Depression and its implications in breast feeding

Abstracts

OBJECTIVE: This study aimed at verifying the incidence of depressive symptoms in a group of mothers of children between 12 and 16 months in the municipality of São Leopoldo (RS, Brazil) and their associations with breast feeding and overall child development. METHOD: This study included 263 mothers who delivered at a hospital providing services to a population of low socioeconomic level. Depressive symptoms were assessed using Beck Depression Inventory. RESULTS: It was observed that 35.7% of mothers presented depressive symptoms. As to classification, 18.3% had mild, 11% moderate and 6.5% severe depression. Mothers without partners (prevalence ratio - PR = 1.70; IC95% = 1.20-2.38) and mothers from non-nuclear families presented more depressive symptoms (PR = 1.38; IC95% = 0.99-1.92). Exclusive breast feeding at 6 (PR = 1.86; IC95% = 0.94-3.68) and 12 months (PR = 1.80; IC95% = 1.26-2.58) was more frequent in the group of mothers without depressive symptoms. CONCLUSION: More attention should be given to women's mental health, considering the high prevalence of depressive symptoms in this population and the strong association with less breastfeeding time.

Depressive symptoms; mothers; children; breast feeding; development

OBJETIVO: O objetivo deste estudo foi avaliar a prevalência de sintomas depressivos num grupo de mães de crianças entre 12 e 16 meses do município de São Leopoldo (RS) e suas associações com tempo de aleitamento materno e aspectos do desenvolvimento da criança. MÉTODO: Foram avaliadas 263 mães de crianças recrutadas ao nascimento em uma maternidade que atende população de baixo nível socioeconômico. Os sintomas depressivos foram avaliados por meio do Inventário para Depressão de Beck. RESULTADOS: Foi observado que 35,7% das mães apresentaram sintomas de depressão. Quanto à classificação, 18,3% apresentaram depressão leve, 11%, depressão moderada, e 6,5%, grave. As mães sem companheiros (razão de prevalência - RP = 1,70; IC95% = 1,20-2,38) e provenientes de famílias não-nucleares apresentaram mais sintomas depressivos (RP = 1,38; IC95% = 0,99-1,92). As freqüências de aleitamento materno exclusivo por 6 meses (RP = 1,86; IC95% = 0,94-3,68) e aleitamento materno aos 12 meses (RP = 1,80; IC95% = 1,26-2,58) foram maiores no grupo de mães sem sintomas depressivos. CONCLUSÃO: É necessária maior atenção à saúde mental das mulheres, considerando a alta prevalência de sintomas depressivos nessa população e a forte associação com o menor tempo de aleitamento materno.

Sintomas depressivos; mães; criança; aleitamento materno; desenvolvimento

ORIGINAL ARTICLE

Depression and its implications in breast feeding

Márcia Regina Vitolo^I; Silvia Pereira da Cruz Benetti^II; Gisele Ane Bortolini^I; Angelice Graeff^II; Maria de Lourdes Drachler^III

^IGraduate Program in Medical Sciences, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre (FFFCMPA), Porto Alegre, RS, Brazil

^IIUniversidade do Vale do Rio dos Sinos (UNISINOS), São Leopoldo, RS, Brazil

^IIISchool of Allied Health Professions, University of East Anglia, Norwich, England

^{Correspondence}

ABSTRACT

OBJECTIVE: This study aimed at verifying the incidence of depressive symptoms in a group of mothers of children between 12 and 16 months in the municipality of São Leopoldo (RS, Brazil) and their associations with breast feeding and overall child development.

METHOS: This study included 263 mothers who delivered at a hospital providing services to a population of low socioeconomic level. Depressive symptoms were assessed using Beck Depression Inventory.

RESULTS: It was observed that 35.7% of mothers presented depressive symptoms. As to classification, 18.3% had mild, 11% moderate and 6.5% severe depression. Mothers without partners (prevalence ratio – PR = 1.70; IC95% = 1.20–2.38) and mothers from non–nuclear families presented more depressive symptoms (PR = 1.38; IC95% = 0.99–1.92). Exclusive breast feeding at 6 (PR = 1.86; IC95% = 0.94–3.68) and 12 months (PR = 1.80; IC95% = 1.26–2.58) was more frequent in the group of mothers without depressive symptoms.

CONCLUSION: More attention should be given to women's mental health, considering the high prevalence of depressive symptoms in this population and the strong association with less breastfeeding time.

Keywords: Depressive symptoms, mothers, children, breast feeding, development.

Introduction

Several studies on maternal affective state in the first year of the baby's life indicate that occurrence of depressive states is associated with changes in child development in the neurological, cognitive and emotional areas,^1–5 with lasting effects throughout a child's development, which may last until adolescence.⁶ Essentially, depressive states interfere with many aspects of maternal affective state and functioning and, consequently, affect the quality of mother–baby relationship.

With regard to maternal behavior and sensitivity, there are difficulties in affective changes, establishment of insecure attachment^5,7 and maternal inability of being sensitive to the baby's cry.⁸ Depressive mothers also had more difficulties in engaging in health cares, both personal and baby's (higher prevalence of tobacco use, nonadherence to baby's health cares and negligence),⁹ breast feed their babies less frequently, interrupt breast feeding earlier and are less confident about their ability to breast feed.¹⁰

In general, most studies identify prevalence of 10–15% in cases of maternal depression in the child's first year of life.^4,11–13 Cases of maternal depression are often not identified by health professionals,² and this situation intensifies the severity of this problem. Therefore, population studies investigating prevalence rates and development factors associated with depression are needed to obtain data and indexes for an early detection and knowledge of health professionals about this problem. Therefore, this study aimed at verifying the prevalence of depressive symptoms in a group of mothers of children aged between 12 and 16 months in the municipality of São Leopoldo (RS, Brazil) and the possible associations with time of breast feeding, general child's development, environmental and relational conditions between mother/child and sociodemographic characteristics, such as schooling, marital status, job situation and age.

Method

This study is part of a larger investigation, carried out in Southern Brazil, about the impact of implementing a nutritional guidance program – "Ten Steps to Healthy Eating"¹⁴ – on a cohort of children during the first year of life, about eating practices, health and development conditions. This study and its detailed methodology have already been published.¹⁵ Sociodemographic data of participating families were also assessed. Nuclear family was defined as that composed of father, mother and children. When there were more family members in the same family nucleus, such family was considered non–nuclear. The children who participated in the study were born at a municipal public hospital. Newborns with birth weight higher than 2,500 g and gestational age higher than 37 weeks were identified. Exclusion criteria were HIV–positive mothers, congenital malformation and multiple childbirth. After identification of newborns who met the criteria, the mothers were explained about the study and invited to participate.

Calculation of sample size in the first project was based on a frequency of exclusive breast feeding (EBF) until 4 months of 21.6% in the control group and estimated a difference of 65% in the frequency of this practice between groups after the intervention. Other parameters for this calculation were 80% power and 95% confidence level, which determined a sample size of 177 children in each group, in a total of 354 children. Considering a loss preview of 25%, 500 mother/child pairs were recruited to reach sample size. By the end of the first year of life, 397 children completed the study. Detailed data about losses were previously published.¹⁵ However, assessment of depression occurred after 129 children had already been assessed. The sample of 263 mothers who participated in the investigation on depression had statistical power to test the hypothesis that depression interferes with breast feeding, considering the prevalence of 51.1% of children being breast fed in mothers who presented depressive symptoms and 69.6% of children being breast fed in mothers who did not have depressive symptoms by the end of the first year. Required sample size would be 238 children, with 80% power and 95% confidence level. Visits were performed between October 2001 and June 2002 and were carried out by nutrition students trained by researchers in psychology and nutrition.

Maternal depression

To assess presence and severity of maternal depression, the Beck Depression Inventory was used, which is an instrument easy to be applied and that assesses behavioral manifestations of depression in the week prior to application.¹⁶ In this study, we used a cut–off point higher or equal than 12 to categorize depressive symptoms.

Development assessment

The Denver II Developmental Screening Test (DDST–R)¹⁷ was used, comprehending assessment of gross motor, adaptive motor, personal–social and language development, from zero to 6 years of age. Suspicion of wide motor development delay was considered when the child was not able to correctly perform an aspect that 75% of the children in the reference population, with lower age, could. These estimates were based on a standardization of aspects of this test for Brazilian children in a study on the development of children aged between zero and 5 years in Porto Alegre, Brazil.¹⁸ Choice of aspects corresponded to all activities performed by at least 75% of the children aged 12 months.

Home Observation for the Measurement of the Environment (HOME)

The HOME inventory is an instrument conceived to measure the quality and quantity of social, emotional and cognitive support available for children in their family environment.^19,20 In the present study, measurements of maternal stimulation and involvement were used. Two classification categories were considered by using a cohort criterion based on frequency of positive maternal behaviors in relation to interaction and involvement with the child and also in the number of assessed items (11 items): unsatisfactory – mothers with five or less (≤ 5) positive behaviors out of 11; satisfactory – mothers with more than five (> 5) positive behaviors.

Family structure

Families that were constituted by father, mother, child and/or siblings were classified as nuclear family. Families that had other people living in the same house, such as grandparents, uncles, aunts and other relatives or family friends, were classified as non–nuclear. Those with absence of father or mother were also classified as non–nuclear.

Breast feeding

The data on breast feeding were obtained using the following criteria: EBF – breast milk without water, tea or any other food; and breast feeding – presence of breast milk independent of other foods.

Ethical aspects

The research project "Implementation and Assessment of the Impact of the Program for Promoting Healthy Eating" for children aged less than 2 years was approved by the Research Ethics Committee of Universidade Federal do Rio Grande do Sul.

Statistical analysis

All quantitative data were inserted in the Epi–Info software, version 6.04, with double data input for validation. The data were organized according to SPSS analyses, and the analyses were performed based on the necessary corrections, considering the results obtained by Pearson's chi–square test and Fisher's exact test (identified in the table) and prevalence ratios (PR) to verify which variables were associated with maternal depressive symptoms. A 95% confidence interval (CI95%) was used, considering rejection of the null hypothesis in 5% (p < 0.05).

Results

Of the 268 mothers selected to participate in the study, five were not at home for the interview, and the child was under the care of another person. Of all the mothers, 94 (35.7%) had depressive symptoms; 48 were classified as mild (18.3%), 29 as moderate (11%), and 17 and severe (6.5%).

Level of total family income, expressed in minimum wages, showed that 2/3 of the families lived with three or less minimum wages. Maternal schooling level was lower than 8 years in 50% of the cases. Concerning family structure, there was more frequency of cases with depressive symptoms in categories of mothers without partners (p = 0.007) and non–nuclear families (p = 0.068) (Table 1).

Assessment of the EBF period showed similar frequencies between the groups of mothers with depressive symptoms and the group of mothers with no depressive symptoms for a period lower than 4 months (p = 0.134). However, frequency of EBF was significantly higher for a 6–month period in the group of mothers without depressive symptoms, when compared with the group with depressive symptoms (p = 0.045). As to presence of breast feeding in the last home visit, there was lower frequency of mothers breastfeeding their children at 12 months of age in the group with depressive symptoms, when compared with the group without symptoms (p = 0.001).

Considering children's behaviors at 12 months of age, there were no significant differences between the groups of mothers with and without depression in psychosocial, language and motor development in children. In terms of environment stimulation, both groups presented similar behaviors in relation to the child, and there were no differences between the mothers with depressive symptoms and those without presence of symptoms (Table 2).

Maternal involvement, however, was different in the group of mothers with depressive symptoms, with a larger number of mothers classified as "unsatisfactory" in relation to positive behaviors observed in mother–child interaction (Table 2).

Discussion

The identification of maternal depressive symptoms during pregnancy and in the first year of the baby's life is essential to provide preventive actions focused on mother–child health. An extensive review of the main studies on maternal depression and the mother–baby relationship indicate that even minor depressive situations can be potentially harmful to the baby's health.^1,7

Studies carried out in developed countries report maternal depression rates of 10–15% in the child's first year of life.^2,11 Another study found a 12% rate in a group of 434 mothers who had 12–month–old babies.¹² However, in South Africa, higher values were found in an investigation on the prevalence of puerperal depression and disorders in the mother–child relationship in 147 women with 2–month–old babies. The rate of major depression was 34.7% in the group of assessed mothers. The authors considered that this value, which is three times higher than samples from developed countries, follows the same tendency in other studies using populations at economic and social risk, stressing the importance of investigating these groups.² Similarly, in an investigation carried out in India, 23% of the women around the second month of pregnancy had depressive symptoms and half of them still maintained the symptoms 6 months later, suggesting that maternal depression could be considered a public health problem.²¹ Another study also mentions rates around 30% in Southern Asia.²²

In Brazil, maternal depression rates equally reflect the data reported in international studies. A study performed with a group of 77 women from São Paulo, considering a period ranging between 3 and 6 months after delivery, a rate of nearly 33% of mothers with depressive symptoms was identified. However, there was no association between depression and social support.²³ Cruz et al.²⁴ identified maternal depression rates of 37.1% in a cross–sectional study including 70 puerperal women receiving care at units of the Family Health Program. In addition, presence of husband's social support was associated with lower incidence of depressive symptoms. Finally, Moraes et al.²⁵ reported prevalence of 19.1% in a sample of 410 mothers, associated with family income, child's gender and desire to interrupt pregnancy.

In this study, the rate of 35.7% of the mothers with depressive symptoms is expressive, even if analysis is limited to moderate and severe classifications, when the rate is 17% of the sample. Furthermore, social support was an important factor for the manifestation of depression, and separated mothers or those with no partners and from non–nuclear families had higher frequency of depressive symptoms.

The lack of support by partners is a frequent characteristic in many studies²² and in samples from different regions, such as in investigations carried out in Germany²⁶ and South Africa.² In both cases, lack of support was associated with higher frequency of maternal depression, which confirms the tendency in the literature in identifying conflictive family relationships and lack of family and partner support as contextual factors associated with cases of maternal depression.²

Time of exclusive and total breast feeding was also different at 6 months and at 12 months in the groups of mothers with depressive symptoms. In both situations, there was lower frequency of breast feeding in groups of mothers with depression. A study including 1,745 mothers in Australia also demonstrated that depression was associated with early weaning. The sooner the depressive episode, the lower the breast feeding time, which stresses the negative impact of depression on maternal engagement in breast feeding practices.²⁷

This study did not corroborate the hypothesis that maternal depression affects children's development. Some factors could be related to this finding, such as sample size, child's age and instrument used. Cicchetti et al.²⁸ did not identify differences in cognitive development (Bailey test) in a group of 97 children, at 18 months of age, whose mothers were identified as depressed, and in a control group of 61 children whose mothers had no current or previous history of mental disorder. However, later on, at 3 years of age, the group of children with depressed mothers that had not been submitted to psychotherapy had lower intelligence scores in Wechsler Intelligence Scale. Another important focus to be stressed in that study was the lower manifestation of emotions in relation to the child in mothers with depressive symptoms. Depressed mothers reported lack of support, isolation, fatigue and physical health problems as factors contributing to a depressive state.²⁹ Such situations can justify the lower interest and predisposition in manifesting tenderness towards the child.

In summary, this study allows us to conclude that it is necessary to provide more attention to women's mental health, considering the high prevalence of depressive symptoms in the assessed group and the strong association with lower breast feeding time, a situation that implies higher risk to the child's health, especially in less privileged socioeconomic classes. Family structure was important in the context of depressive symptoms, suggesting that this aspect should be considered by professionals in charge of maternal and child health care.

Therefore, development of protocols with mothers and pregnant women dealing with depression under a multidimensional perspective is relevant, taking into account the different levels of this problem, from individual situation to relationship with the father and relatives. In addition, the fact that most cases are not detected and remain without treatment should be stressed, since maternal depression in vulnerable groups is a severe health problem that requires early identification. This is the only form of providing early detection and development of actions that will certainly have an impact on the quality of children development.

References

Received April 19, 2007.

Accepted May 6, 2007.

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Publication Dates

• Publication in this collection
  06 Sept 2007
• Date of issue
  Apr 2007

History

• Received
  19 Apr 2007
• Accepted
  06 May 2007