development.6 After birth, breastfeeding plays an important role in preventing mortality and achieving optimal nutrition and health outcomes for the newborn.7 Studies from a variety of societies have examined factors that influence mothers at risk of a short breastfeeding duration.8–10 Only a few have investigated the effects of antenatal depression on breastfeeding practices, but their findings remain inconclusive. For instance, a study of two maternal cohorts in Britain found no association between 1 2 3
antenatal depression and early cessation of breastfeeding,11 yet a recent longitudinal study of American primiparous mothers reported that those with fewer depressive symptoms during pregnancy breastfed for a longer period.12 In Malaysia, the available data suggested a range of 8.6– 30.2% of mothers suffering from antenatal depression.13–15 According to the most recent nationwide survey, the prevalence of ‘‘ever breastfeeding’’ was 94.7%, and about 37% of children were breastfed for at least 2 years.16 However, there has been no published report on the relationship between depression during pregnancy and infant feeding practices in Malaysia or South East Asia. The present study thus aimed to determine whether antenatal depressive symptoms could increase the risk of lactation cessation within 6 months postpartum in Sabah, Malaysia. Subjects and Methods Study design and participants
A prospective cohort study of maternal depression was undertaken at five maternal and child health clinics in the
School of Medicine, University Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia. Department of Management Sciences, City University of Hong Kong, Kowloon, Hong Kong. School of Public Health, Curtin University, Perth, Western Australia, Australia.
300
ANTENATAL DEPRESSIVE SYMPTOMS AND BREASTFEEDING
Kota Kinabalu and Penampang Districts of Sabah, Malaysia, between 2009 and 2010. Sabah, with a population of 3.5 million, is situated on the Island of Borneo in East Malaysia. Estimates from the Department of Statistics Malaysia showed that the Gross Domestic Product per capita in Sabah was 18,603 Ringgit (approximately 5,200 USD) in 2013, well below the national average of 32,984 Ringgit (approximately 9,100 USD). Pregnant women who attended the clinics for their routine antenatal care at 36–38 weeks were approached and invited to participate in this study. Women were excluded if they had a multiple pregnancy, were illiterate, or were deemed unsuitable as advised by health professionals. A minimum sample size of 570 mothers at 6 months postpartum was required, calculated by assuming a prevalence of any breastfeeding between 82% and 88%. In total, 2,072 eligible women consented to participate (response rate, 92.2%). They were asked to complete a selfadministered questionnaire in a private space. Trained nurses were available for clarification if required. Information collected from the baseline questionnaire included demographic, socioeconomic, and health characteristics, as well as depressive symptoms during pregnancy. Mothers were then followed up at 1, 3, and 6 months postpartum when they returned to the clinics for immunization and routine examination of the infants. Detailed information on infant feeding methods was obtained at each follow-up. The content validity of the questionnaire was verified through a pilot study involving 50 pregnant women from the same catchment area. At the end of 6 months postpartum, 979 participants (47.2%) remained in the cohort. Measurements
The presence of depressive symptoms was measured using the Edinburgh Postnatal Depression Scale (EPDS), which has been widely used in antenatal and postnatal depression research.17 The EPDS consists of 10 items rated on a 4-point scale (from 0 to 3). The total score thus ranges from 0 to 30, with higher scores indicating more severe depressive symptoms. The reliability and validity of the Malay version of the EPDS have been verified.18 In this study, ‘‘any breastfeeding’’ was defined as feeding with breastmilk (direct from the breast or expressed) with or without other drinks, formula, or other infant food.19 Statistical analysis
Descriptive statistics were first applied to profile the characteristics of participants. In addition to univariate statistics, a full Cox regression analysis was performed to ascertain the effects of antenatal depressive symptoms on discontinuation of ‘‘any breastfeeding’’ before 6 months. The antenatal EPDS score was categorized according to the tertiles of its distribution, with the lowest level being the reference group. Confounding variables considered in the regression model included maternal age (in years), ethnicity (indigenous; nonindigenous), education level (primary; secondary or above), monthly household income (
