SILVA, Victória Marques. Et al. Impact of Postpartum Depression on Breastfeeding: An Integrative Literature Review. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 06, Ed. 06, Vol. 10, pp. 60-74. June 2021. ISSN: 2448-0959, Access link: https://www.nucleodoconhecimento.com.br/health/postpartum-depression
Objective: To bring the necessary knowledge to nursing professionals about the importance of identifying pregnant women with signs and symptoms of postpartum depression and how this impacts exclusive breastfeeding. Question problem: How can PPD affect breastfeeding and the relationship between mother and baby? Methodology: Integrative literature review study, exploratory conducted in 2020. Main results: With some studies, it was possible to realize that due to the lack of psychological conditions, the relationship between mother-baby presents barriers to be developed and that the lack of exclusive breastfeeding increases the risk of infant death by 15 times when comparatous the health of babies with EMB.
Keywords: Breastfeeding, Depression, Nursing, Child Health.
Major depression is a mental disorder that persists for at least two weeks with episodes that present deep sadness and loss of interest in activities that once aroused pleasure. To support the diagnosis, it is necessary to have confirmed the presence of at least four other specific symptoms, according to the Diagnostic and Statistical Manualof Mental Disorders IV (DSM) (INSTITUTO MUNICIPAL DE INVESTIGACIÓN MÉDICA, 1995). It is also considered a public health problem, where it is estimated to affect more than 300 million people worldwide, of any age group (ORGANIZAÇÃO MUNDIAL DA SAÚDE, 2018). According to the World Health Organization (WHO), in the Brazilian population, the predominance is 15.5%and, only in primary care, it has a prevalence of 10.4%. (MINISTÉRIO DA SAÚDE, 2019)
Women are more likely to develop depression (ORGANIZAÇÃO MUNDIAL DA SAÚDE, 2018), and during the pregnancy period, the nurse/a seeks signs and symptoms indicative of the diagnosis of depression early in prenatal care, as a form of prevention, as it is a delicate stage in the woman’s life that will involve a series of physiological and hormonal changes, in addition to other changes involving the emotional and rational scope, becoming a risk factor for such a condition. (SOCIEDADE BENEFICENTE ISRAELITA BRASILEIRA ALBERT EINSTEIN, 2019)
During the puerperal period, the risk of developing postpartum depression (PPD) is high because the woman is dealing with new routines, in addition to physical and mental changes. Depressive symptoms can be noticed from the first week or up to three months after delivery and may be similar to those of major depression, adding to the impairment of the mother-child bond. (LINO et al., 2020) (ABUCHAIM et al., 2016)
According to the Theory of Self-Efficacy, an individual’s behavior is shaped as he interprets his feelings, so PPD negatively influences all maternal actions (ABUCHAIM et al., 2016). According to Vieira et al., (2018) women with low self-efficacy are three times more likely to stop breastfeeding early.
Women who presented depression during pregnancy and postpartum have great difficulty in creating the mother-child bond and because of the feeling of insufficiency or guilt, do not feel able to take care of their children. Children who are exposed to depressive conditions end up having impairments in relation to cognitive and motor development, sudden temperament changes and, in their nutritional status, due to the lack of exclusive maternal breastfeeding (EMB) until the sixth month of life. (LINO et al., 2020)
Breast milk is crucial in the first months of life because from a nutritional point of view it is from this food that the baby will have the strengthening of its immune system and will have a better development. Breastfeeding also brings numerous benefits to the mother, because withlactation, stress levels are decreased and consequently reduces depressive symptomatology. (LINO et al., 2020)
The motivation of the authors for the development of this study is to show how much is necessary and important the provision of humanized care to women from prenatal to postpartum, making it indispensable to care for nursing and the detection of possible future harmful repercussions on breastfeeding and the relationship of the mother-child binomial. So, the question of this study is: How can PPD affect breastfeeding and the relationship between mother and baby?
The aim of this study is to conduct a literature review in order to expand the knowledge of nursing professionals about the importance of identifying pregnant women with risk factors of postpartum depression and on their impacts on breastfeeding.
This article was elaborated by the method of integrative literature review, which deals with the construction of a text that aims to put in a simple and objective way the results obtained from research on a single subject in a systematic, orderly and comprehensive way, providing a lot of broad information, thus forming a body of knowledge. (HASSAN et al., 2016)
For the development of this article, researches were carried out during the month of October, 2020, using the descriptors researched in the Health Sciences Descriptors (DeCS) platform: Breastfeeding; Depression; Nursing and Child Health.
The databases used were: Virtual Health Library (BIREME), Latin American and Caribbean Literature on Health Sciences (LILACS), Medline International Literature in Health Sciences (MEDLINE), Scientific Electronic Library Online (ScieLO), Google Scholar, Direct Science and the official website of the World Health Organization (WHO).
The inclusion criteria were used the Portuguese and English, from 2016 to 2020, with at least two of the selected descriptors, text compatible with the theme, excluding articles that did not meet the main idea of this article.
Because this is a bibliographic study, the approval of the Research Ethics Committee was not necessary. There is also no conflict of interest between the authorsinvolved.
This article is an integrative review of the literature, using as inclusion criteria: texts in Portuguese and English, between the years 2016-2020, a theme related to the intention of the research and the descriptors selected by the authors.
After adding the pre-established criteria, seven articles were found in the SciELO database, six in the VHL, two in Google Scholar and one in Direct Science. After reading the articles in full, 13 studies were highlighted, which are detailed in table 1.
As for the categories of the studies found, 30.77% addressed discussions focused on the “relationship of PPD and breastfeeding”, 23.08% on “breastfeeding”, 15.38% on “depression during pregnancy” and “Primary Health Care in the puerperium”, and 7.69% “maternity” and “child nutrition”.
Table 1 includes the synthesis of the articles collected through the inclusion and exclusion criteria.
Table 1: Characteristics of the publications used in this study.
|authorship||Year of publication||periodic||Title of the study||Study objective|
|Silva et al.||2017||Jornal de Pediatria (Rio J.)||Associação entre depressão pós-parto e prática do aleitamento materno exclusivo nos primeiros três meses de vida.||To verify the association between postpartum depression and the occurrence of exclusive breastfeeding.|
|Moraes et al.||2020||Revista de Enfermagem Referência||Percepção sobre a importância do aleitamento materno pelas mães e dificuldades enfrentadas no processo de amamentação.||Know the perception of mothers about the importance of BF and identify the main difficulties faced in the practice of BF and/or its maintenance.|
|Oliveira M et al.||2019||Enfermagem foco||Sentimento de mulheres com depressão pós-parto frente ao aleitamento materno.||Describe feelings of women with postpartum depression in the face of breastfeeding.|
|Vieira et al.||2018||Revista Latino-Americana de Enfermagem||Autoeficácia para amamentação e depressão pós-parto: estudo de coorte.||To evaluate self-efficacy for breastfeeding, the presence of symptoms of depression in the postpartum period and the association between self-efficacy in breastfeeding and postpartum depression, with the interruption of exclusive breastfeeding.|
|Abuchaim et al.||2016||Acta Paulista de Enfermagem||Depressão pós-parto e autoeficácia materna para amamentar: prevalência e associação.||To identify the prevalence of symptoms of postpartum depression and the level of self-efficacy for breastfeeding among postpartum women attended at a Breastfeeding Incentive Center, and to analyze possible associations.|
|Baratieri et al.||2019||Ciência e Saúde Coletiva||Ações do programa de puerpério na atenção primária: uma revisão integrativa.||Systematize the knowledge produced about the actions of postpartum care programs within PHC, both nationally and internationally.|
|Giordani et al.||2018||Ciência e Saúde Coletiva||Maternidade e amamentação: identidade, corpo e gênero.||It proposes a reflection around motherhood, problematizing the experience of breastfeeding and the construction of identity, approaching sociological concepts of interactionism by Anselm Levi Strauss.|
|Costa et al.||2018||Ciência e Saúde Coletiva||Transtornos mentais na gravidez e condições do recém-nascido: estudo longitudinal com gestantes assistidas na atenção básica.||To verify the presence and association between probable diagnoses of mental disorders in primary care pregnant women and newborn conditions.|
|Lima et al.||2017||Acta Paulista de Enfermagem||Sintomas depressivos na gestação e fatores associados: estudo longitudinal.||To identify the frequency of depressive symptoms during pregnancy and verify their association with sociodemographic, obstetric and health variables.|
|Silva et al.||2020||Revista de Enfermagem UFPE||Intervenções do enfermeiro na atenção e prevenção da depressão puerperal.||Identify the scientific production on the actions/interventions that can be developed by nurses in the care and prevention of damage from puerperal depression.|
|Lino et al.||2020||Nursing Magazine||O impacto da depressão pós-parto no aleitamento materno e no desenvolvimento infantil: Uma revisão integrativa.||Identify the impact of postpartum depression on breastfeeding and child development.|
|Hassan et al.||2016||Revista de Saúde Pública||Saúde mental materna e estado nutricional de crianças aos seis meses de vida.||To analyze whether maternal mental health is associated with child nutritional status in the sixth month of life.|
|Menezes et al.||2019||BIUS||A importância da amamentação na formação de vínculos afetivos saudáveis entre mamãe/bebê.||To analyze whether breastfeeding positively interferes with the constitution of healthy affective bonds between mother/baby.|
Source: Own Authorship (2020)
For women, pregnancy is marked by constant changes and many transformations in their organism and in sociopsychological sectors, where the greatest challenge is knowing how to live with this new experience that was often not planned, where the woman is not prepared for this important event. “Among the psychic manifestations, the most common in the puerperium period are: baby blues or maternal sadness, postpartum depression (PPD) and puerperal psychosis.” PPD appears as the most frequent and is the one that has the greatest impact for both the mother and the baby that has just been born. (DE OLIVEIRA et al., 2019)
According to Giordani et al. (2018), female identity undergoes several changes after the birth of a child, because in addition to psychological and physiological changes, responsibility is also found. With this, we see transformations in their personal and interpersonal relationships. The authors mentioned state that “women start to assume a new condition of self, life, relationships, others, causing a transformation of behavior, postures and, finally, a complete change in their self-image”.
For women who are completely healthy, breastfeeding is already a time considered delicate due to all the complication risks that are associated despite the correct technique.
In a study conducted by De Oliveira et al., (2019), with 20 women who have or had postpartum depression, there was an interview in which they reported how the experience of psychological disorder diagnosed with breastfeeding was. It was noticed that the relationship between mother and child presented barriers due to the lack of psychological conditions with very impactful speech.
“I was barely able to breastfeed my son, it was horrible, I had a feeling of abuse, I had no desire to breastfeed the child” (Violet): “It was bad, I felt the obligation to breastfeed, I was not happy breastfeeding” (Orchid): “ The child would not take the breast and this stressed me” (Gloriosa): “It was strange, I did not feel affection for the baby” (Jasmine): “I felt forced to breastfeed, I had no desire to breastfeed” (Anthurium): “I had a feeling of fear accompanied by sadness, fear to breastfeed” (Cherry): “When I put the baby on my breast, I felt pain and discomfort, every time I remembered that I had to breastfeed, I felt sadder” (Lily). (DE OLIVEIRA et al., 2019, p. 90)
From these reports, it was noticed that the maternal bond is impaired by postpartum depression, since breastfeeding is responsible for strengthening this binomial and is treated with rejection and fear when it is in these conditions. Oxytocin is released when the baby receives an act of affection and when this does not occur in an expected way, he stops feeling proportionally the feeling of security and affection. (de OLIVEIRA et al., 2019) (COELHO, et al., 2019)
A study by Hassan, Werneck and Hasselmann (2016) aims to analyze the mental health of postpartum women and relate them to the nutritional status of their children until the sixth month of life. Average weight, height and length of childrenwere taken, and expressed in scores considering the curves of the Word Health Organization (WHO), 2006. Women’s mental health was measured by the General Health Questionnaire and in view of all the results obtained, a significant number of women who had mental health compromised by depression were obtained and, consequently, their children presented below-expected levels in relation to weight, height and length. Thus, it was found that the quality of the mother’s mental health is related to the nutritional status of the baby positively and negatively.
An article published in September by Silva et al., (2017), in Spain, shows how stress, postpartum depression and depositional optimism influence the ame’s EMB, in addition to highlighting that sociocultural, work and family issues are important factors. It also demonstrates that psychological factors were little explored during lactation, showing the importance of taking these factors into account to help develop an effective breastfeeding intervention program.
In Europe, countries have maternity leave with different durations, where in some countries it ends up being only three months, the most common time for the beginning of work-family conflicts, associating the stress of the mother and exclusive maternal breastfeeding, resulting in one of the main reasons for its interruption. Among other reasons are also: early hospital discharge, mastitis, deficiency of child growth, low mental or emotional health, postpartum depression, low support and breastfeeding counseling. (SILVA et al., 2017)
The study also shows that there is a 15-fold higher risk of infant death in children without exclusive maternal breastfeeding when compared to infants with EMB. In addition to bringing that breastfeeding rates worldwide are lower than recommended and that they decrease during the first six months after delivery. In the first month, EMB rates range from 68% to 84%, while in the sixth month after delivery, only 13-20% of women remain in EMB. The European Region has the lowest rates in Spain, only 66% of babies are breastfed exclusively in the first month, with a drop to 28% in the sixth month. (SILVA et al., 2017)
In research conducted to trace depressive symptoms during pregnancy, it was identified that pregnant women at early ages (under 18 years), low income, without support or family ties, over 40 years, low schooling, users of illicit drugs, smokers, alcoholics, primiparous women who have suffered some type of physical or psychological violence and those of unplanned or unwanted pregnancy are more susceptible to depressive symptoms in any period of pregnancy (LIMA et al., 2017).
Early interrupted breastfeeding brings with it numerous damages, mostly negative for the mother and baby. The woman stops stimulating the production of oxytocin that would happen during breastfeeding and thenconsequently decreases its beneficial action of uterine involution, weight loss, reduction of postpartum hemorrhage and decreased risk of breast and cervical cancer. (MORAES et al., 2020)
It is known that breast milk contains all the nutrients that the newborn (NB) needs for a healthy cognitive and motor development, since it is rich in proteins, oils, vitamins, fats and fatty acids. The benefits range from the prevention of infant mortality to infections, diabetes and obesity (MORAES et al., 2020). However, for Vieira et al., (2018) “women with depressive symptoms during pregnancy are more likely to introduce, early, milk formula in the child’s diet”.
According to Costa et al., (2018) the investigation of depressive symptoms in primary care is still a challenge for health professionals, with difficulties even in the preparation of diagnoses. Prenatal care is performed in primary care, where the physiological and psychological follow-up of the woman and fetal development is done. Breastfeeding is also stimulated even before the baby is born, due to its numerous benefits.
Primary health care (PHC) is the main one when it comes to postpartum care for women. It is during the consultations of this period that the prevention, early detection and treatment of complications occurs, that is, the qualification of professionals is fundamental for the reduction of injuries. When it comes to breastfeeding, PHC has a greater focus on the baby, being insufficient regarding the reception of the woman and the difficulties she may be facing. (BARATIERI and NATAL, 2019)
It is of paramount importance that nursing has knowledge about puerperal depression, as they can intervene in several ways, from prenatal consultations with investigations of personal conflicts, signs and symptoms of a possible PPD, or even after childbirth, performing a home visit providing health promotion and the necessary reception for the mother and baby.
It is verified that the consultation and home visit are opportune moments for the reception and qualified listening, aiming at comprehensive care, giving freedom to answer the doubts and, consequently, stimulating self-care and care for the child. (SILVA et al., 2020)
It is noticed that for women diagnosed with PPD, breastfeeding is a difficult phase, accompanied by several negative sensations such as sadness, fear and hopelessness.
When the mother breastfeeds her child, it gives him the feeling of comfort, safety andaffection, but when The EMB is interrupted, the baby may have sudden behavior changes such as irregular sleep and irritation, besides having a delay in its development and even failures in the immune system.
The probability of replacing breast milk with milk formula is considered when the mother presents depressive symptoms, being a factor that should be considered carefully by all professionals who monitor the health of the nutritionally injured child.
This study addressed the impacts of postpartum depression on breastfeeding, showing the importance of nursing interventions in the face of prenatal care, on the mental health of the postpartum mother, how significant the careful look and reception of the nursing professional is. Thus, implementing actions so that the baby has a good development and the mother-child relationship is healthy, where this bond is directly affected by the presence of PPD, because with it many women lose or have no affection for the child, having a constant feeling of insecurity and uncertainty.
It was observed that there is a need for more research in the field on PPD and on nursing interventions on the subject, because we find a greater number of integrative literature review, which limits the health professional to have more knowledge to promote adequate care.
ABUCHAIM, E. de S. V. et al. Depressão pós-parto e autoeficácia materna para amamentar: prevalência e associação. Acta paul. enferm., São Paulo, v. 29, n. 6, p. 664-670, dez. 2016. Disponível em: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-21002016000600664&lng=en&nrm=iso>. Acesso em: 03 dez. 2020. doi: http://dx.doi.org/10.1590/1982-0194201600093.
BARATIERI, T.; NATAL, S. Ações do programa de puerpério na atenção primária: uma revisão integrativa. Ciênc. saúde coletiva, Rio de Janeiro, v. 24, n. 11, p. 4227-4238, nov. 2019. Disponível em: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232019001104227&lng=en&nrm=iso>. Acesso em: 03 dez. 2020. Epub out. 28, 2019. https://doi.org/10.1590/1413-812320182411.28112017.
COELHO, A.; et al. A importância da amamentação na formação de vínculos afetivos saudáveis entre mamãe/bebê. Boletim Informativo Unimotrisaúde em Sociogerontologia Online. 2019; 12(5). Disponível em: https://www.periodicos.ufam.edu.br/index.php/BIUS/article/view/6191.
COSTA, D. O.; et al. Transtornos mentais na gravidez e condições do recém-nascido: estudo longitudinal com gestantes assistidas na atenção básica. Ciênc. saúde coletiva, Rio de Janeiro, v. 23, n. 3, p. 691-700, Mar. 2018. Disponível em: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232018000300691&lng=en&nrm=iso>. Acesso em: 03 dez. 2020. https://doi.org/10.1590/1413-81232018233.27772015.
DE OLIVEIRA, M. G. et al. Sentimentos de mulheres com depressão pós-parto frente ao aleitamento materno. Enfermagem em Foco, [S.l.], v. 10, n. 3, nov. 2019. ISSN 2357-707X. Disponível em: <http://revista.cofen.gov.br/index.php/enfermagem/article/view/1702/595>. Acesso em: 03 dez. 2020. doi: https://doi.org/10.21675/2357-707X.2019.v10.n3.1702.
GIORDANI, R. C. F. et al. Maternidade e amamentação: identidade, corpo e gênero. Ciênc. saúde coletiva, Rio de Janeiro, v. 23, n. 8, p. 2731-2739, Aug. 2018. Disponível em: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232018000802731&lng=en&nrm=iso>. Acesso em: 03 dez. 2020. https://doi.org/10.1590/1413-81232018238.14612016.
HASSAN, B. K.; et al. Maternal mental health and nutritional status of six-month-old infants. Rev. Saúde Pública, São Paulo, v. 50, 7, 2016. Disponível em: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102016000100206&lng=en&nrm=iso>. Acesso em: 03 dez. 2020. Epub Mar 22, 2016. http://dx.doi.org/10.1590/S1518-8787.2016050006237.
INSTITUTO MUNICIPAL DE INVESTIGACIÓN MÉDICA. DSM-IV. Manual diagnóstico y estadístico de los trastornos mentales. 1995. Disponível em: <https://www.eafit.edu.co/ninos/reddelaspreguntas/Documents/dsm-iv-manual-diagnostico-estadistico-trastornos-mentales.pdf>. Acesso em: 29 de setembro.
LIMA, M. de O. P. et al. Sintomas depressivos na gestação e fatores associados: estudo longitudinal. Acta paul. enferm., São Paulo, v. 30, n. 1, p. 39-46, jan. 2017. Disponível em: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-21002017000100039&lng=en&nrm=iso>. Acesso em: 03 dez. 2020. https://doi.org/10.1590/1982-0194201700007.
LINO, C.; et al. O impacto da depressão pós-parto no aleitamento materno e no desenvolvimento infantil: Uma revisão integrativa. Nursing, São Paulo. 2020.
MINISTÉRIO DA SAÚDE. Depressão: causas, sintomas, tratamentos, diagnóstico e prevenção. 21 de agosto de 2019. Disponível em: <https://antigo.saude.gov.br/saude-de-a-z/depressao>. Acesso em: 29 de setembro.
MORAES, I. C. de; et al. Percepção sobre a importância do aleitamento materno pelas mães e dificuldades enfrentadas no processo de amamentação. Rev. Enf. Ref., Coimbra, v. serV, n. 2, p. e 19065, abr. 2020. Disponível em: <http://www.scielo.mec.pt/scielo.php?script=sci_arttext&pid=S0874-02832020000200009&lng=pt&nrm=iso>. Acesso em: 03 dez. 2020. http://dx.doi.org/10.12707/RIV19065.
ORGANIZAÇÃO MUNDIAL DA SAÚDE. Depressão. Mar. de 2018. (Folha informativa). Disponível em: <https://www.paho.org/pt/topicos/depressao>. Acesso em: 29 de set.
SILVA, C. S.; et al. Association between postpartum depression and the practice of exclusive breastfeeding in the first three months of life, J. Pediatr. Rio J. Porto Alegre, v. 93, n. 4, p. 356-364, ago. 2017. Disponível em: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0021-75572017000400356&lng=en&nrm=iso>. Acesso em: 03 dez. 2020. https://doi.org/10.1016/j.jped.2016.08.005.
SILVA, J. F. da; et al. Intervenções do enfermeiro na atenção e prevenção da depressão puerperal. Revista de Enfermagem UFPE online, [S.l.], v. 14, jul. 2020. ISSN 1981-8963. Disponível em: <https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/245024/35555>. Acesso em: 03 dez. 2020. doi:https://doi.org/10.5205/1981-8963.2020.245024.
GOMES, M. N. de A.; SANTOS L. K. de O. Saúde da Mulher na Gestação, Parto e Puerpério. São Paulo: Hospital Israelita Albert Einstein: Ministério da Saúde, 2019. 56 p.: il. Disponível em: <https://atencaobasica.saude.rs.gov.br/upload/arquivos/202001/03091259-nt-gestante-planificasus.pdf>. Acesso em: 5 de outubro.
VIEIRA, E. de S.; et al. Breastfeeding self-efficacy and postpartum depression: a cohort study. Rev. Latino-Am. Enfermagem, Ribeirão Preto, v. 26, e3035, 2018. Disponível em: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692018000100348&lng=en&nrm=iso>. Acesso em: 03 Dec. 2020. Epub set. 06, 2018. https://doi.org/10.1590/1518-8345.2110.3035.
 Graduation in Nursing.
 Graduation in Nursing.
 Graduation in Nursing.
 Graduation in Nursing.
 Guidance counselor.
Submitted: December, 2020.
Approved: June, 2021.