Elsevier

Midwifery

Volume 23, Issue 1, March 2007, Pages 66-76
Midwifery

An exploration of the relationship between postnatal distress and maternal role attainment, breast feeding problems and breast feeding cessation in Australia

https://doi.org/10.1016/j.midw.2005.12.003Get rights and content

Summary

Objectives

to explore the relationships between maternal distress, breast feeding cessation, breast feeding problems and breast feeding maternal role attainment.

Design

longitudinal cohort study.

Setting

three urban hospitals within Sydney, Australia.

Participants

449 women were invited to participate in the study, with an 81% response rate.

Measurement

self-report questionnaires were used to collect the data in pregnancy (28–36 weeks) and 2 weeks and 3 months after birth. The Edinburgh Postnatal Depression Scale (EPDS) was used to measure postnatal distress, and the Maternal Role Attainment subscale (MRA) of the Maternal Breast Feeding Evaluation Scale (MBFES) was used to measure breast feeding maternal role attainment.

Findings

women with high MRA were less likely to stop breast feeding (even when they had breast feeding problems) than women with low MRA. Antenatal EPDS and anxiety scores were not related to breast feeding cessation or breast feeding problems when analysed alone. As hypothesised, the relationship between breast feeding cessation and postnatal distress (EPDS scores) varied according to MRA level. Women who were categorised as high MRA and no longer breast feeding had higher EPDS scores and were more likely to be categorised as distressed (36%) than women who had low MRA (<12%) or women who had high MRA and continued to breast feed (7%).

Implications

there is a complex relationship between maternal identity, stopping breast feeding earlier than desired, and psychological distress. Women with strong beliefs about the importance of breast feeding to their maternal role may benefit from psychological assessment and support should they decide to stop breast feeding earlier.

Introduction

The aim of this research was to explore the relationship between psychological distress, stopping breast feeding in the first 3 months after birth, perceived breast feeding problems and beliefs about the importance of breast feeding to maternal role attainment.

Breast milk is the undisputed healthiest form of baby feeding in scientific, professional and popular literature. ‘Breast is best’ is a common theme in the breast feeding literature. World Health Organization and Australian guidelines (Nutbeam, 1993; NHMRC, 2003) recommend that women breast feed exclusively for the first 6 months of a baby's life and then, partially, for up to 2 years. Although initiation rates in Australia are generally high (80–90%), the duration of breast feeding for most women does not meet the targets set by the Australian Government (Nutbeam, 1993; Donath and Amir, 2000). Only 50–60% of women are breast feeding at 3 months (Donath et al., 2000). More importantly, women often do not meet their own goals for the length of time they would like to breast feed and stop breast feeding earlier than they originally plan, before birth (Cooke et al., 2003).

Researchers have attempted to identify the factors that influence initiation and duration of breast feeding. These researchers have found that breast feeding is a multi-factorial, physiological, psychological and socio-cultural, experience that occurs between two individuals (Tarkka et al., 1999). That is, breast feeding can be influenced by the physical and psychological well-being of the woman and her baby, the breast feeding practices of women, the breast feeding behaviours of babies and maternal beliefs and motivation to breast feed. All these factors can be influenced by social and cultural mores of the mother's friends and family, professionals who support breast feeding and of the wider society and culture in which they live (Bick et al., 1998; Papinczak and Turner, 2000). The aim of this study was to examine the relationship between the cessation of breast feeding and a woman's psychological health.

Researchers investigating the relationship between maternal dysphoria and early breast feeding cessation have shown an association (Isabella and Isabella, 1994). Women with low levels of anxiety and dysphoria (using the Duke Health profile) have been found to have greater self-confidence in breast feeding and to have breast fed for a longer duration (Papinczak and Turner, 2000). In a survey of 906 women, Bick et al. (1998) found that women with high Edinburgh Postnatal Depression Scale scores (EPDS) were more likely to stop breast feeding within 3 months. Soo (1987) found that women who were no longer breast feeding at 1 month had higher anxiety scores (using State-Trait Anxiety Inventory [STAI] scale scores). These authors suggest that women who are stressed and distressed are less likely to cope with the difficulties associated with breast feeding and are therefore more likely to stop breast feeding.

In a survey of breast feeding women, Wambach (1998) found a moderate positive relationship between distress and breast feeding problems. Similarly, Amir et al. (1997) investigated the differences in EPDS scores of women who had nipple pain and those who did not. Women in a control group who did not have nipple pain had significantly lower EPDS scores than women who had nipple pain. The EPDS scores in the nipple pain group, after pain resolution, were similar to the control group and significantly lower than when the women had nipple pain. Similarly, distressed women in a Finnish sample also experienced more problems with breast feeding, and breast fed for a shorter period (Tarkka et al., 1999). Other studies have also found a relationship between breast feeding difficulties and early breast feeding cessation (Cox et al., 1987; Lowe, 1988; Bailey and Sherriff, 1992; Hailes and Wellard, 2000).

Qualitative researchers argue that the incongruity between women's expectations about breast feeding combined with their experience of early breast feeding problems leads to incremental disillusionment and cessation of breast feeding (Mozingo et al., 2000). However, when women's motivation and commitment to breast feed is taken into account, breast feeding difficulties do not always significantly influence breast feeding duration (Lawson and Tulloch, 1995; Cooke et al., 2003). That is, commitment to breast feed can influence a woman's ability to persevere with breast feeding problems and mediates to some degree the distress associated with these difficulties (Bottoroff, 1990; Schmied et al., 2001).

These findings can be interpreted in several ways. By far the most common interpretation assumes that psychological distress, regardless of whether it is associated with breast feeding difficulties or not, is one of the causes of early cessation of breast feeding. This interpretation is undoubtedly true for some women. Such an interpretation informs the development of programmes to support women who have depression, breast feeding problems, or both. An alternative interpretation can also be proposed; that is, women become distressed because they have stopped breast feeding earlier than intended (Papinczak and Turner, 2000). Qualitative researchers investigating the experience of breast feeding and breast feeding cessation suggest that, for at least some women, distress is caused by breast feeding cessation (Cooke, 1997; Schmied and Barclay, 1999; Hailes and Wellard, 2000; Mozingo et al., 2000).

Qualitative researchers have also suggested that a woman's evaluation of her breast feeding experience can be closely associated with her assessment of her ability to mother (Warden, 1988). One of the motivators for breast feeding seems to be the perception of being a ‘good mother’ (Schmied et al., 1999). The small number of participants in these qualitative studies makes it difficult to generalise the findings beyond the samples investigated. Nevertheless, investigators using larger quantitative studies have also suggested that exclusive breast feeding at 1 month is associated with adjustment to motherhood (Isabella and Isabella, 1994). Using a sample of 271 women, Tarkka et al. (2000) found that women coped better with breast feeding when they felt compelled as mothers to breast feed, felt society appreciated motherhood and thought breast feeding was very important to motherhood.

After interviewing mothers, Leff et al., 1994, Leff et al., 1994 developed the Maternal Breast feeding Evaluation Scale, and identified three sub-scales (Maternal Role Attainment, Infant Satisfaction/Growth and Lifestyle/Body Image). The Maternal Role Attainment sub-scale has been used as a measure of the degree to which breast feeding is related to maternal identity in this study. Maternal role attainment ‘is a process in which a mother integrates mothering behaviours into her established role so that she is comfortable with her identity as a mother’ (Mercer, 1985, p.198). The Maternal Role Attainment sub-scale (MRA) reflects the importance of breast feeding to maternal attachment, nurturing and confidence. Women with high breast feeding maternal role attainment believe that breast feeding is essential to their maternal identity, and report that breast feeding is associated with inner contentment, nurturing and being a good mother. Both the total score and the sub-scales of the of the Maternal Breast feeding Evaluation Scale have been found to have a positive relationship with initiation and duration of breast feeding (Leff et al., 1994, Leff et al., 1994; Riordan et al., 1994). Although beliefs about the importance of breast feeding for maternal role attainment may improve breast feeding outcomes, a breast feeding decision that is not consistent with those beliefs may be associated with negative psychological outcomes.

It is hypothesised that the effect of breast feeding problems on decisions about early breast feeding cessation is moderated by women's level of psychological distress and their beliefs about breast feeding and maternal role attainment. That is, women with breast feeding problems are less likely to stop breast feeding early if they have low levels of psychological distress and strong beliefs about breast feeding and maternal role attainment. It is also hypothesised that women can experience psychological distress as a result of breast feeding cessation, and that the level of psychological distress experienced after breast feeding cessation is higher for women who have strong beliefs about the importance of breast feeding to their maternal role attainment.

Section snippets

Method

In this paper, we describe an analysis of survey data gained from a cohort of women who birthed in three urban public hospitals in Sydney in 1999. It is part of research that investigated postnatal care and postnatal outcomes over a 6-month period. Hospital and university research ethics committees approved the study. Approval for access to potential participants was obtained from the Hospital Division of Maternity, and women were recruited from antenatal and booking clinics in the hospitals.

Sample

The demographic and birth characteristics of women who had completed the surveys are provided in Table 1.

Women were aged between 16 and 45 years. Most of them were English-speaking, married and employed during the pregnancy, with only 9% of the sample requiring a government pension. The sample was also highly educated, with 49% having tertiary level education. Fifty-two per cent of the sample was having their first baby, and only 61% of the sample reported having a normal pregnancy and

Discussion

The aim of this study was to examine the relationship between early breast feeding cessation, breast feeding problems, maternal beliefs about motherhood and breast feeding, and postnatal distress.

Acknowledgment

This research has been supported by an Australian Research Council Research grant.

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