Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Mikayla Crookshanks

Bon Secours Memorial College of Nursing

NUR 4122: Nursing Research

Christine Turner, PhD

April 5, 2018

“I pledge…”
INTEGRATIVE LITERATURE REVIEW 2

Abstract

Purpose: The purpose of this integrative review is to identify a relationship between

breastfeeding, or lack thereof, and symptoms of postpartum depression.

Background: Postpartum depression stands out as one of the most common postpartum

psychological complications that new mothers experience. While the relationship between

breastfeeding and postpartum depression is unclear, it is certain that both have numerous

physical and psychological effects on mothers and their newborns.

Method: The research for this integrative review was collected from online databases. The

articles chosen are quantitative studies that resulted in data to support different approaches to the

discussed topic. The information from these articles was then used to determine the degree to

which postpartum depression correlates with the act of breastfeeding.

Limitations: The main limitation the author faced was a lack of experience and previous

knowledge in composing an integrative literature review.

Results and Findings: The evidence collected from the articles used all support the existence of

a relationship between postpartum depression and breastfeeding. However, the specifics of said

relationship differ in some articles. Overall, it is agreed that both aspects are becoming

increasingly important in the physical and emotional wellbeing of postpartum mothers.

Implications and Recommendations: The ability and willingness of mothers to successfully

breastfeed their newborns has been correlated with a decreased prevalence of postpartum

depression. It is recommended that further research be conducted on this topic to further confirm

the relationship and explore various aspects of it.

INTEGRATIVE LITERATURE REVIEW 3

Integrative Literature Review

The purpose of this integrative literature review is to identify and discuss a relationship

between the implementation of breastfeeding and the prevalence of postpartum depression (PPD)

in new mothers. The postpartum period for new mothers is consider one of the most delicate

times in a woman’s life because numerous aspects of it are changing both physically and

psychologically, which can have a positive or negative effect on mental and emotional wellbeing

(Vieira Abuchaim, Torquato Caldeira, Moraes Di Lucca, Varela, & Aparecida Silva, 2016). An

average of about 13% of women experience symptoms of postpartum depression during the first

14 weeks after giving birth (Borra, Iacovou, & Sevilla, 2014). However, the impact

breastfeeding, or lack thereof, makes on a postnatal woman’s mental and emotional health is not

completely understood or defined.

The psychological disappointment caused by unmet expectations is one possible

causation of the proposed relationship of breastfeeding to PPD (Gregory, Butz, Ghazarian,

Gross, & Johnson, 2015). This is a problem because not only do feelings of anxiety and

depression take an emotional toll on the mother and her long-term mental health, but it can also

affect how their child develops cognitively, socially, and physically (Borra, Iacovou, & Sevilla,

2014). The aim of this review is to examine the researcher’s PICOT question: For childbearing

women, does breastfeeding reduce the risk of postpartum depression compared to bottle/formula

feeding?

Design & Methods

The focus of this integrative review is five articles collected from online databases. To

begin, the researcher conducted an engine search of EBSCO’s Nursing Center Reference Plus

and PubMed. The search words used were postpartum depression, breastfeeding, unmet
INTEGRATIVE LITERATURE REVIEW 4

expectations, and postpartum mental health. Using these keywords, over 40,000 articles were

found. From there, the researcher narrowed down the articles by publication year, language,

peer-reviewed, access to full text, and relevance to the PICOT question. When considering

publication year, the articles were limited to those that had been published between 2012 and

2018. It was also important that these articles were written in the English language, peer-

reviewed, and that the researcher could gain access to the full text.

Lastly, articles were further excluded based on their level of relevance to the PICOT

question. To be considered relevant, the aim or purpose of the chosen articles had to be to

explore the possible relationship between breastfeeding and postpartum depression and/or its

aspects. In order to find data in support of the hypothesis or against it, the articles needed to be

quantitative to include statistics and percentages. After all of these exclusions, five articles were

chosen in which quantitative studies were conducted and sufficient results were yielded (Borra et

al., 2014; Gregory et al., 2015; Silvia et al., 2016; Vieira Abuchaim et al., 2016; Ystrom, 2012).

Findings

The resulting data and findings of the articles all support a cause and effect relationship

between symptoms of postpartum depression and the ability or inability of breastfeeding (Borra

et al., 2014; Gregory et al., 2015; Silvia et al., 2016; Vieira Abuchaim et al., 2016; Ystrom,

2012). A summary of each of the five articles is included at the end of this paper in Table 1 –

Article Evaluation. The following is a brief summary of each of the articles, the included studies,

and their findings.

In a quantitative study conducted by Borra et al. (2014), the authors aimed to find

evidence to support their hypothesis that the relationship between postpartum depression and

breastfeeding depends on each mother’s breastfeeding intentions. The framework for their
INTEGRATIVE LITERATURE REVIEW 5

research was based on data collected from the Avon-Longitudinal Survey of Parents and

Children (ALSPAC) that was conducted in Bristol, England around the early 1990s. The sample

size consisted of 14,541 pregnant mothers which resulted in 14,676 fetuses.

Borra et al. (2014) collected data by administering questionnaires to both parents

prenatally, which included asking mothers how they planned to breastfeed. They were then asked

at several postnatal points how they were actually feeding their babies. They were also evaluated

for symptoms of postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS)

at 8 weeks, 8 months, 21 months, and 33 months. The EPDS is a screening tool for PPD that

consists of 10 questions with answers ranging from 0-3 points each. The points are then added up

and a score of 12 or greater is considered indicative of depressive symptoms.

According to Borra et al. (2014), data showed that 80% of the mothers in this study

initiated breastfeeding and 74% continued to breastfeed for 1 week or more. However, by 4

weeks postnatal only 56% of mothers were breastfeeding at all and only 43% were exclusively

breastfeeding. Of the 14,541 mothers, between 9 and 12% experienced symptoms of postnatal

depression. The conclusive results of this study showed that breastfeeding decreases the risk PPD

in mothers who intended to breastfeed. The positive effects of breastfeeding on mothers’ mental

health were highest at 8 weeks postnatal as opposed to 8 months.

In another quantitative study conducted by Gregory et al. (2015), the purpose was to

explore whether meeting prenatal expectations for exclusive breastfeeding contributed to

symptoms of postnatal depression. As for the framework of this study, the authors used the

Infant Feeding Practices Study II (IFPSII) which took place from 2005 to 2007 and was

conducted by the US Food and Drug Administration and the Centers for Disease Control and
INTEGRATIVE LITERATURE REVIEW 6

Prevention. After many rounds of exclusions, the final sample size consisted of 1501 prenatal

women who intended to exclusively breastfeed their newborns.

Gregory et al. (2015) collected their data by surveying the mothers at 2 months

postnatally to assess their met or unmet breastfeeding expectations. They also evaluated them for

any symptoms of depression during this time. These researchers used the Edinburgh Postnatal

Depression Scale (EPDS) as well but they considered a score of 10 or higher to be indicative of

postpartum depression. After completing a cross-sectional data analysis, Gregory et al. (2015)

discovered that the results support their hypothesis that mothers’ unmet breastfeeding

expectations do in fact contribute to symptoms of PPD. When the researchers conducted the 2-

month survey, they found that 82.6% of mothers were still breastfeeding, 39.2% had met their

expectations, and 23% received a score of 10 or higher on the EPDS, indicating PPD.

Next is a cross-section quantitative study conducted by Silvia et al. (2017). This study

aims to verify the relationship between PPD and the practice of exclusive breastfeeding (EBF) in

mothers up to 3 months postnatal. Researchers used data collected from the survey “Evaluation

of prenatal, birth care and care of infants under one year old in the Legal Amazon and the

Northeast regions, Brazil”. This survey was conducted in June 2010 during a child vaccine

campaign in Brazil. The sample size was 2,259 mothers and their infants.

Silvia et al. (2017) gathered their data by distributing forms with questions pertaining to

family characteristics and their intention to exclusively breastfeed (ESF). An interview was then

conducted in which mothers were assessed on their ability to ESF and their symptoms of

postnatal depression using the EPDS. Results showed that about 12% of mothers interviewed

experienced PPD. According to the data, mothers with symptoms of PPD have a 1.63-fold higher

chance of EBF difficulty. This article proved that not only can inability to breastfeed cause PPD,
INTEGRATIVE LITERATURE REVIEW 7

but symptoms of PPD can also impede a mother’s ability to successfully breastfeed. Considering

this research, it can be assumed that maternal mental health is an important determinant of early

breastfeeding cessation.

The fourth article used is a cross-sectional quantitative study conducted by Vieira

Abuchaim et al. (2016). In this study, the researchers aimed to analyze the prevalence of

postpartum depression and levels of self-efficacy for breastfeeding among their participants.

They also wanted to explore the possibility of a cause and effect relationship between PPD and

women’s self-efficacy to breastfeed. The framework for this study was based off of Bandura’s

theory of self-efficacy which, in layman’s terms, is the level of belief postnatal women have in

their ability to successfully breastfeed their children. The sample size consisted of 208 puerperal

women and took place at the Incentive and Support Center for Breastfeeding and Human Milk

Bank in San Paulo, Brazil.

Vieira Abuchaim et al. (2016) used the Breastfeeding Self-Efficacy Scale (BSES) to

evaluate mothers’ confidence in their ability to breastfeed. The BSES consists of 33 items

separated into categories of technical management of breastfeeding and personal thoughts or

opinions. They also used the Edinburgh Postnatal Depression Scale (EPDS) to detect symptoms

of postnatal depression and set a cutoff score of 10 as an indication for PPD.

According to Vieira Abuchaim et al. (2016), their results showed that 31.25% of the

women in this study experienced PPD symptoms. As for their self-efficacy for breastfeeding

levels, 39.9% had medium levels, 36.06% had high, and 24.04% had low levels. Prenatal

mothers with medium or high self-efficacy decreased the EPDS score by 27.4%-38.8%. The data

also showed that high EPDS scores decreased mothers’ self-efficacy score by 11.84 points and

that exclusive breastfeeding increased the self-efficacy score by 14.86 points. All of this data is
INTEGRATIVE LITERATURE REVIEW 8

supportive of a cause and effect relationship between women with high or medium levels of

confidence in their abilities to breastfeed and their decreased risk of complications and PPD. The

relationship goes both ways in that women with a high EPDS score, show reduced levels of

confidence or self-efficacy to breastfeed.

In a longitudinal cohort study by Ystrom (2012), the author’s intention was to explore

whether breastfeeding cessation increases the prevalence of feelings of anxiety and depression

during the time period between pregnancy and 6 months postpartum. The author also wanted to

investigate if symptoms of postpartum depression were more evident in individuals already

suffering with anxiety and depression before birth of their infant. The Norwegian Mother and

Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health was used as

the framework for this study. The sample size consisted of 42,225 prenatal mothers.

To collect data, Ystrom (2012) sent mothers questionnaires at 17 weeks pregnancy, 30

weeks pregnancy, and 6 months postpartum. The prenatal questionnaires at 17 and 30 weeks’

gestation were used to assess for preexisting symptoms of anxiety and depression and their

intentions to breastfeed their newborns. The 6-month postpartum questionnaire was used to

collect month by month details of how the mothers fed their newborns. This questionnaire also

included a shortened version of the Hopkins Symptom Checklist (SCL-8) which is a self-

reporting survey used to assess for symptoms of anxiety and depression.

Results of the study conducted by Ystrom (2012) showed that at 6 months postpartum,

15.1% of mothers were still exclusively breastfeeding, 68.8 were using mixed forms of feeding

such as formula and breastmilk, and 16.1% were not breastfeeding at all. When these mothers

were assessed using the SCL-8, the average score in mothers who were exclusively breastfeeding

was 1.22. Scores for mothers who were mixed feeding their newborns were slightly higher at
INTEGRATIVE LITERATURE REVIEW 9

1.24 but non-breastfeeding mothers received the highest score at 1.31. Using this data, the author

concluded that breastfeeding is related to a reduction in anxiety and depression and that

unintended breastfeeding cessation correlates with higher levels of anxiety and depression. The

results also showed that women who have preexisting high levels of anxiety and depression are

more at risk than others for an increase in those symptoms after breastfeeding cessation.

Discussion/Implications

The articles chosen for this review indicate a definite relationship between breastfeeding

and the symptoms of postpartum depression. The next section includes a discussion about the

implications of the articles. It is organized into the following categories: maternal outcomes and

clinical interventions. These categories are common themes found in the articles as well as

important aspects related to the author’s PICOT question.

Maternal Outcomes

Maternal outcomes of breastfeeding, or lack thereof, was discussed in all five articles in

relation to mental and emotional wellbeing (Borra et al., 2014; Gregory et al., 2015; Silvia et al.,

2016; Vieira Abuchaim et al., 2016; Ystrom, 2012). Among these outcomes, postpartum

depression in mothers was one of the most evident and relevant to the author’s PICOT question.

A common tool used to assess for symptoms of PPD was the Edinburgh Postnatal Depression

Scale (EPDS) (Borra et al., 2014; Gregory et al., 2015; Silvia et al., 2016; Vieira Abuchaim et

al., 2016). However, one study by Ystrom (2012) used a shortened version of the Hopkins

Symptom Checklist (SCL-8). By utilizing these tools and their various data collection methods,

the studies were able to identify many differing relationships between breastfeeding and

postpartum depression. The consensus for all the articles was that mothers need more resources

such as lactation consults and increased education. It is also important to enhance support
INTEGRATIVE LITERATURE REVIEW 10

systems because of the negative impact unmet expectations can make on maternal mental and

emotional health.

Clinical Interventions

All of the articles and studies discussed in this integrative review have implications for

clinical interventions and improvements (Borra et al., 2014; Gregory et al., 2015; Silvia et al.,

2016; Vieira Abuchaim et al., 2016; Ystrom, 2012). Education is the key to improving

postpartum maternal mental and emotional wellbeing. In regard to postpartum depression

specifically, these articles highlight the need for increased screening, support resources, and

education for mothers. The author recommends future research to collect in-depth details about

personality factors that can affect coping. Studies should also be conducted to test various coping

strategies and support methods for mothers at risk for postpartum depression.

Limitations

While conducting this integrative literature review, the author encountered many

limitations. The most challenging one was the author’s inexperience and lack of previous

knowledge related to the integrative review process and how to conduct it. Combined with the

author’s lack of relevant credentials or nurse licensure, the author had a hard time providing

insight into such a complicated but prevalent problem in today’s healthcare.

In regard to study limitations, the majority of the articles found were quantitative reviews

of data collected from other surveys. Due to the lack of diversity in types of articles and the

publication year constraints, this review does not provide a comprehensive review of all the

literature available on the subject. Each of the articles had their own limitation such as

complicated wording the author had difficulty understanding and charts the average reader would
INTEGRATIVE LITERATURE REVIEW 11

not be able to interpret. All of these limitations should be considered and addressed in further

research.

Conclusions

The evidence collected from these articles all supports a relationship between postpartum

depression and breastfeeding (Borra et al., 2014; Gregory et al., 2015; Silvia et al., 2016; Vieira

Abuchaim et al., 2016; Ystrom, 2012). However, some of the articles discuss the relationship in

different degrees and using varying concepts. Even though there has yet to be a concrete

definition of the correlation, these studies raise awareness of the need for research and

interventions to aid this growing maternal healthcare problem. In relation to the PICOT question,

whether breastfeeding decreases the risk of postpartum depression as opposed to formula/bottle

feeding all depends on the mother’s prenatal intentions and mental/emotional wellbeing. For

these reasons, the risk of postpartum depression is highly individualized and varies from mother

to mother.
INTEGRATIVE LITERATURE REVIEW 12

References

Borra, C., Iacovou, M., & Sevilla, A. (2015). New evidence on breastfeeding and postpartum

depression: The importance of understanding women’s intentions. Maternal & Child

Health Journal, 19(4), 897-907. doi: 10.1007/s10995-014-1591-z

Gregory, E. F., Butz, A. M., Ghazarian, S. R., Gross, S. M., & Johnson, S. B. (2015). Are unmet

breastfeeding expectations associated with maternal depressive symptoms?. Academic

Pediatrics, 15(3), 319-325. doi:10.1016/j.acap.2014.12.003

Silvia, C. S., Lima, M. C., Sequeira-de-Andrade, L. A., Oliveria, J. S., Monterio, J. S., Lima, N.

M.,… & Lira, P. I. (2016). Association between postpartum depression and the practice

of exclusive breastfeeding in the first three months of life. Jornal De Pediatria, 93(4),

356-364. doi: 10.1016/j.jpedp.2016.08.005

Vieira Abuchaim, E. S., Torquato Caldeira, N., Moraes Di Lucca, M., Varela, M., & Aparecida

Silva, I. (2016). Postpartum depression and maternal self-efficacy for breastfeeding:

Prevalence and association. Acta Paulista De Enfermagem 29(6), 664-670. doi:

10.1590/19820194201600093

Ystrom, E. (2012). Breastfeeding cessation and symptoms of anxiety and depression: A

longitudinal cohort study. BMC Pregnancy & Childbirth, 12(1), 36-41. doi:

10.1186/1471-2393-12-36
Running head: INTEGRATIVE LITERATURE REVIEW 13

TABLE 1 – ARTICLE EVALUATION

First Author  Gregory, E. F., Butz, A. M., Ghazarian, S. R., Gross, S. M., & Johnson, S. B. (2015). Are unmet
(Year)/Qualifications breastfeeding expectations associated with maternal depressive symptoms?. Academic
Pediatrics, 15(3), 319-325. doi:10.1016/j.acap.2014.12.003
Background/Problem  Studies and research show a relationship between met or unmet breastfeeding expectations and
Statement postpartum depression (PPD). However, the true nature of the relationship and the underlying
correlation remains undefined.
Conceptual/theoretical  Infant Feeding Practices Study II (IFPSII) done by the US Food and Drug Administration and
Framework the Centers for Disease Control and Prevention between the years 2005 to 2007.
 Researchers wanted to prove that unmet expectations for breastfeeding can lead to postpartum
depression in mothers
Design/  Quantitative review of the study conducted and results yielded from the IFPSII
Method/Philosophical
Underpinnings

Sample/ Setting/Ethical  1501 prenatal women who intended to exclusively breastfeed their newborns and had specific
Considerations goals
 Women who did not attempt to breastfeed or did not complete the 2-month survey were
excluded from the study and its data
 Authors did not discuss whether participants remained anonymous or not
Major Variables Studied  Postpartum depression symptoms
(and their definition), if  Meeting mothers’ prenatal breastfeeding expectations
appropriate

Measurement Tool/Data  The Edinburgh Postnatal Depression Scale (EPDS) – screening tool consisting of 10 criteria
Collection Method with assigned points used to identify women who may need further evaluation for postnatal
depression. Researchers chose a score of 10 or higher to be indicative of depressive symptoms.
 Researchers – surveyed mothers at 2 months postnatal to evaluate their met or unmet
breastfeeding expectations and use the EPDS to screen for depressive symptoms
Data Analysis  Cross-sectional data analysis of link between the mothers’ met or unmet breastfeeding goals and
their scoring on the EPDS
INTEGRATIVE LITERATURE REVIEW
Findings/Discussion
Appraisal/Worth to practice
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
14
 When researchers conducted the 2-month survey, they found 82.6% of mothers were still
breastfeeding, 39.2% had met their breastfeeding expectations, and 23% received a score of 10
or higher on the EPDS, indicating PPD.
 The study supports the hypothesis that mothers’ unmet breastfeeding expectations do in fact
contribute to symptoms of PPD.
 Considering mothers’ breastfeeding expectations can help predicate experiences of symptoms
related to postpartum depression.
 Borra, C., Iacovou, M., & Sevilla, A. (2015). New evidence on breastfeeding and postpartum
depression: The importance of understanding women’s intentions. Maternal & Child Health
Journal, 19(4), 897-907. doi: 10.1007/s10995-014-1591-z
 Postnatal depression can have long-term effects of mothers’ mental health, as well as their
babies’ development socially, cognitively, and physically.
 The relationship between breastfeeding and its influence of symptoms of PPD is not clearly
defined by previous research.
 Avon Longitudinal Survey of Parents and Children (ALSPAC) which took place in Bristol,
England around the early 1990s.
 Researchers chose to explore the hypothesis that the relationship between breastfeeding and
postnatal mental health of mothers depends on the mothers’ breastfeeding intentions.
 Mothers were asked prenatally how they planned to feed their babies for the first 4 weeks
following delivery. They were then asked at several points how they were actually feeding.
 Mothers were also surveyed using the EPDS at 8 weeks, 8 months, 21 months, and 33 months
postnatal to evaluate for symptoms of PPD.
 The sample size consisted of 14,541 pregnant mothers which resulted in 14,676 fetuses. Of
these fetuses, 14,062 were live births and 13,988 babies were still alive at 1 year old.
 The ALSPAC Law and Ethics Committee and the Local Research Ethics Committees granted
the researchers ethical approval to conduct this study.
 Whether mothers intended to breastfeed or not
 If breastfeeding was initiated
 Duration of breastfeeding
 Maternal mental health during pregnancy
INTEGRATIVE LITERATURE REVIEW
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author
(Year)/Qualifications
Background/Problem
Statement
15
 Scoring on the EPDS postnatally
 The Edinburgh Postnatal Depression Scale (EPDS) – screening tool for PPD consisting of 10
questions with four possible answers each and assigned points. Researchers considered a score
of greater than 14 for prenatal mothers and greater than 12 for postnatal mothers to indicative of
depressive symptoms.
 Data was collected via self-answered questionnaires given to both parents.
 Prenatal: Symptoms of depression were evident in 7% of mothers at 18 weeks pregnancy and
8% at 32 weeks pregnancy.
 Results also showed that 9-12% of mothers showed symptoms of depression postnatally.
 Breastfeeding decreases the risk of PPD in mothers who intended to breastfeed. However, it
increased the risk in mothers who did not intend to breastfeed but ended up breastfeeding
anyways.
 The positive effects on mothers who met their breastfeeding expectations was highest at 8
weeks postnatally as opposed to 8 months where it was weaker.
 In terms of prenatal depression, mothers without symptoms who planned to breastfeed and did
showed lower risks for PPD.
 This study shows the importance of providing excellent lactation consults and education to
mothers wishing to breastfeed.
 The results also underline the importance of support for mothers who are unsuccessful in their
breastfeeding intentions because of the possible negative impact it can take on them.
 Vieira Abuchaim, E. S., Torquato Caldeira, N., Moraes Di Lucca, M., Varela, M., & Aparecida
Silva, I. (2016). Postpartum depression and maternal self-efficacy for breastfeeding: Prevalence
and association. Acta Paulista De Enfermagem 29(6), 664-670. doi:
10.1590/19820194201600093
 The puerperium period is considered one of the most delicate times in a women’s life because
her body changes both physically and psychologically and these changes directly influence her
mental and emotional stability.
 Postpartum depression (PPD) stands out by effecting 13%-19% of puerperal women in
developed countries. However, the risk between breastfeeding and postnatal depression is
inconclusive.
INTEGRATIVE LITERATURE REVIEW 16

Conceptual/theoretical  Bandura’s theory of self-efficacy – in layman’s terms, the level of belief of postnatal women in
Framework their ability to successfully breastfeed their child.
 The aim of this study is to explore the relationship between mothers’ level of self-efficacy to
breastfeed, their success in breastfeeding, and symptoms of PPD.
Design/  Cross-sectional study of data collected at the Incentive and Support Center for Breastfeeding
Method/Philosophical and Human Milk Bank during the time period of July 2013 to April 2016
Underpinnings

Sample/ Setting/Ethical  The sample size consisted of 208 puerperal women.

Considerations  The study took place at the Incentive and Support Center for Breastfeeding and Human Milk
Bank in San Paulo, Brazil.
 The women that participated in this study all signed an Informed Consent form.
Major Variables Studied  Puerperal women’s level of self-efficacy for breastfeeding
(and their definition), if  The women’s actual ability to breastfeed
appropriate  The same women’s postnatal scoring on the EPDS

Measurement Tool/Data  The Edinburgh Postnatal Depression Scale (EPDS) – instrument used to detect depressive
Collection Method symptoms in postnatal mothers. It is composed of 10 questions with four possible responses
each and assigned points. The scoring ranges from 0-30 with 10 as a cutoff for indication of
PPD symptoms.
 The Breastfeeding Self-Efficacy Scale (BSES) – scale used to evaluate technical management of
breastfeeding and personal thought/opinion. There are 33 questions with answers ranging from
1-5 points each.
Data Analysis  31.25% of the women in this study experienced PPD symptoms
 Self-efficacy for breastfeeding: 39.9% had medium, 36.06% had high, and 24.04% had low
 Prenatal mothers with medium or high self-efficacy decreased the EPDS score by 27.4%-38.8%
 High EPDS scored decreases mother’s self-efficacy by 11.84 points
 Exclusive breastfeeding increases the self-efficacy score by 14.86 points
Findings/Discussion  Reveals a cause and effect relationship: women with a high or medium levels of confidence in
their abilities to breastfeed, decrease their risk of PPD. The relationship goes both ways in that
women with a high scoring EPDS, show reduced levels of confidence (self-efficacy).
 These factors also influence whether or not these women will be able to successfully breastfeed
INTEGRATIVE LITERATURE REVIEW
Appraisal/Worth to practice
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
17
 Shows the importance of implementing tools for health professionals to use to help screen
women for low confidence for breastfeeding
 Also shows the need for national policies related to postnatal mental health aimed at reducing
the prevalence of PPD
 Ystrom, E. (2012). Breastfeeding cessation and symptoms of anxiety and depression: A
longitudinal cohort study. BMC Pregnancy & Childbirth, 12(1), 36-41. doi: 10.1186/1471-2393-
12-36
 Mothers who experience postpartum anxiety and depression have an increased risk of their
children encountering developmental delay.
 It is unclear whether symptoms of anxiety and depression are caused by early breastfeeding
cessation.
 Look at whether breastfeeding cessation increases the prevalence of feelings of anxiety and
depression during the time period between pregnancy and 6 months postpartum.
 The researcher also wanted to investigate if the proposed symptoms increase was higher in
individuals already suffering with anxiety and depression before birth.
 Longitudinal cohort study of the Norwegian Mother and Child Cohort Study (MoBa) conducted
by the Norwegian Institute of Public Health.
 Mothers were sent questionnaires at 17 weeks pregnancy, 30 weeks pregnancy, and 6 months
postpartum.
 47,659 mothers began the study but 5,434 were excluded because they left missing data on their
questionnaires, leaving a final sample size of 42, 225.
 All participants signed informed consents and the author states that he had no competing
interests.
 The study also received ethical approval from the regional committee for ethics in medical
research for Southeastern Norway.
 If the women had preexisting symptoms of anxiety and depression or not
 How the mothers fed their newborns month by month – breast, bottle, or mixed
 The mothers’ scoring on the SCL-8
INTEGRATIVE LITERATURE REVIEW
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
18
 A shorten version if the Hopkins Symptom Checklist (SCL-8) – self-reporting survey used to
assess for symptoms of anxiety and depression
 Mothers were sent questionnaires at multiple different time periods, were expected to report
how they fed their child month by month at six months postpartum, and where assessed using
the SCL-8.
 At 6 months postpartum, 15.1% of mothers were still fully breastfeeding, 68.8 were using mixed
forms of feeding (bottle and breast), and 16.1% were not breastfeeding at all.
 At 6 months pregnancy, the average SCL-8 score in mother was 1.22 in breastfeeding, 1.24 in
mixed feeding, and 1.31 in non-breastfeeding.
 Mixed feeding and solely bottle-feeding mothers had higher levels of anxiety and depression.
 Conclusion is that breastfeeding is related to the reduction in anxiety and depression and
breastfeeding cessation correlates with higher levels of anxiety and depression.
 Women who have preexisting high levels of anxiety and depression are more at risk than others
for an increase in those symptoms after breastfeeding cessation.
 Mothers with preexisting anxiety and depression may need additional support and coping
strategies in the case of unintended breastfeeding cessation.
 Silvia, C. S., Lima, M. C., Sequeira-de-Andrade, L. A., Oliveria, J. S., Monterio, J. S., Lima, N.
M.,… & Lira, P. I. (2017). Association between postpartum depression and the practice of
exclusive breastfeeding in the first three months of life. Jornal De Pediatria, 93(4), 356-364.
doi: 10.1016/j.jpedp.2016.08.005
 In recent years, breastfeeding numbers have been on the rise but the early cessation of
breastfeed before recommendation is still a major health consider for mothers and their infants.
 There is no official decision about the relationship of PPD symptoms and the duration of
breastfeeding due to multiple conflicting studies.
 For this reason, authors aimed this study to verify the relationship between PPD and the practice
of exclusive breastfeeding (EBF) in mothers up to 3 months postnatal.
 Researchers used data collected from the study “Evaluation of prenatal, birth care and care of
infants under one year old in the Legal Amazon and the Northeast regions, Brazil”.
INTEGRATIVE LITERATURE REVIEW
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
19
 This was a cross-sectional study conducted during June 2010 during a child vaccine campaign
in Brazil.
 The sample size was 2,259 mothers and their infants.
 The study was approved by the Research Ethics Committee of the National School of Public
Health. Participants of the study all signed informed consents and were assured of their
confidentiality and privacy. The authors also declare no conflicts of interest.
 Mothers with symptoms of PPD
 Mothers who were able to EBF without interruption
 The Edinburgh Postnatal Depression Scale (EPDS) – self-applied scale that includes 10 items
with answers ranging from 0-3 points each and is used to detect depressive symptoms in
postnatal mothers. Researchers considered a score of greater than 12 as an indication of PPD
symptoms.
 Data was collected via forms with questions pertaining to characteristics of the family. An
interview was then carried out in which mothers were evaluated on their ability to EBF and their
scoring on the EPDS.
 About 12% of mothers interviewed experienced symptoms of PPD.
 Results also showed an increased risk of difficulty with EBF in mothers with high EPDS scores
and associated PPD.
 Mothers with symptoms of PPD has a 1.63-fold higher change of EBF difficulty.
 Indicates that maternal mental health is an important determinant of early breastfeed weaning.
 This study highlights the need for additional studies to provide information about the influence
of mental health on postpartum women due to the negative impacts it can make on mother-child
relationships and the ability to exclusively breastfeed.