Association between breastfeeding cessation among under six-month-old infants and postpartum depressive symptoms in Nevada

Smriti Neupane; Clariana Vitória Ramos de Oliveira; Cláudia Nery Teixeira Palombo; Gabriela Buccini

doi:10.1371/journal.pone.0297218

. 2024 Jan 26;19(1):e0297218. doi: 10.1371/journal.pone.0297218

Association between breastfeeding cessation among under six-month-old infants and postpartum depressive symptoms in Nevada

Smriti Neupane ¹, Clariana Vitória Ramos de Oliveira ², Cláudia Nery Teixeira Palombo ³, Gabriela Buccini ^1,^*

Editor: Rita Amiel Castro⁴

PMCID: PMC10817202 PMID: 38277396

Abstract

Background

Postpartum depression affects 13% of women after childbirth in the United States. Mothers who experience depression are less likely to breastfeed than those who do not experience depression. On the other hand, breastfeeding may have a positive effect on maternal mental health.

Research aim

We aimed to analyze whether breastfeeding cessation is associated with postpartum depression symptoms among mothers of infants under six months old in Clark County, Nevada.

Method

A cross-sectional study was conducted in 2021 using a purposive sample of 305 mother-infant dyads. Postpartum depression symptoms were assessed using the Patient Health Questionnaire-2 (PHQ-2), and the breastfeeding cessation was determined through a 24-hour dietary recall. Descriptive, bivariate, and multivariate logistic regression analyses were conducted.

Results

Most participants were between 25 and 34 years old (n = 183, 60.0%), multiparous (n = 167, 55.1%), and had a vaginal delivery (n = 204, 70.6%). High frequency of postpartum depressive symptoms was found among mothers who were young (18–24 years) (24.2%), without a partner (25.0%), had unplanned pregnancies (12.7%), and were primiparous (13.2%). Breastfeeding cessation was independently associated with postpartum depressive symptoms (AOR = 3.30, 95% CI: 1.16–9.32) after controlling for sociodemographic, environmental, and obstetric characteristics.

Conclusion

Breastfeeding cessation is strongly associated with postpartum depressive symptoms among mother-infant dyads in Nevada. Early identification of postpartum depressive symptoms and the promotion of breastfeeding can create a positive feedback loop to foster the well-being of mothers and infants.

Background

During pregnancy, a woman goes through different hormonal, physical, physiological, and emotional changes, and even after childbirth, she experiences diverse and mixed emotions, from joy and excitement to sadness, fear, lamentation, and anxiety [1]. Many mothers who just delivered a baby can experience ‘baby blues’, which usually do not affect a mother’s capability to take care of a newly born baby and include symptoms like mood swings, worry, sadness, and tiredness that commonly begin within the first 2 to 3 days and resolve in two weeks [1]. However, the persistence and intensity of these symptoms can lead to postpartum depression, which affects the mother’s ability to perform her daily routines and take proper care of the child [2]. Postpartum depression occurs after giving birth to an infant, starts soon after the baby’s delivery, and lasts up to a year [1]. It influences how mothers feel, act, and think [3, 4]. The clinical symptoms of postpartum depression are feelings of sadness, hopelessness, restlessness, anxiety, irritation, excessive concern, sleep difficulties, problematic decision-making, and suicidal thoughts [2, 3, 5].

Globally, postpartum depression is a common yet serious problem that affects around 15% of women [6]. In the United States (US), 13% of mothers experience postpartum depression after giving birth [2]. Postpartum depression has a critical impact on mothers and poses a long-term risk to their mental health and well-being. Furthermore, it negatively influences the physical, social, and cognitive development of their children [7]. Postpartum depression also impacts the parenting and relationship between the mother and the infant, which eventually affects breastfeeding practices [1, 8].

Breast milk is one of the best sources of nutrition for infants [9]. There is strong evidence that breastfeeding positively impacts the physical, cognitive, and neurological health and well-being of infants, as well as mothers, which translates into economic benefits for society as a whole [10–12]. The American Academy of Pediatrics (AAP) and the World Health Organization (WHO) recommend exclusively breastfeeding an infant for six months and continuing breastfeeding for at least two years or longer if desired [13]. However, less than half of the world’s infants are being breastfed as recommended [14], which represents a loss of more than $300 billion each year in unintended benefits from breastfeeding to health and human development [15], when estimating the premature deaths of children due to diarrhea, pneumonia, the occurrence of obesity [16, 17], and other negative outcomes for mothers’ health that are demonstrably prevented by breastfeeding [16, 18].

Early breastfeeding cessation refers to a mother who interrupts any type of breastfeeding before an infant completes six months old. On average, the prevalence of any breastfeeding cessation at 6 months in the US is 44.2% [19]. Similarly, sixty percent of the mothers who initiated breastfeeding do not continue breastfeeding as recommended. The common reasons for early cessation are having latching issues, concerns about infant nutrition and weight, illness or using medication, issues with pumping milk, unsupportive work and hospital policies, lack of adequate maternal leave, lack of family support, and cultural barriers [20, 21]. Other risk factors that diminish breastfeeding practices include low education, first-time pregnancy, lack of prenatal care visits, lack of social support, and postpartum depression [22].

The causal pathways between breastfeeding and postpartum depression can be bidirectional and are still not fully understood [23, 24]. On the one hand, postpartum depression is linked with a greater risk for early breastfeeding cessation [25]. Mothers who experience postpartum depression can face breastfeeding difficulties due to emotional distress and may be less responsive to their infant’s feeding cues [26]. As a result, breastfeeding difficulties can lead the mother to feel frustrated and guilty, which exacerbates the risk for postpartum depression symptoms [27]. On the other hand, breastfeeding cessation is linked with a higher risk of postpartum depression [5, 27]. However, the psychological benefits of breastfeeding for the mother are not widely explored and require more research [5, 23, 27].

Better understanding of the factors that impact maternal mental health and depression is important for the health and wellness of mothers and children. Thus, determining factors that are protective against postpartum depression is a high research priority. Our hypothesis is that practicing breastfeeding is associated with maternal mental health. Therefore, the aim of this study is to identify whether breastfeeding cessation is associated with postpartum depressive symptoms.

Methods

Study design

A cross-sectional secondary analysis of data from the Early Responsive Nurturing Care (EARN) survey conducted in Clark County, Nevada, in 2021 was conducted. The EARN survey targeted mothers of infants under 6 months living in Clark County, Nevada. The survey consisted of questions regarding socio demographic maternal characteristics, pregnancy, maternal mental health, infant feeding, soothing, and sleeping practices. Ethical approval was provided by the Institutional Review Board of the University of Nevada, Las Vegas, USA (protocol 1767759–2). Maternal consent was obtained before starting the data collection, participation was voluntary and anonymous, and the privacy of the information was maintained.

Study setting

Clark County is a predominantly urban area located in the southern region of the US state of Nevada. Clark County comprises six jurisdictions–the City of Henderson, the City of Las Vegas, the City of North Las Vegas, Boulder City, the City of Mesquite, and Unincorporated Clark County. As of 2022, the total population of Clark County was 2,350,206, of which 50.2% are female, and 35.6% belong to the age group between 18 and 44. In Clark County, 35.7% of households have an income of less than $49,999, and 7.2% of families with children live below the poverty line [28]. The prevalence of adult depression is higher among females (20.7%) than among males (12.3%) in Clark County, Nevada [28]. Specifically, Nevada’s data on the prevalence of postpartum depression after childbirth is not available [29]. The prevalence of any breastfeeding cessation at six months is higher in Nevada (47.5%) than the national average (44.2%) [20].

Sampling and data collection

The Southern Nevada Health District’s (SNHD) 2020 vital records statistics (birth certificates) were the source of the sampling frame for this study. In 2020, 25,604 live births were recorded in the SNHD, and the live births of infants from mothers residing in Clark County were considered the sampling unit. Considering a 95% confidence interval, a 5% error, and assuming 50% completion, the minimum sample size of 268 mothers was estimated. A purposive sampling technique was adopted to recruit mothers for this study.

Only mothers who were 18 years of age or older, had an infant under six months of age, and resided in Clark County (Boulder City, Henderson, Las Vegas, North Las Vegas, and Mesquite), Nevada, were eligible to participate in this study. Similarly, those mothers who were under 18 years of age, had an infant over six months old, and resided outside the Clark County area were excluded from the study. Also, mothers with infants having specific illnesses or needs such as Down syndrome, cleft lip and/or palate, neurological conditions, congenital heart disease, or cardiac problems that prevented or made breastfeeding practices difficult were excluded. Data was collected from August 2021 to October 2021. Mothers were reached through outreach in the community (e.g., distributing flyers in maternal-child care centers, such as prenatal and pediatric offices and daycare centers) and through social media (e.g., Facebook). The majority of the respondents to the survey were enrolled through social media, because in 2021, there were still concerns about the COVID-19 pandemic and in-person interactions were considered unsafe for mothers with infants under 6 months old. The survey was disseminated in Qualtrics [30] and made available in Spanish and English. A total of 323 mothers responded to the survey; however, 18 (5.6%) mothers did not respond to the survey question regarding postpartum depressive symptoms. Thus, the analytical sample of 305 mothers was used to explore the associations between breastfeeding cessation and postpartum depressive symptoms.

Measurements

Outcome

Postpartum depressive symptoms were the main outcome measure for this study. These symptoms were assessed using the Patient Health Questionnaire-2 (PHQ-2) [31], which is a validated tool widely used to screen mothers for depression [32]. It is a two-item instrument that was derived from the PHQ-9 [33]. Each item asked how often the mother has been bothered by the problems over the past two weeks: little interest or pleasure in doing things; and feeling down, depressed, or hopeless. The responses were recorded as not at all, several days, more than half the days, and nearly every day, based on the seriousness of the situation, and were scored as 0, 1, 2, and 3, respectively. The PHQ-2 score ranged from 0 to 6, and a score of 3 or greater was used as the cutoff to determine if the mothers had postpartum depression symptoms [31].

Independent variable

Breastfeeding is a feeding practice indicator defined by the WHO and United Nations Children’s Fund (UNICEF) as the act of feeding breast milk to an infant (including milk expressed or from a wet nurse) while the infant may receive any food or liquid including non-human milk and formula [34]. Following this definition, the key independent variable was breastfeeding cessation in the last 24 hours (yes/no). The WHO describes several breastfeeding indicators to measure or study breastfeeding practices among infants and young children during the last 24 hours of the survey to prevent recall bias [11, 34]. Hence, breastfeeding cessation (one of the indicators) information was collected through a 24-hour dietary recall, as recommended by the WHO [34]. The questionnaire asked, ‘From yesterday morning until this morning, what has your child eaten?’. The response options were breastmilk, formula or another milk, water/tea/juice, meat/eggs, vegetables, rice/potatoes, beans, sweetened beverages, and others. Breastfeeding cessation was determined if an infant was not fed breast milk within that 24-hour period.

Covariables

Covariables were selected based on the conceptual framework [35] and evidence that supported associations with postpartum depression [8, 22, 36]. Study variables were categorized as sociodemographic, environmental, and obstetric characteristics.

Sociodemographic characteristics included maternal age (18–24; 25–34; 35–44), maternal education (primary-secondary-vocational; some college, no degree; associate’s, bachelor’s, graduate degree), housing situation (owned; rented or others), annual household income (up to $59,999; $60,000–149,000; more than $150,000), marital status (living without a partner; living with a partner), and the number of people living in the household (1–3; more than 4 people).

Environmental characteristics included mothers enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program (yes; no) and received any public assistance or welfare payments from the government (yes; no). The WIC program is a part of the federal assistance program of the United States that protects and promotes the health of low-income mothers and children up to the age of five, and provides nutritious food, gives information on healthy eating practices, and provides referrals as needed to health care [37]. Obstetric characteristics included planned pregnancy (yes; no), parity (primiparous/multiparous), infant’s sex (male; female), co-sleeping (yes; no), mothers with difficulty falling asleep (yes; no), and mothers’ sleep hours (less than 5 hours; more than 5 hours), type of delivery (vaginal; c-section), infant separated during the first 24 hours (yes; no), infant admitted in the neonatal unit (yes; no), duration of stay in the maternal ward (1 to 3 days; more than 4 days), and infant breastfed within the first hour (yes; no).

Data analysis

The Statistical Package for Social Sciences (SPSS), Version 28, was used for the statistical analysis. First, descriptive analysis was conducted to explore the outcome (postpartum depressive symptoms), independent variable (early breastfeeding cessation), and covariables (sociodemographic, environmental, and obstetric characteristics of mothers) using frequencies and percentages. Then, bivariate analysis was computed between postpartum depressive symptoms (a dependent variable) and early breastfeeding cessation (an independent variable), including other covariables, using the chi-square test to explore if there were any correlations among them and also to select the variables to include in the multivariate logistic regression model. All variables with a p-value <0.20 in the bivariate analyses were included in the multivariate logistic regressions. Finally, multivariate logistic regressions were conducted to assess the association of breastfeeding cessation with the postpartum depressive symptoms and estimate the adjusted odds ratios (AOR) at corresponding 95% confidence intervals (CI), after adjusting for confounders. A p-value <0.05 was used as a statistical significance criterion to assess the correlation between the outcome, independent variable, and co-variables.

Results

A total of 305 mother-infant dyads were included in the analytical sample. Among them, 9.2% of the mothers reported postpartum depressive symptoms. The prevalence of breastfeeding cessation was 26.2%. The majority of the mothers were between 25 and 34 years old (n = 183, 60.0%), had bachelor’s or graduate degrees (n = 223, 73.1%), and were not enrolled in the WIC (n = 262, 85.9%). Likewise, most mothers were multiparous (n = 167, 55.1%), had a vaginal delivery (n = 204, 70.6%), and infants were breastfed within the first hour (n = 225, 78.1%) (Table 1).

Table 1. Descriptive analysis of maternal sociodemographic, environmental, and obstetric characteristics, 2021 (n = 305).

Variables	Frequency (n)	Percentage (%)
Postpartum Depressive Symptoms
Yes	28	9.2
No	277	90.8
Breastfeeding Cessation
Yes	80	26.2
No	225	73.8
Maternal Age
18–24	33	10.8
25–34	183	60.0
35–44	89	29.2
Maternal Education
Primary-Secondary-Vocational	34	11.2
Some college, no degree	48	15.7
Associate’s, Bachelor, Graduate Degree	223	73.1
Housing
Owned	201	65.9
Rented or others	104	34.1
Annual Household Income
Up to $59,999	79	25.8
$60,000- $149,000	177	58.1
More than $150,000	49	16.1
Marital Status
Living without partner	16	5.2
Living with partner	289	94.8
People Living in the Household
1–3	124	40.7
More than 4 people	181	59.3
Enrolled in WIC Program
Yes	43	14.1
No	262	85.9
Received any Public Assistance or Welfare Payments from the Government (n = 304)
Yes	37	12.2
No	267	87.8
Planned Pregnancy(n = 303)
Yes	193	63.7
No	110	36.3
Parity (n = 303)
Primiparous	136	44.9
Multiparous	167	55.1
Infant Sex
Male	138	45.2
Female	167	54.8
Co-sleeping (n = 275)
Yes	131	47.6
No	144	52.4
Mother with Difficulty Falling Asleep (n = 275)
Yes	148	53.8
No	127	46.2
Mother’s Sleep Hours (n = 275)
Less than 5 hours	68	24.7
More than 5 hours	207	75.3
Type of Delivery (n = 289)
Vaginal	204	70.6
C-section	85	29.4
Infant Separated During First 24 Hour (n = 284)
Yes	145	51.1
No	139	48.9
Infant Admitted in the Neonatal Unit (n = 287)
Yes	35	12.2
No	252	87.8
Duration of Stays in the Maternity Ward (n = 281)
1 to 3 days	252	89.7
More than 4 days	29	10.3
Infant Breastfed within the First Hour (n = 288)
Yes	225	78.1
No	63	21.9

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Young mothers of 18–24 years (n = 8, 24.2%) had a greater prevalence of postpartum depressive symptoms than mothers of the older age group. Similarly, mothers with some college-level education without a degree (n = 10, 20.8%) were more likely to experience postpartum depressive symptoms compared to mothers with primary, secondary or vocational education, and a degree. Mothers without a partner presented a higher frequency of experiencing postpartum depressive symptoms (n = 4, 25.0%) compared to those with partners. Mothers with an unplanned pregnancy (n = 14, 12.7%) and having their first child (primiparous) (n = 18, 13.2%) had a higher frequency of experiencing postpartum depressive symptoms compared to mothers with a planned pregnancy and having more than one child (multiparous). In addition, mothers who ceased breastfeeding (n = 13, 16.2%) and those who got less than 5 hours of sleep (n = 9, 13.2%) were more likely to present postpartum depressive symptoms compared to the reference group. Finally, mothers whose infants were admitted to the neonatal unit (n = 6, 17.1%) and not breastfed within the first hour (n = 9, 14.3%) also showed a greater frequency of postpartum depressive symptoms (Table 2).

Table 2. Prevalence of postpartum depressive symptoms by maternal sociodemographic, environmental, and obstetric characteristics, 2021 (n = 305).

^#.

Variables	Postpartum Depressive Symptoms		P-value
Variables	No	Yes	P-value
	n (%)	n (%)
Breastfeeding Cessation			0.01^*
Yes	67 (83.75)	13 (16.25)
No	210 (93.33)	15 (6.67)
Maternal Age			0.006^*
18–24	25 (75.76)	8 (24.24)
25–34	169 (92.35)	14 (7.65)
35–44	83 (93.26)	6 (6.74)
Maternal Education			0.006^*
Primary-Secondary-Vocational	30 (88.24)	4 (11.76)
Some college, no degree	38 (79.17)	10 (20.83)
Associate’s, Bachelor, Graduate Degree	209 (93.72)	14 (6.28)
Housing			0.54
Owned	184 (91.54)	17 (8.46)
Rented or others	93 (89.42)	11 (10.59)
Annual Household Income			0.64
Up to $59,999	70 (88.61)	9 (11.39)
$60,000- $149,000	163 (92.09)	14 (7.91)
More than $150,000	44 (89.80)	5 (10.20)
Marital Status			0.02^*
Living without partner	12 (75.00)	4 (25.00)
Living with partner	265 (91.70)	24 (8.30)
People Living in the Household			0.02^*
1–3	107 (86.29)	17 (13.71)
More than 4 people	170 (93.92)	11 (6.08)
Enrolled in WIC Program			0.54
Yes	38 (88.37)	5 (11.63)
No	239 (91.22)	23 (8.78)
Received any Public Assistance or Welfare Payments from the Government (n = 304)			0.11^**
Yes	31 (83.78)	6 (16.22)
No	245 (91.76)	22 (8.24)
Planned Pregnancy (n = 303)			0.11^**
Yes	179 (92.75)	14 (7.25)
No	96 (87.27)	14 (12.73)
Parity (n = 303)			0.03^*
Primiparous	118 (86.76)	18 (13.24)
Multiparous	157 (94.01)	10 (5.99)
Infant Sex			0.28
Male	128 (92.75)	10 (7.25)
Female	149 (89.22)	18 (10.78)
Co-sleeping (n = 275)			0.49
Yes	119 (90.84)	12 (9.16)
No	134 (93.06)	10 (6.94)
Mother with Difficulty Falling Asleep (n = 275)			0.33
Yes	134 (90.54)	14 (9.46)
No	119 (93.70)	8 (6.30)
Mother Sleep Hours (n = 275)			0.06^**
Less than 5 hours	59 (86.76)	9 (13.24)
> More than 5 hours	194 (93.72)	13 (6.28)
Type of Delivery (n = 289)			0.44
Vaginal	188 (92.16)	16 (7.84)
C-section	76 (89.41)	9 (10.59)
Infant Separated during First 24 Hours (n = 284)			0.32
Yes	131 (90.34)	14 (9.66)
No	130 (93.53)	9 (6.47)
Infant Admitted in the Neonatal Unit (n = 287)			0.05^*
Yes	29 (82.86)	6 (17.14)
No	233 (92.46)	19 (7.54)
Duration of Stays in the Maternity Ward (n = 281)			0.24
1 to 3 days	233 (92.46)	19 (7.54)
More than 4 days	25 (86.21)	4 (13.79)
Infant Breastfed within the First Hour (n = 288)			0.07^**
Yes	209 (92.89)	16 (7.11)
No	54 (85.71)	9 (14.29)

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*p<0.05

**p<0.20; ^#total sum (100%) in a row

Multivariate logistic regression revealed that postpartum depressive symptoms are independently associated with early cessation of breastfeeding (AOR = 3.30, 95% CI: 1.16–9.32) after controlling for maternal sociodemographic, environmental, and obstetric characteristic (Table 3).

Table 3. Multivariate logistic regression on the association between postpartum depressive symptoms and selected maternal sociodemographic, environmental, and obstetric characteristics, 2021.

Variables	Unadjusted			Adjusted
Variables	OR	95% CI	P>\|z\|	OR	95% CI	P>\|z\|
Breastfeeding Cessation
Yes	2.71	1.23; 5.99	0.01^*	3.30	1.16; 9.32	0.02^*
No	1			1
Planned Pregnancy
Yes	1			1
No	1.86	0.85; 4.07	0.11	1.95	0.68; 5.56	0.20
Parity
Primiparous	1			1
Multiparous	0.41	0.18; 0.93	0.03^*	0.89	0.08; 8.90	0.92
Infant Admitted in the Neonatal Unit
Yes	1			1
No	0.39	0.14; 1.06	0.06	0.46	0.1; 1.81	0.26
Mother Sleep Hours
Less than 5 hours	1			1
>More than 5 hours	0.43	0.17; 1.07	0.07	0.52	0.17; 1.50	0.22
Infant Breastfed within the First Hour
Yes	1			1
No	2.17	0.91; 5.19	0.08	1.13	0.33; 3.82	0.83

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*p<0.05; Adjusted for maternal age and education, marital status, number of people living in the household, and welfare program.

Discussion

To our knowledge, this is one of the first studies to assess factors associated with postpartum depressive symptoms in Clark County, Nevada. We found a significant relationship between postpartum depressive symptoms and breastfeeding cessation among six-month-old infants. Mothers who ceased breastfeeding had 3.30 times higher odds of postpartum depressive symptoms compared to mothers who were breastfeeding. Our results are consistent with prior studies that showed an association between breastfeeding and the mental health of mothers, in which non-breastfeeding mothers were at greater risk of depression [8, 22, 36, 38, 39]. A similar study in the United States also concluded that breastfeeding mothers (AOR = 0.87, p = 0.001) had significantly lower risks for depression than non-breastfeeding mothers [40]. Correspondingly, a recent meta-analysis revealed that breastfeeding mothers have a 14% reduced risk of depression compared to mothers who were not breastfeeding [8]. This might be because breastfeeding mothers are more likely to regulate negative moods and perceived stress, which ultimately prevents them from developing depressive symptoms [41, 42]. Breastfeeding can promote hormonal processes that protect mothers against postpartum depressive symptoms by attenuating cortisol response to stress [22]. Breastfeeding mothers are also more likely to produce calm reactions to stress, which fosters their nurturing behavior [43]. Moreover, evidence indicates that if a mother is unable to breastfeed, it may increase anxiety and depressive symptoms [43]. This is because the social culture of mandatory breastfeeding can make a mother feel responsible for its success or unsuccess [44]. Even though the current study presented strong support for such a relationship, more research is needed to determine the relationship between breastfeeding and postpartum depression outcomes.

Our study did not find an association between postpartum depressive symptoms and maternal characteristics such as planned pregnancy, mother sleep hours, and parity. Corroborating our findings, a longitudinal study in the Netherlands found that women with an unplanned pregnancy reported persistently higher levels of depressive symptoms compared to women with a planned pregnancy [45]. Concerning maternal sleeping hours, similarly to our study researchers found that depressive symptoms during postpartum were associated with poorer sleep, and poorer sleep quality increased postpartum depression symptom severity [46]. On the other hand, the lack of association between parity and postpartum depressive symptoms found in our study differed from the findings from other studies [47, 48]. Martnez-Galiano and colleagues showed that first-time mothers (primiparous) had greater postnatal depressive symptoms and that such mothers were more likely to have issues related to lactation, sadness, and anxiety [47]. On the other hand, Hartmann and colleagues observed an association between having more than one child (multiparous) and greater depression [48]. Overall, it can be inferred that giving birth to a baby, either for the first time or multiple times, can be stressful, and mothers can easily be anxious about how to handle new responsibilities related to their infant. Additionally, the influence of parity on a mother’s mental health is poorly studied, and the results are incongruous, highlighting the need to critically analyze and do extensive research on this aspect in the near future.

Infant characteristics such as infant breastfed within the first hour and infant admitted in the neonatal unit were also not associated with postpartum depressive symptoms. Corroborating our findings, in Sweden, pregnant women reported depressive symptoms when they could not accomplish the first breastfeeding session within two hours after birth [49]. Regarding infants admitted to the neonatal intensive unit, a study in Australia showed that postpartum depression was reported within the first 2 weeks after their baby was admitted to the neonatal intensive care unit [50]. Despite the lack of association with postpartum depressive symptoms almost half of the infants were routinely separated from their mothers during the first 24 hours after birth even though very low admission to the neonatal unit was reported. Evidence has demonstrated that routine maternity ward procedures such as early skin-to-skin contact and breastfeeding within the first hours promoted by Baby-Friendly Hospital are protective factors for immediate postpartum depression [51] as well as support maternal role competence [52].

Our results showed that the prevalence of postpartum depressive symptoms (9.2%) among mothers living in Clark County, Nevada, was slightly below the US average (13%) [2]. A recent meta-analysis found increased postpartum depressive symptoms at 6 months postpartum and reported that the prevalence of postpartum depression varied according to country (from 5.0% to 26.32%) [53]. According to their findings, the prevalence of postpartum depression was 8.6% in the US, which is similar to our findings [53]. Our study is the first to date to report the prevalence of postpartum depressive symptoms in Nevada, which is critical to determine the resources and support needed as well as to tailor existing interventions to the needs of the population.

Our findings emphasize the importance of universal mental health screening for postpartum women and appropriate treatment for those with depressive symptoms. Similarly, supportive and evidence-based interventions that address and encourage both breastfeeding and maternal mental well-being should be formulated and implemented. Evidence shows that providing support for mental health well-being may increase breastfeeding practices [54]. Moreover, breastfeeding may protect against or ameliorate depressive symptoms [55]. A systematic review found twelve interventions with a significant positive effect on both maternal mental health and breastfeeding outcomes, including psychoeducational group programs, relaxation therapy, skin-to-skin contact between mother and infant, psychological nursing, motivational interviewing, a health and infant care education program, stepped-care psychological treatment, peer support with home visits, breastfeeding training with home visits, and risk-based treatment with home visits [54]. Thus, health and mental health professionals should inform, educate, and advocate for breastfeeding as it can positively impact mothers’ mental health. Most importantly, when delivering these interventions, professionals should take a holistic, integrative approach considering that the impact of depressive symptoms, medication, sleep arrangements, and social support is critical to maternal-child well-being and breastfeeding promotion.

Our study has some limitations that should be considered when interpreting the findings. We surveyed a convenience sample of mothers with infants under six months old in Clark County, Nevada. Data collection efforts across birth, lactation, and pediatric care centers were made to recruit a diverse population of mothers; however, due to the COVID-19 pandemic, most participants were recruited through a paid advertisement on social media. The survey was provided in both English and Spanish, allowing participants to respond to the survey in their preferred language. A comparison of our data to the demographic data (i.e., ethnicity, educational attainment, and household income) in Clark County showed similar trends. Nevertheless, our findings may only be generalized to areas in the US with a similarly high proportion of urban populations as Clark County. Another limitation is that we did not collect the age of the infant at the time of the survey. We acknowledge that some care practices are influenced by the infant’s age, and some associations may not be found or weakened due to the lack of the infant age information. Also, we adopted the 24-hour diet recall method as recommended by the WHO to measure breastfeeding cessation to avoid the recall bias. However, if an infant was breastfed before 24 hours or only a couple of days a week, or even never breastfed, it would be classified as breastfeeding cessation. Our questionnaire did not include questions about previous medical diagnosis of depression or other types of psychiatric disorder, and the use of medications such as antidepressants, mood stabilizers, etc. We acknowledge that the lack of this information may underestimate the prevalence of depression symptoms. Finally, because this study was cross-sectional, the causal relationship between postpartum depressive symptoms and breastfeeding cannot be established. In fact, as there was no data regarding postpartum depression in Nevada, our cross-sectional study may establish a baseline for future longitudinal research to clarify this causal relationship. Collectively, our findings contribute to Nevada context-specific hypotheses and support transferability for future public health research exploring the relationship between postpartum depression and breastfeeding [56].

Conclusion

Our study showed a significant association between postpartum depressive symptoms and breastfeeding cessation. Early identification of postpartum depressive symptoms and the promotion of breastfeeding can create a positive feedback loop to foster the well-being of mothers and infants. More research is needed to clarify the bidirectional causal relationship between postpartum depressive symptoms and breastfeeding cessation.

Supporting information

S1 Checklist. STROBE statement—checklist of items that should be included in reports of observational studies.

(DOCX)

Click here for additional data file.^{(22.4KB, docx)}

Data Availability

A de-identified data set is not possible to provide due to ethical considerations due to potentially identifying information in the database. These sharing restrictions are imposed by the UNLV Institutional Board Review (IRB). The authors declare that a de-identified data set from this study is available upon request directly to the UNLV IRB (irb@unlv.edu).

Funding Statement

The author(s) received no specific funding for this work.

References

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PLoS One. doi: 10.1371/journal.pone.0297218.r001

Decision Letter 0

Rita Amiel Castro

3 Aug 2023

PONE-D-23-18811Association between maternal postpartum depressive symptoms and breastfeeding among six-month-old infants in Nevada.PLOS ONE

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Reviewer #1: There is no major issue with the manuscript. It is well written and present everything they intended to present. However, there is no new finding arose from this study. Mental health and breastfeeding practices study are well established and the results supported many other previous studies.

Reviewer #2: The manuscript at hand describes a cross-sectional study on the association between breastfeeding and postnatal depression. The authors conducted an online survey in which 305 mothers living in Nevada (U.S.) participated. After controlling for variables, such as sociodemographic, environmental, and obstetric characteristics, the authors found an association between breastfeeding cessation and postnatal depression. The manuscript is generally of interest, but there are a few concerns that should be addressed, before the manuscript can be accepted for publication.

Page 3, line 65 to 66: The authors should state more recent research on the impact of postpartum depression on the development of children. Here, the authors cite Borra et al. (2015). This study is actually not focusing on the association between postpartum depression and infant development.

The authors could cite, e.g.:

Kaplan PS, Danko CM, Everhart KD, et al. Maternal depression and expressive communication in one-year-old infants. Infant Behav Dev. 2014;37(3):398-405.

Murray L, Cooper PJ, Wilson A, Romaniuk H. Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression, 2: impact on the mother-child relationship and child outcome. Br J Psychiatry. 2003;182(5):420-427.

Murray L, Arteche A, Fearon P, Halligan S, Croudace T, Cooper P. The effects of maternal postnatal depression and child sex on academic performance at age 16 years: a developmental approach. J Child Psychol Psychiatry. 2010;51(10):1150-1159.

Schaadt G, Zsido RG, Villringer A, Obrig H, Männel C, Sacher J. Association of Postpartum Maternal Mood With Infant Speech Perception at 2 and 6.5 Months of Age. JAMA Network Open. 2022; 5(9):e2232672.

Page 3, line 69 an following: The authors state that breastfeeding positively impacts society. The authors should elaborate more on this impact, as it might not be obvious at first sight.

Page 4, line 74-75: The authors should elaborate a bit more on the statement that the fact that less than half of the world’s infants are being breastfed as recommended, represents a loss of more than $300 billion each year.

Page 4, line 95 to page 5, line 98: I was a little bit confused that authors state that they hypothesized that practicing breastfeeding can positively influence maternal mental health and reduce maternal postpartum depressive symptoms and that their aim was to identify whether maternal postpartum depressive symptoms are associated with early breastfeeding cessation. The hypothesis, from what I understood, is focusing on the direction of breastfeeding leading to less maternal postpartum mood, while the aim is focusing on the other direction that postpartum depression leads to cessation. As the authors are reporting a cross-sectional study, both cannot really be investigated. I strongly encourage the authors to rephrase the last part of the introduction.

Page 5, line 101: There seems to be a word missing in this sentence.

Page 8, line 167-168: The word “program” should be omitted once, if I am not mistaken.

Page 8, line 179: The authors state that “bivariate analysis between maternal postpartum depressive symptoms was computed across the independent variables”. Here the authors should state why these analyses were performed. At first sight this does not come across.

Table 1: I suggest having the same order for “no” and “yes”. For maternal postpartum depression, the authors first report yes-answers, while they first report no-answers for breastfeeding cessation. This should also be checked for the other variables.

Table 2: I am still not sure whether I understand what the bivariate statistics tell. What exactly did the authors analyze and what does a significant p-value mean. Further, I was confused about the numbers in parenthesis. It is stated that these are percentages. However, the numbers do not add to 100%. Where do the numbers come from? This should be explained or corrected.

Discussion: The authors outline in which way their findings are (mainly) inconsistent with other studies. It would be appropriate to also discuss why these inconsistencies might have occurred. I am not familiar with the sociodemographic characteristics of Nevada or the U.S., but to me the sample did not seem to be entirely representative. I was surprised about the proportion of marital status, as well as annual household income. Maybe this could be one of the reasons for inconsistencies? Independent of the reasons, the authors should elaborate on this more carefully.

Further, I strongly encourage the authors to discuss more deeply on the causality of their results, especially when considering their aim (see comment above). The authors cannot make any conclusions about causality and therefore cannot conclude that breastfeeding reduces the risk of postpartum depression.

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2024 Jan 26;19(1):e0297218. doi: 10.1371/journal.pone.0297218.r002

Author response to Decision Letter 0

16 Sep 2023

To the Editor and reviewers of PLOS ONE:

Thank you for taking the time to review our manuscript and provide detailed and constructive feedback. We reviewed your comments meticulously and revised them accordingly. We hope they meet your expectations. Please find our point-by-point response below.

Reviewer #1

There is no major issue with the manuscript. It is well written and present everything they intended to present. However, there is no new finding arose from this study. Mental health and breastfeeding practices study are well established and the results supported many other previous studies.

Response: Thank you for this feedback. While our study did not unveil groundbreaking findings, it contributes to discussing the context of large urban areas in the US, specifically in Nevada where maternal mental health and breastfeeding practices are understudied. We included more about the context in the introduction (page 6, lines 100-109) and in the discussion sections (pages 17-18, lines 258-265).

1. The title needs to be changed/rephrased and this study did not measure among six-month-old infants. Please mention ‘breastfeeding cessation’ and ‘under six months’ in the title.

Response: Thank you for specifying this. It has been corrected (page 1, lines 3-5).

2. Line 53 – please clarify the term ‘new mother’. Does it refer to first-time mother?

Response: ‘New mother’ refers to mothers who just delivered a baby, either for the first time or not. It has been clarified (page 4, lines 49-52).

3. Line 86 – statement needs reference/s

Response: Done. (page 5, lines 89).

4. What are the exclusion criteria? Please describe.

Response: Thank you for the comment. We have specified the exclusion criteria (page 8, lines 136-140).

5. As the known prevalence of depression is higher among females, do you include those with mental disorder diagnoses in this study?

Response: Mental health diagnoses were not an exclusion criterion. Thus, everyone who was eligible and wished to participate in the survey could do so, irrespective of their mental health status. (page 8, lines 140-142).

6. Line 157 - please explain more about the 24-hour diet recall used to determine breastfeeding practice. Why this method is chosen? Is 24-hour diet recall accurate to measure breastfeeding cessation? If infants are still fed with breast milk a few times a week, does it consider ‘breastfeeding cessation’?

Response: As recommended by WHO, we used the 24-hour dietary recall method to assess breastfeeding cessation. We clarified the method used and the definition of the breastfeeding cessation indicator in the methods section (page 9, lines 164-176). In addition, we added a discussion of the potential bias in the discussion section (pages 20-21, lines 328-333).

7. Line 167 – please describe WIC

Response: A brief description has been added (page 10, lines 187-190).

8. Line 196 – Please rearrange the paragraph according to the variables in Table 2. The current arrangement makes it harder to refer to the table.

Response: Thank you for the suggestion. It has been rearranged. (page 13-14, lines 221-233).

9. Table 2: Some categories include only very few participants. Even though the result is significant if only three participants are included in the category, how marked the result is? Please kindly discuss this.

Response: We have rectified the mentioned categories and thoroughly reevaluated the analysis (Table 2, pages 14-15).

10. Relationship between postpartum mental health and breastfeeding and well-versed. What is the difference with your study?

Reviewer #2:

The manuscript at hand describes a cross-sectional study on the association between breastfeeding and postnatal depression. The authors conducted an online survey in which 305 mothers living in Nevada (U.S.) participated. After controlling for variables, such as sociodemographic, environmental, and obstetric characteristics, the authors found an association between breastfeeding cessation and postnatal depression. The manuscript is generally of interest, but there are a few concerns that should be addressed, before the manuscript can be accepted for publication.

Response: Thank you for this feedback. We appreciate your detailed notes to help to improve the manuscript.

The authors could cite, e.g.:

Kaplan PS, Danko CM, Everhart KD, et al. Maternal depression and expressive communication in one-year-old infants. Infant Behav Dev. 2014;37(3):398-405.

Response: Thank you for pointing this out. We added the reference (page 4, line 64).

Page 3, line 69 a following: The authors state that breastfeeding positively impacts society. The authors should elaborate more on this impact, as it might not be obvious at first sight.

Response: We restructured the sentence including a new reference (page 4, lines 67-70).

Response: We included new references to support the statement (page 5, lines 72-77).

Response: We corrected the hypothesis and rephrased the last part of the introduction (page 6, lines 103-105).

Page 5, line 101: There seems to be a word missing in this sentence.

Response: We have corrected the sentence (page 7, lines 112-113).

Page 8, line 167-168: The word “program” should be omitted once, if I am not mistaken.

Response: Done (page 10, lines 185-187).

Response: We have explained why bivariate analysis was done (page 11, lines 202-206).

Response: Done. We have checked with other variables and updated the tables accordingly (Table 1, page 12).

Response: Bivariate analysis is a statistical method to determine if there is a statistical association between the two variables and, if so, how strong and in which direction that association is (reference). Our bivariate analysis is presented in Table 2. First, the cross-tabulation helped to clarify the existence and the direction of an association between maternal postpartum depression outcome, the independent variable, and covariables, individually. For example, among mothers with postpartum depression, 16.25% had ceased breastfeeding compared to 6.67% who did not cease breastfeeding; on the other hand, among mothers without postpartum depression, 83.75% had ceased breastfeeding, while 93.3% did not cease breastfeeding. This description illustrates the direction of a possible association (without any cause-and-effect relationship), which in this case, shows the presence of maternal mental health increases the frequency of breastfeeding cessation. Second, the goal of the chi-square test was to explore how strong the association between maternal postpartum depression and covariables was individual. All covariables with a p-value <0.20 in the bivariate analysis were included in the multivariate logistic regression model.

Reference:

Bertani, A., Di Paola, G., Russo, E., & Tuzzolino, F. (2018). How to describe bivariate data. Journal of thoracic disease, 10(2), 1133–1137. https://doi.org/10.21037/jtd.2018.01.134

Response: Thank you for this note. We added a paragraph discussing the hypothesis of the different findings from our study to other studies as well as how it relates to the Nevada context (pages 19-20, lines 305-317).

Response: We agree with your comment. Following the suggestions, we reframed the aim of the study in the background section (page 6, lines 107-109). We added a paragraph expanding on the discussion of the limitations of our study due to sampling and design (page 18, lines 274-279, page 19, lines 300-304, & page 20, lines 318-322). We also redid the conclusion (page 21, lines 335-346).

Attachment

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PLoS One. doi: 10.1371/journal.pone.0297218.r003

Decision Letter 1

Rita Amiel Castro

5 Dec 2023

PONE-D-23-18811R1Association between maternal postpartum depressive symptoms and breastfeeding cessation among under six-month-old infants in Nevada.PLOS ONE

Dear Dr. Buccini,

Please submit your revised manuscript by Jan 19 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Rita Amiel Castro

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes

Reviewer #3: Partly

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Reviewer #2: The manuscript at hand is a study I reviewed earlier. The authors have done a good job in revising the manuscript and responding to the reviewer comments.

I have one minor comment left and can then suggest the manuscript for publication.

In my previous comments, I asked the authors to explain why they performed the bivariate statistics. Further, I pointed out that in Table 2, the numbers do not add to 100%. In their revised manuscript the authors explained the aim of the bivariate statistics more precisely and in their response, the authors explained why the numbers in table 2 do not add up to 100%. However, I could not find any information in the manuscript and would strongly suggest to add a note to table 2, to explain the percentage more precisely. If I overread this information, please feel free to ignore this comment.

Reviewer #3: Thank you for the well-written manuscript. However, although I acknowledge that there are no estimates for postpartum depression symptoms, the study was conducted with a small sample using purposive sampling and a cross-sectional study design, so this manuscript does not contribute new knowledge to the field.

Reviewer #4: You provide these two statements: Line 27 (abstract): “We aimed to analyze whether maternal postpartum depression symptoms are associated with early breastfeeding cessation”; Line 108 (background): “Thus, we aimed to find out whether early breastfeeding cessation is an independent risk factor for maternal postpartum depression”. You should be clearer about the aim of the study/ in which direction are you seeking an association.

Line 171: A 24h dietary recall is not the best method, since a mother could need to transiently interrupt breastfeeding due to medication/medical exams and resume again later. You explain this in the discussion, however, if a mother was not breastfeeding, how do you know when she stopped? If you don’t have this information, you should state it as a limitation of your study.

Besides, did you have the option “breastmilk + formula” in your questionnaire?

Line 177: Regarding the covariables, did you ask the mothers if they had a diagnosis of depression/other psychiatric disorder and/or if they were taking any medication? It is important to know this as some treatments are not compatible with breastfeeding.

Table 1: I suggest you write “postpartum depression symptoms” instead of “maternal postpartum depression” in your table, since you do not have a clinical diagnosis.

Table 1: There is a high prevalence of newborns separated from their mothers in the first hour, yet a low prevalence of admissions in the neonatal unit. While it is not the primary goal of the study, this finding deserves some discussion.

Table 2: You should not write in the title “risk for” since you did not evaluate causality.

Line 305: there is a grammatical error.

Overall, the study is well written and gives information about the prevalence of postpartum depression symptoms and mothers who did not breastfeed in the previous 24h. While this is useful information and the study has a good sample size, there are some variables that were not taken into account: there is no information regarding a diagnosis of depression or medication taken by mothers, no information about the timing of breastfeeding cessation or if there were mothers who never breastfed. These are important limitations and should be mentioned.

**********

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Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

**********

PLoS One. 2024 Jan 26;19(1):e0297218. doi: 10.1371/journal.pone.0297218.r004

Author response to Decision Letter 1

21 Dec 2023

To the Editor and reviewers of PLOS ONE:

Reviewer #2: The manuscript at hand is a study I reviewed earlier. The authors have done a good job in revising the manuscript and responding to the reviewer comments.

I have one minor comment left and can then suggest the manuscript for publication.

In my previous comments, I asked the authors to explain why they performed the bivariate statistics. Further, I pointed out that in Table 2, the numbers do not add to 100%. In their revised manuscript the authors explained the aim of the bivariate statistics more precisely and in their response, the authors explained why the numbers in table 2 do not add up to 100%. However, I could not find any information in the manuscript and would strongly suggest adding a note to table 2, to explain the percentage more precisely. If I overread this information, please feel free to ignore this comment.

Response: Thank you for your feedback. We added a footnote in Table 2 explaining 100% is the sum of the numbers in a row (page 14, line 215).

Response: Thank you for the opportunity to reflect on your contribution to new knowledge in the field. Our team believes that research should always seek to strike a balance between (1) context-specific knowledge as well as (2) transferability. Our study contributes to the field by being the first to report the prevalence of postpartum depressive symptoms and investigate the independent association with breastfeeding cessation in Nevada (context). Furthermore, while corroborating existing literature, it also invites readers of the research to make connections between elements of our study and their own experiences (transferability). Collectively, our findings contribute to context-specific hypotheses and support transferability for future public health research exploring the relationship between postpartum depression and breastfeeding. Therefore, we believe that this manuscript, despite its limitations (detailed in the discussion section), makes a valuable contribution to the literature and the field of public health.

Response: Thank you for pointing this out. We now have stated our aim in a consistent way or direction: ‘To analyze whether breastfeeding cessation is associated with postpartum depression among mothers of infants under six months old in Clark County, Nevada (both in title, abstract (lines 26–27), and introduction (lines 91–92)).

Response: Thank you for this comment. Specifically, we do not have information on when the mother stopped breastfeeding and have included it in the limitation paragraph. While we acknowledge the potential limitations of a 24-hour dietary recall, we used it to standardize measurement when assessing infant feeding outcomes and to avoid recall bias as recommended by the WHO. It also allows future comparisons across studies and populations. We added a paragraph in the discussion section to discuss the limitations pointed out by the reviewer (Page 18, lines 304–309).

Besides, did you have the option “breastmilk + formula” in your questionnaire?

Response: We did ask about mixed feeding with ‘breastmilk+formula’ in the 24-hour dietary recall. Because our independent variable refers to any breastfeeding, in the case of the affirmative response, this dyad was classified as breastfeeding (Page 7, lines 154-157).

Response: We do acknowledge the importance of these questions; however, unfortunately, they were not included in the questionnaire. We added a paragraph in the discussion section to discuss the limitations pointed out by the reviewer (Page 18, lines 307-309).

Table 1: I suggest you write “postpartum depression symptoms” instead of “maternal postpartum depression” in your table, since you do not have a clinical diagnosis.

Response: We standardize “postpartum depressive symptoms” throughout the manuscript. It also has been corrected in Table 1.

Response: Thank you for this feedback. We added a paragraph to discuss this important insight in our discussion (Page 16, lines 259 - 269).

Table 2: You should not write in the title “risk for” since you did not evaluate causality.

Response: Thank you for your suggestion. We removed it throughout the manuscript.

Line 305: there is a grammatical error.

Response: Thank you for noticing this. It has been corrected (Pages 20, line 312-316).

Response: Thank you for your feedback. We updated this information in our discussion, where we specified our limitations (Page 18, lines 304-309).

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PLoS One. doi: 10.1371/journal.pone.0297218.r005

Decision Letter 2

Rita Amiel Castro

2 Jan 2024

Association between breastfeeding cessation among under six-month-old infants and postpartum depressive symptoms in Nevada.

PONE-D-23-18811R2

Dear Dr. Buccini,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Rita Amiel Castro

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0297218.r006

Acceptance letter

Rita Amiel Castro

19 Jan 2024

PONE-D-23-18811R2

PLOS ONE

Dear Dr. Buccini,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

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on behalf of

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PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. STROBE statement—checklist of items that should be included in reports of observational studies.

(DOCX)

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Data Availability Statement

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PERMALINK

Association between breastfeeding cessation among under six-month-old infants and postpartum depressive symptoms in Nevada

Smriti Neupane

Clariana Vitória Ramos de Oliveira

Cláudia Nery Teixeira Palombo

Gabriela Buccini

Roles

Abstract

Background

Research aim

Method

Results

Conclusion

Background

Methods

Study design

Study setting

Sampling and data collection

Measurements

Outcome

Independent variable

Covariables

Data analysis

Results

Table 1. Descriptive analysis of maternal sociodemographic, environmental, and obstetric characteristics, 2021 (n = 305).

Table 2. Prevalence of postpartum depressive symptoms by maternal sociodemographic, environmental, and obstetric characteristics, 2021 (n = 305).

Table 3. Multivariate logistic regression on the association between postpartum depressive symptoms and selected maternal sociodemographic, environmental, and obstetric characteristics, 2021.

Discussion

Conclusion

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Rita Amiel Castro

Roles

Author response to Decision Letter 0

Decision Letter 1

Rita Amiel Castro

Roles

Author response to Decision Letter 1

Decision Letter 2

Rita Amiel Castro

Roles

Acceptance letter

Rita Amiel Castro

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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