Breast-feeding may be natural but that doesn’t mean it comes easily to every new mom. A new study in the August edition of the journal Obstetrics & Gynecology finds that women who struggle to breast-feed in the first two weeks after giving birth are more prone to postpartum depression.
The study was not able to determine whether depressed moms were more likely to have trouble breast-feeding or whether difficulty breast-feeding sparked depression, but the paper’s authors, from the University of North Carolina at Chapel Hill (UNC), recommend a two-pronged holistic approach: screen women with breast-feeding difficulties for depression and assess how breast-feeding is going for depressed mothers.
“Clearly all women who have pain breast-feeding are not depressed, but the message for clinicians is to look not just at baby’s mouth and the boob but to also look at mom’s brain,” says Dr. Alison Stuebe, the study’s senior author and an assistant professor in the department of obstetrics and gynecology in the UNC School of Medicine. “The mind has to be part of the evaluation.”
To reach their conclusions, the researchers relied on data from 2,586 women in the government-funded Infant Feeding and Practices Study II, which assessed issues of feeding and depression. Nine percent of the women fell into the category of “major depression.”
MORE: Pediatricians Should Start Screening for Postpartum Depression
Women who reported dissatisfaction with breast-feeding early on were 42% more likely to have postpartum depression two months after delivery compared with women who enjoyed breast-feeding. Mothers who initially experienced severe breast pain initially and at two weeks postpartum were twice as likely to be depressed as pain-free women. Depression, in general, has been linked to increased pain sensitivity, which may explain why depressed women have more pain while breast-feeding.
The association is unlikely to be coincidental. In a pilot study Stuebe is conducting, she’s found that new moms who report feeling anxious have lower levels of oxytocin — the feel-good hormone that courses through the body while nursing — during feeding. “Is there something hormonal in women who are depressed that makes breast-feeding less enjoyable?” she says.
Stuebe first began wondering about a possible correlation when she was a medical resident in Boston. Lactation consultants in the community would tell her that patients who needed help breast-feeding frequently seemed depressed. When she came to UNC, she suggested administering the Edinburgh Postnatal Depression Scale, a 10-question screen that is widely used to gauge depression in new mothers, to women who had problems breast-feeding. (The questions include: “I have been able to laugh and see the funny side of things” and “I have been so unhappy that I have been crying.”) She found an “impressive” number of women were both depressed and having difficulty breast-feeding.
MORE: Child’s Play: What’s So Bad About ‘The Breast Milk Baby’?
Though women are urged to breast-feed for the health benefits it conveys to both mom and baby, a single-minded focus on nursing as the only acceptable choice — without the accompanying support necessary for breast-feeding success — may be putting too much pressure on some mothers.
“We have seen a really positive shift in the attitude of public-health experts away from ‘mothers have to breast-feed, or else’ to ‘we need systems to support mothers in their breast-feeding goals,’” says Stuebe. In January, the U.S. Surgeon General issued a Call to Action to Support Breastfeeding that urged communities, relatives, employers and health providers to pitch in to help women attain their breast-feeding goals.
In fact, wrote Stuebe earlier this year in a blog for the Academy of Breastfeeding Medicine, it’s time to recognize that breast is not necessarily best for every woman:
We should not change the public health message that breast-feeding is the physiologic norm. Soft-pedaling medical advice because we might hurt someone’s feelings is patronizing at best, and unethical at worst. Further, backing away from evidence-based medical recommendations for 6 months of exclusive breastfeeding gives policy makers permission to cut back support for mothers and families.
In so many cases, a terrible breast-feeding experience is the downstream effect of subpar maternity care, unsupportive family and friends, poor medical advice and unrealistic expectations of motherhood.
But there is a major difference between a public health message on a billboard and a conversation between a struggling mother and her medical provider.
In routine care, we need to ask each mother how she feels about how feeding is going, and then we need to take time to listen to her response. And 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.
Says Stuebe: “A lot of the pain that women experience with breast-feeding reflects the now-outdated concept that moms have to power through, no matter what. It is helpful to have a more honest, realistic expectation of motherhood as a whole.”
Bonnie Rochman is a reporter at TIME. Find her on Twitter at @brochman. You can also continue the discussion on TIME‘s Facebook page and on Twitter at @TIME.