Breastfeeding provides significant benefits for mothers, infants and society, yet breastfeeding rates in the UK are among the lowest in the world (McAndrew et al, 2012). Typically, in the UK, 80% of women initiate breastfeeding; however, exclusive breastfeeding rates are less than 50% by 6 weeks, and drop to less than 1% after 6 months (Renfrew et al, 2012; Nicholson and Hayward, 2021). The World Health Organization (WHO, 2022) recommends exclusive breastfeeding for the first 6 months, followed by breastfeeding alongside the introduction of solids up to and past 2 years old. Breastmilk provides protection from infection and disease, while also supporting physical and cognitive development (Victoria et al, 2016), and the maternal benefits include a lower risk of breast and ovarian cancer (Gonzalez-Jimenez et al, 2004; Ip et al, 2009).
Low breastfeeding rates in the UK led UNICEF to launch the baby friendly hospital initiative in 1994, working in partnership with the WHO (WHO and UNICEF, 2012). The initiative's aim was to encourage maternal and neonatal healthcare services and professionals to implement ‘ten steps to successful breastfeeding’, a combination of policies and practices to support breastfeeding. Revised in 2012, the steps include discussing the importance and management of breastfeeding with pregnant women and their families and supporting mothers to initiate and maintain breastfeeding and manage common difficulties (WHO and UNICEF, 2012). While these steps were useful, they fail to address the common difficulties expressed by people who breastfeed (Keevash et al, 2018).
The emotional and psychological changes that occur in the immediate postnatal period can be the greatest changes a woman may experience in her lifetime (O'Hara and Wisner, 2014). Distress or disappointment about birth, anxiety about the baby and the perceived inability to cope are among the negative feelings a woman may experience after birth (O'Hara and Wisner, 2014). While they are likely to be short-lived and transient for many women, an important complication of pregnancy and childbirth is perinatal mental illness, with childbirth having been associated with the onset of depressive and anxiety disorders (O'Hara and Wisner, 2014; Keevash et al, 2018; Norman et al, 2022) and trauma-related symptoms (Baptie et al, 2021). While perinatal mental health difficulties occur in a small subset of individuals, they can cause extreme distress to the mother and her family, as well as costing an estimated £8.1 billion each year to society in the UK (Bauer et al, 2014). Of this cost, only 28% relates to mother, with 72% relating to adverse impacts on the child, such as long-term physical and mental illness, reduced quality of life and reduced career prospects over a lifetime. Women experiencing perinatal mental health difficulties should have access to specialist advice, clear referral pathways and management protocols in accordance with the National Institute for Health and Care Excellence (NICE, 2014) guidelines. However, service provision in the UK remains inadequate (Bauer et al, 2014; Baptie et al, 2021; Norman et al, 2022).
Negative changes to maternal mental health can have a significant impact on women, specifically influencing a mother's ability to breastfeed, with research highlighting the association between maternal mental health and breastfeeding behaviour (Britton, 2007). Field et al (2010) found that women experiencing antenatal depressive symptoms were less likely to initiate breastfeeding and stopped earlier compared to non-symptomatic mothers. While many factors that do not include perinatal mental health issues can lead to early cessation (Norman et al, 2022), early cessation has been identified in other studies on postnatal depressive symptoms (Dennis and McQueen, 2007; Silva et al 2016) and wider studies looking at factors influencing breastfeeding cessation (Keevash et al, 2018; Norman et al, 2022). Some studies have identified that a longer breastfeeding duration is significantly associated with lower levels of anxiety and depression (Borra et al, 2015; Webber and Benedict, 2019) and further studies have identified breastfeeding as a possible long-term protective factor against later symptoms of depression in some women up to 2 years after birth (Hahn-Holbrook et al, 2013).
The literature has identified a relationship between breastfeeding and mental health and the impact of mental illness after birth can influence an individual's choice to continue or cease breastfeeding. While there is evidence of the protective impact of breastfeeding on mental health (Krol and Grossman, 2018), other studies have outlined that breastfeeding can negatively affect maternal mental health, usually because of feeding complications and a lack of support (Norman et al, 2022). Therefore, the aim of the present study was to use a mixed-methods approach to better understand the relationship between mental health and breastfeeding, with specific focus on the possible bi-directional relationship. A secondary aim was to use qualitative methods to better understand the factors that influence the relationship between mental health and breastfeeding. The rationale for using a mixed-methods approach was to gather qualitative data about the experiences of breastfeeding people, while collecting data from a broader sample to better understand how these experiences may be extrapolated to a wider population of breastfeeding people.
Methods
The project used a mixed-methods design (Hanson et al, 2005) to make use of the advantages of both qualitative and quantitative approaches and ameliorate any potential disadvantages (Johnson et al, 2007; Creswell et al, 2013). The study involved two stages, an initial survey followed by telephone interviews with a small sample of those who completed the survey. The aim was to use a predominantly qualitative approach, but the additional data gathered from the survey meant the authors were able to explore whether the data gained from interviews could be extrapolated to a wider population.
Participants
Participants were eligible to take part in the study if they had breastfed in the 5 years preceding data collection (from 2018 to 2019). This time limit was applied to ensure the documented experiences reflect recent breastfeeding practice and policy in the UK. The length of time that mothers had to have spent breastfeeding was not stipulated, to allow for all women who had initiated breastfeeding to take part. The study focused on understanding lived experiences, so the authors were interested in capturing the experiences of all those who had breastfed, even for a very limited period of time.
Participants (n=109) were recruited through adverts on social media, specifically breastfeeding support sites on Facebook, inviting them to take part in a survey about their breastfeeding experience.
The survey received 109 responses and those who expressed interest were invited to participate in telephone interviews. The study interviewed 24 women (aged 20–45 years), with data collected between May 2018 and July 2019. The breastfeeding duration ranged from 10 days to over 25 months.
Data collection
The survey questionnaire was self-designed and adapted from a previous larger-scale study of breastfeeding behaviour (Norman et al, 2022). The survey was predominantly qualitative in structure but included a series of Likert scales to provide quantitative ratings. The aspects of the original survey that related specifically to breastfeeding experiences and maternal mental health were used for the present study, which included additional qualitative questions to gain a better understanding of mental health issues that affected the sample antenatally, perinatally and postnatally.
Stage 1
Participants completed an online survey that consisted of 17 closed questions, and additional open-ended questions, allowing the participants to elaborate on their responses. These questions focused on their experiences of breastfeeding and its impact on their mental health. At the end of the survey, participants were given the option to provide their email address if they wished to take part in semi-structured interviews. Of the 27 participants who expressed an interest, 24 took part in the second phase.
Stage 2
Semi-structured telephone interviews of approximately 30 minutes each were conducted. The interview schedule asked for basic demographic information as well as open-ended questions about feeding choices (knowledge, experience, difficulties breastfeeding), any support received (from family or healthcare professionals, pressure to feed a certain way), mental health (antenatal, postnatal, support they received) and their overall breastfeeding experience.
The responses allowed the researcher to gain insight into participants' feelings and experiences and to attribute meaning to their experiences, giving a rich interview response. The interviews were recorded and transcribed from the audio recordings. The transcribed interviews were then analysed using a mixed thematic approach or framework analysis (Smith and Firth, 2011), with both a deductive and inductive approach following the processes outlined in Braun and Clarke (2006).
Data analysis
The data from the online survey were analysed using a mixed-methods approach. Quantitative questions were analysed using descriptive statistics and combined with qualitative data on related themes. The qualitative sections were then analysed using conventional content analysis. This was an appropriate approach as although there is literature outlining links between mental health and breastfeeding, the multiple ways in which these two factors might be linked is still not fully understood. Conventional content analysis is often used to describe phenomena with a limited research base (Hsieh and Shannon, 2005). The analysis involved reading the data repeatedly and writing exploratory comments, re-reading the data to derive codes that captured key thoughts and concepts, organising codes into related categories and meaningful clusters, which identified the master themes, and conducting a validation analysis of the codes (done by another member of the research team). The qualitative survey data were then triangulated with the quantitative survey results. Finally, the themes generated were used as a framework for analysis in the subsequent interviews.
The interview data were analysed using a mixed thematic approach. Initially, a form of deductive analysis was undertaken using the framework generated from the survey data. This was undertaken to identify similarities between the survey and interview data. Further inductive analysis was applied in order to look for any new themes or codes that were not part of the original analysis. This was done after an initial deductive sweep, to allow changes to be made to the original analysis based on emerging constructs from the data or from changes to the original themes based on the richer interview data. Both processes were validated by an additional member of the research team.
Ethical considerations
Ethical approval was obtained from the university's Faculty of Health and Human Sciences before recruitment (approval number: SOPLC/JS_17/18_18/19) and all ethical guidelines and data protection procedures were followed throughout the study.
Results
Overall, 77 (70.6%) respondents rated their breastfeeding experience as positive or very positive, while 20 (18.3%) rated it as negative or very negative. Data pertaining to mental health issues pre-pregnancy, antenatally and postnatally can be seen in Table 1.
| Variable | Category | Frequency, n=109 (%) |
|---|---|---|
| Age (years) | 20–24 | 18 (16.5) |
| 25–39 | 37 (33.9) | |
| 30–34 | 27 (24.8) | |
| 35–39 | 21 (19.3) | |
| 40–45 | 6 (5.5) | |
| Mean (standard deviation) | 30.11 (5.58) | |
| Gender | Female | 109 (100.0) |
| Ethnicity | White British | 106 (97.2) |
| White European | 2 (1.8) | |
| Black Caribbean | 1 (0.9) | |
| Education | School leaver | 31 (28.4) |
| Further education | 28 (25.7) | |
| Higher education | 34 (31.2) | |
| Postgraduate qualification | 16 (14.7) | |
| Marital status | Single | 11 (10.1) |
| Living with partner | 29 (26.6) | |
| Married | 52 (47.7) | |
| Divorced/separated | 17 (15.6) | |
| Breastfeeding duration | <1 week | 0 (0.0) |
| 1 week–1 month | 4 (3.7) | |
| 1–3 months | 18 (16.5) | |
| 3–6 months | 24 (22.0) | |
| 6–12 months | 49 (45.0) | |
| 12–24 months | 10 (9.2) | |
| Over 2 years | 4 (3.7) | |
| Range | 10 days–25 months | |
| Number of children | 1 | 64 (58.7) |
| 2 | 39 (35.8) | |
| 3 | 4 (3.7) | |
| ≥4 | 2 (1.8) | |
| Premorbid mental health issues (n=15) | Comorbid anxiety and depression | 7 (6.4) |
| Depression | 3 (2.8) | |
| Anxiety | 4 (3.7) | |
| Post-traumatic stress disorder | 3 (2.8) | |
| Emotionally unstable personality disorder | 3 (2.8) | |
| Bipolar disorder | 1 (0.9) | |
| Antenatal mental health issues (n=28) | Comorbid depression and anxiety | 11 (39.3) |
| Depression | 8 (28.6) | |
| Anxiety | 8 (28.6) | |
| Post-traumatic stress disorder | 3 (10.7) | |
| Emotionally unstable personality disorder | 3 (10.7) | |
| Bipolar disorder | 1 (3.6) | |
| Postnatal mental health issues (n=38) | Comorbid depression and anxiety | 13 (34.2) |
| Depression | 9 (23.7) | |
| Anxiety | 10 (26.3) | |
| Post-traumatic stress disorder | 6 (15.8) | |
| Emotionally unstable personality disorder | 3 (7.9) | |
| Bipolar disorder | 1 (2.6) |
Detailed analysis of the free-text responses and interviews identified five main themes: pressure to breastfeed, provision of information and support, mixed impact on mental health, mental health impacting breastfeeding and attachment (Figure 1). Quotes are presented with ID numbers, with R referring to survey participants and P referring to interview participants.
Pressure to breastfeed
Pressure to breastfeed was experienced by 41 respondents, and was reported to be driven internally (n=13), by midwives and health visitors (n=10), by society (n=9) or friends and family (n=3). The remaining participants did not disclose where they felt pressure coming from. The three subthemes were internal pressure, pressure from healthcare individuals and societal pressure, such as from the ‘breast is best’ campaign.
Participants in both the survey and interviews discussed feeling pressure to breastfeed from multiple sources, with internal pressure being most common.
‘I didn't feel pressure from anyone but myself.’
‘I pressured myself to breastfeed the second because I hadn't with my first.’
‘I pushed myself to be able to do that but yeah, probably more than I should have pushed myself.’
Several participants perceived there to be pressure from health professionals. One mother described feeling ‘that pressure, like a threat’ from midwives, which may have had a negative impact on mental wellbeing. Societal pressure was also described by some participants.
‘[It was] expected to breastfeed and [you're ]made to feel as though you've failed as a parent if you don't or can't.’
‘The stress and the fact that I felt like I was being threatened and there was that pressure and that obviously has a negative effect.’
‘I was quite upset about it, and I'm quite a strong person really but I do remember sobbing my heart out after they left.’
The message ‘breast is best’, and the negative impact it had on mental wellbeing, was discussed by 11 interview participants. Many reported feelings of guilt or failure to do the best for their baby if they did not breastfeed, because of the breast is best message.
‘Breast is best and it's the right thing to do. If you gave up it was frowned upon.’
‘Pressure from society and the advice that “breast is best” from breastfeeding advocates making me feel that if I didn't, I wasn't doing the best for my baby.’
Provision of information and support
Overall, participants reported that healthcare professionals provided inadequate and insufficient information, specifically on breastfeeding difficulties and what to expect. Difficulties were experienced by 93 respondents, with the most common issue being poor latching (n=30), followed by tongue tie (n=16) and painful feeding (n=16). The subthemes were information provided by healthcare professionals, information provided by friends, family and others, support from healthcare professionals and mental health support from healthcare professionals.
The information participants received reportedly emphasised the benefits of breastfeeding, meaning participants felt unprepared for difficulties such as pain.
‘Cracked nipples, the actual gritting your teeth when you've got mastitis’.
‘I had mastitis once and the pain is unbelievable, and no one prepares you for that.’
Participants reported that not having information left them lacking confidence, feeling upset and unprepared for unexpected difficulties. The participants wanted information to help them feel more prepared.
‘I think that's why you get upset, that you can't do something because you've not been told so you think I'm not normal, this is not normal.’
‘I think if you're prepared and you know about something, there's no surprise, no element of surprise and also you don't feel, I think sometimes if someone has told you, you already know that, you've been told, other people will be having this, it kind of makes you feel normal.’
Some participants received information from friends, family or other mothers, but it often focused on the negative aspects of breastfeeding or ‘scaremongering’.
‘It was mostly through all those stories you hear from other women that were saying it's so difficult, so painful and it's almost like an act of heroism to feed your own baby…I felt like there were lots of scary stories about it.’
‘It felt like scaremongering.’
Participants highlighted a ‘distinct lack of support’ from health professionals. In some cases, women were unable to initiate breastfeeding or ceased early. In some cases, the lack of support from health professionals ‘played a major role’ in negative maternal wellbeing.
‘I didn't feel very supported. They would just grab my very painful boob and force in the baby's mouth telling me that's the way it should be done.’
‘I'm saying yes, but actually it wasn't the breastfeeding that affected my mental health, it was the lack of support and understanding that affected me.’
Not all participants had negative experiences of support from health professionals. Some reported valuable support with ‘different feeding positions and latch techniques’. However, participants highlighted the lack of mental health support, with only three reporting a positive experience with mental health intervention and support. In these instances, participants reported feelings of depression and anxiety on the standard checklist given to UK mothers during routine home visits. Of the interview sample, 11 participants specifically referred to these checklists and many commented on having good experiences when reporting mental health issues. Three participants described reporting symptoms and being told someone would get back them. In all three instances, at least 6 months (9 months in one instance) passed before they received a phone call offering support.
‘[There was] minimal support for mental health’
‘Mental health wise, I also feel there isn't enough awareness outside of the specialist mental health
teams about mental health issues and how their treatment can affect people.’
‘Not nearly enough support with my postnatal depression.’
Mixed impact on mental health
Mental health issues were experienced before pregnancy by 21 survey participants. Of these, all continued to experience mental health issues during pregnancy, and an additional seven participants experienced new mental health issues during pregnancy, with the most common issue being comorbid depression and anxiety (n=11) and some respondents experiencing comorbidities.
Postnatally, 45 participants reported mental health issues. This included all those who experienced mental health issues in pregnancy as well as a further 17 respondents. Postnatal mental health issues were reported by 9 individuals (37.5%), and 49 survey respondents reported their births were traumatic, with reasons given such as emergency caesarean section (n=23) and assisted birth (n=9). The subthemes for the mixed impact of breastfeeding on mental health were the impact of failure to breastfeed, the impact of breastfeeding, the impact of ceasing breastfeeding and the positive impact of a positive breastfeeding experience.
Mothers reported feeling like ‘a failure for giving up’ if they were unable, or struggled, to breastfeed. For some mothers, feeding was possible, but pain and/or frequency of feeding left them feeling tired, isolated and exhausted.
‘I really wanted to and when I struggled, I felt I was failing.’
‘The struggle made me feel like a failure.’
Some mothers reported feeling lonely and depressed. In one case, a mother began hallucinating and needed specialist care. Participants reported ‘horrendous guilt’ when they ceased breastfeeding, particularly when they had stopped earlier than anticipated.
‘Felt trapped and pressured during first 3 months. Isolated and pinned to the sofa.’
‘I managed a few months with my second child but had intense feelings of claustrophobia during feeding.’
‘The sleep deprivation caused by breastfeeding caused me to hallucinate and the crisis team were sent out.’
‘I stopped breastfeeding so that I could take anti-anxiety medication. I then felt guilty.’
‘I felt such a horrendous guilt when I stopped, particularly because it was so soon after the birth and I felt I was neglecting my child. My mental health became a downward spiral from this point.’
However, many mothers felt that a positive breastfeeding experience had a positive impact on their mental wellbeing, describing their experiences as ‘empowering’ and ‘rewarding’.
‘How powerful it made me feel as a woman, that my body could give life and continue to nourish it too.’
‘I really felt as though I had a superpower whilst doing it.’
Mental health impacting breastfeeding
Maternal mental illness can negatively impact on a mother's ability to breastfeed and her breastfeeding experience. One participant reported that it was not the mental illness that affected breastfeeding, but that anxiety led to poor eating behaviours as a way of coping, which in turn affected her milk supply and consequently, led to the early cessation of breastfeeding.
‘I was sectioned and basically told that my medication was being increased and the psychiatrist just basically laughed at me wanted to express sort of thing, so yeah, it was, and they had no procedures in place around expressing.’
In extreme cases, mothers require inpatient mental health intervention. One mother admitted with bipolar disorder highlighted how a lack of support, clean equipment and milk storage facilities resulted in early cessation, despite wanting to continue breastfeeding.
‘I was being handed equipment with dirt and dried on milk and being told it was sterile when it clearly wasn't.’
‘There was nothing in place to support me with breastmilk so that was the end of it.’
Attachment
There were two subthemes to attachment: positive and negative breastfeeding experiences. Participants reporting a positive breastfeeding experience discussed the closeness they felt with their infant and how breastfeeding helped with ‘bonding with baby’.
‘I loved breastfeeding and the bond it has given me with my children. I have never felt so needed in my entire life.’
‘Absolutely love breastfeeding and the relationship it builds with your baby. The bond is amazing.’
‘Helped with bonding and claiming my role as mum.’
In contrast, those reporting a negative breastfeeding experience felt breastfeeding was detrimental to establishing a bond with their infant because of feeling ‘resentful’ and in ‘pain’.
‘I became resentful of every feed because it was so, so painful. I did not bond with her until she was about 6 weeks [old].’
‘Very painful, uncomfortable and felt I didn't bond with baby as quickly due to pressure to breastfeed and pain.’
Discussion
The present study used a mixed methods approach with both a wider survey and telephone interviews with a smaller sample to explore the relationship between mental health and breastfeeding. The study identified five themes associated with breastfeeding and maternal mental health; pressure to breastfeed, provision of information and support, a mixed impact on mental health, mental health impacting breastfeeding and attachment.
Participants reported feeling pressure to breastfeed from multiple sources, including it being internally driven, with mothers putting pressure on themselves to breastfeed successfully. This affected participants' mental health, particularly if they continued to breastfeed despite difficulties and feeling exhausted, and at times, anxious. Others referred to feeling pressure from the ‘breast is best’ campaign, which promotes exclusive breastfeeding for the first 6 months. Mothers who struggled with low milk supply, pain, exhaustion and illness noted the profound effect on their mental health. Feelings of guilt and failure were expressed by mothers who felt unable to meet the expectations set by this campaign, with some describing a disconnect between the message of strongly encouraging breastfeeding but the lack of sufficient support in place to facilitate successful breastfeeding.
NICE (2014) guidelines state that health professionals should ensure pregnant women are offered breastfeeding information and education, including indicators of good attachment, positioning and successful feeding. The present study suggests this was not always the case, with information from health professionals often felt to be inadequate and limited, particularly surrounding breastfeeding difficulties. Appropriate information can promote a positive continuation of breastfeeding (Heidari et al, 2017), and women should be given sufficient information on not only the benefits, but also the difficulties they may encounter. While what is regarded as appropriate and sufficient information is likely to vary across individuals, many studies have identified that breastfeeding mothers and people felt they did not receive enough information about the difficulties of breastfeeding (Keevash et al, 2018; Norman et al, 2022; Thurgood et al, 2022). This may be a deliberate attempt by healthcare professionals to promote the benefits of breastfeeding, but psychologically, this leaves people feeling unprepared for the challenges associated with breastfeeding. A more honest approach is required, to provide a more balanced perspective.
While some mothers reported that they received a good level of support, others did not receive information that matched the standards recommended by NICE (2008). Guidelines state that healthcare professionals should have sufficient time to support a woman during initiation and continuation of breastfeeding, as a priority (NICE, 2008). Inadequate support from health professionals meant many women were unable to initiate breastfeeding or experienced early cessation. In some cases, mothers felt that a lack of support had a negative impact on their mental health. This supports the view that providing additional support may prevent or reduce the incidence of depression in new mothers, a known risk factor for postnatal depression (Webber and Benedict, 2019).
Hahn-Holbrook et al (2013) suggested that breastfeeding could protect some mothers from depressive symptoms and lead to a reduction in stress. While the reverse was true for some of the present study's participants, a large proportion of mothers felt breastfeeding did have a positive effect on their mental health. Some participants described their breastfeeding experience as empowering and rewarding, with one mother stating that breastfeeding helped with her postnatal depression.
Research suggests that breastfeeding facilitates a secure attachment between mother and infant, a bond essential for the infant to grow and thrive (Gibbs et al, 2018). For many mothers, breastfeeding is not solely about meeting the nutritional needs of the infant, it is about the transition to motherhood and their role as a ‘good mother’ (Marshall et al, 2007; Keevash et al, 2018). The present study found that, for many participants, breastfeeding strengthened the bond between mother and infant, with many reporting that it made them feel they were fulfilling their role as a ‘good mother’. However, failure to breastfeed or early cessation had a negative impact on mental health, with some mothers reporting feelings of guilt and failure, regardless of the reason for early cessation. This in turn led to self-reported poor attachment relationships with their infants.
A small number of study participants reported that pre-existing poor mental health was exacerbated during breastfeeding. Others reported postnatal onset of poor mental health, particularly surrounding mood disturbance and related poor nutrition, which resulted in difficulties breastfeeding and led to early cessation. Optimal maternal nutrition is necessary for effective breastfeeding (Lewallen et al, 2006). Some women suggested poor nutrition and hydration had a negative impact on milk supply, which in turn led to the use of formula. This highlights the importance of supporting mothers with their mental health throughout their breastfeeding journey. For many participants, this was also an area they felt was inadequate and ineffective.
Strengths and limitations
Using a qualitative approach allowed women to openly discuss their breastfeeding experiences, increasing understanding of the issues around breastfeeding and maternal mental health. The limitation of this approach is that data cannot necessarily be extrapolated to all breastfeeding women of different cultural, socioeconomic or educational backgrounds, as most participants identified as white British from middle class backgrounds with a high level of educational attainment. However, women from across the UK participated, suggesting this study may reflect breastfeeding experiences across different healthcare trusts. It must be noted that the rate of perinatal mental health issues in the survey and interviews was higher than in the general population (35% before pregnancy, 37.5% prenatally and 20% postpartum) (NHS England, 2022), suggesting the sample was not entirely representative of the population. However, this may suggest that rates of mental ill-health following pregnancy and birth are currently underreported.
This study's data were based on the experiences of mothers who breastfed from 2013 to 2019. It is possible that this does not reflect current practice in the UK. As a result of the recent COVID-19 pandemic, studies have suggested that there has been a decline in the availability of advice and support for breastfeeding mothers over the last 2 years (Brown and Shenker, 2021; Costantini et al, 2021; Vasquez-Vasquez et al, 2021; Thurgood et al, 2022).
Implications for practice and policy
This study identified pressure among mothers to breastfeed, which in some instances had a negative impact on their mental health. While it is important to promote the benefits of exclusive breastfeeding (Couto et al, 2020), it is important that this is done in a cautious and compassionate way that provides information and support to mothers without judgement. The findings from this study and others suggest that while well-intentioned, campaigns such as ‘breast is best’ may not be promoting breastfeeding in the positive and inclusive way mothers need (Keevash et al, 2018; Srivastava et al, 2022). Instead, encouraging breastfeeding while being honest about the difficulties and having compassion for those who struggle may prove more effective (Keevash et al, 2018).
Midwifery and health visiting services throughout the UK need to provide tailored support and information to those attempting to initiate and continue breastfeeding (Keevash et al, 2018; Norman et al, 2022; Srivastava et al, 2022). It is also imperative that services provide better mental health support to mothers who are experiencing either pre-morbid mental health issues or who start to experience difficulties as a result of breastfeeding. While good attachment can come from breastfeeding, this study clearly highlights that for individuals with poor mental health, a lack of perceived support can lead to apparent attachment difficulties.
Conclusions
This study investigated the bidirectional relationship between breastfeeding and mental health. Mental health could have a positive or negative impact on breastfeeding behaviour, with poor pre-morbid mental health leading to breastfeeding difficulties. Additionally, breastfeeding itself can impact mental health both negatively, because of pressure, poor support and information, and positively, in terms of a sense of empowerment. This bi-directional relationship is crucial to understanding the impact of breastfeeding on infant attachment and provides direction for healthcare professionals in providing better support for breastfeeding mothers.