Mental Health Risks Many Lactating Parents Face
Moorea Malatt LEC, PMH-C
Many studies show how beneficial human milk is for babies and lactating parents and how breastfeeding and bodyfeeding* can be very supportive of parental mental health. But in the United States, within a culture so unsupportive of new parents, and when facing early physiological lactation challenges, trying to feed our babies can become a mental health risk.
The American Academy of Pediatrics (AAP) recently joined the World Health Organization in recommending breastfeeding babies for two years. A long-term feeding relationship requires all kinds of support: educational, familial, financial and workplace support, to name a few. It also requires the nursing parent enjoy the feeding relationship enough to continue and the mental capacity to manage any feeding challenges.
A study from the University of Massachusetts Chan Medical School found that if a nursing parent experienced difficulties with lactation or differences between expectations and actual experience, breastfeeding was associated with negative mental health outcomes. Risks and benefits of each feeding method must be considered within a cultural context to understand the lived experience of parents, especially in the U.S. where we don’t have adequate healthcare, education or guaranteed paid leave from work.
There are 5 main areas where feeding babies become a risk factor for postpartum anxiety and depression in lactating parents:
Latch challenges and a lack of support
A bit of help in the hospital is not enough for most families. Babies don’t really eat much in the first couple of days, and by the time engorgement happens (and latch may become more challenging), most parents have left the hospital and feel they are on their own. Most parents do not experience lactation challenges until four to five days after birth or later.
As a volunteer supporting postpartum parents, I noticed that most of the parents reporting anxiety and sadness over their feeding challenges had not seen an IBCLC (International Board of Lactation Consultant Examiners) lactation professional outside of the hospital. Most pediatric practices do not provide IBCLC support and parents often are not aware that there are professionals who do home visits covered by insurance, professionals in special clinics, and professionals available at WIC for low-income families. But even when resources are available, it can be very difficult to search for the right care or advocate for oneself while recovering from birth.
Without prenatal education on lactation and the resources available, many lactating parents feel that the inability to breastfeed or breastfeeding challenges are a personal failure. A privileged parent might work very hard to find help and exhaustively feed and pump, making feeding more than a full-time job. Over weeks or months this can lead to burnout, struggling connecting with baby, relationship stress and sleep deprivation.
A parent who has less privilege, less help, less time, other children or who must return to work may decide that formula feeding will give them back their time and sanity. But that choice may come with guilt and shame over not being able to breastfeed. Guilt and shame can cause depression, and postpartum depression typically comes with its own dose of guilt and shame, feeding a vicious cycle. Powering through breastfeeding challenges carries some mental health risk – so can weaning. Especially weaning abruptly, which is extremely risky in terms of mental health due to sudden hormonal shifts in the brain.
Black families in the U.S. are much less likely to initiate and continue breastfeeding than white women for a myriad of reasons, but a few of the most important are the lack of black breastfeeding professionals and the lack of breastfeeding professionals available in communities of color in general.
If a bodyfeeding parent is not making enough milk, the solution is often simple: feed and pump more frequently. There is a trick we use in lactation called triple feeding: nurse and pump, then bottle feed. This typically takes an hour and starts again an hour later. This intensive process can lead to parents feeling like they never get to relax and focus on enjoying their new baby or like they have no idea who they are other than a milk machine.
Many parents, even with all the support in the world, don’t have the physiology to produce the amount of milk their baby needs, or their baby has physiology that may be causing feeding challenges and supply issues. Finding the right assessment, treatment and therapies is another stressor while also trying to heal from birth and care for baby.
Recently, formula-feeding and combo-feeding families experienced similar supply issue stress when formula manufacturing collapsed in the U.S. Much of the lactation community took the opportunity to lament, “This wouldn’t be an issue if more families breastfed” without recognizing that the field of lactation is constantly about managing supply issues.
Most families who are dependent on formula previously attempted to feed from their bodies. Maybe they did not have the right lactation support and education, or found the pressure of being the sole food provider too stressful. Many people initiate breastfeeding or bodyfeeding in the hospital for a couple of days, but continuing to breastfeed comes with a handful of systemic and highly stressful conundrums that often effect mental health.
The external pressure to perform
There is an anxiety-provoking mentality that good parents exclusively breastfeed. The AAP also tells parents that no formula should be introduced for the first six months.
These cultural and medical directives persist even though we have data that mindful supplementation can decrease stress and give the parent time and space to focus on developing great latch and supply. We have also found that the Baby Friendly Hospital Initiative that aimed to increase breastfeeding rates by keeping formula out of hospitals didn’t actually raise the rates of breastfeeding for families coming out of those hospitals. I’ve rarely seen a parent able to learn and master milk-increasing procedures while simultaneously worrying that baby is actively starving – without developing anxiety or depression. Formula is an essential tool of lactation professionals.
While the AAP tells parents that babies should be exclusively on breastmilk for six months, and while the hospital IBCLCs may tell you the same, nurses or doctors in the hospital may provide formula for a myriad of usually unnecessary reasons. They may send you home with formula samples but without clear guidelines on how to decide if they are needed and when to administer them. It is cruel to give parents such a conflicted start.
If the lactating parent has friends or family who feel positively about bodyfeeding and they experience social pressure to bodyfeed, this can compound the feelings of inadequacy, sadness and disappointment that come with lactation challenges.
The internal pressure to measure up
Many parents-to-be have specific ideas about parenting before baby arrives. When breastfeeding is part of that parenting style and it proves challenging in the beginning or after going back to work, this identity dissonance can lead to postpartum anxiety or depression.
We may not be able to identify why or how we have internalized the idea that parents who bottle feed are inferior, but the feeling of disappointment if things aren’t going well looms large. It might be as simple as repeatedly hearing the simple scientific fact that breastmilk is optimal for infants – of course we want to only give them the best.
While that message gets driven home again and again, we could relieve a lot of pressure by reminding new parents just as frequently that what is best for infants is also the mental wellness of their caregivers. Some families struggling with lactation may need to downgrade from “optimal nutrition” to “just fine” nutrition in favor of upgrading to “mentally well parent.”
There is a pervasive and damaging underlying belief, especially around mothering, that a good mother becomes a martyr to the infant and ignores her own needs to provide the most optimal upbringing for the child. In this game, both parent and baby often lose.
Twelve years ago, I was making just enough milk for a baby who woke up every hour at night for feedings. I happily obliged because it was building my milk supply (we make most of our prolactin at night). Getting out of bed that frequently wasn’t sustainable and friends told me that bedsharing would give me more sleep. I still woke up for feedings anyway and bedsharing did not create more sleep for me. Months went on and I became more and more sleep deprived, never completing a full adult sleep cycle – and I didn’t have help during the day. I developed postpartum psychosis. I was manic, had grandiose thoughts, and stayed up all night “writing my book.” I declared that I no longer had any need for sleep.
Fortunately, with a background in psychology and training as a postpartum doula, I was able to catch my illness quickly and found the perfect therapist. I started making changes to how we slept and understanding both the biology of infant sleep and the specific sleep challenges of bodyfeeding families. After solving my own sleep challenges, sleep consulting for lactating families is my life’s work, with the goal of balancing feeding needs and parenting values with the parents’ need to protect sleep and mental health.
Many bodyfeeding parents suffer sleep deprivation past one year because of fears that even gradual night weaning will lead to plugged ducts or mastitis, loss of milk supply, or any form of sleep modification will hinder emotional attachment.
Multiple studies confirm that bed-sharing improves the amount of sleep breastfeeding parents get. Yet parents who utilize this sleep method because baby eats frequently at night may become anxious or feel shame because the AAP considers bedsharing dangerous. Parents are caught between a rock and a hard place in many of the sleep choices they face. Exclusively breastfeeding families may want to read the AAP guidelines as well as the safer sleep guidelines from the Academy of Breastfeeding Medicine.
To promote breastfeeding, most lactation professionals neglect to share that most babies fed human milk simply wake more frequently than formula-fed babies. Infants are designed to wake and eat frequently as milk is digested rapidly and a high frequency of feeding helps produce more milk and keep infants breathing more regularly. Frequency of waking keeps parents more alert to predators. This is the theory behind the idea that breastfeeding is protective against sudden infant death.
Poor sleep is the greatest risk factor for the worsening of postpartum depression and one of the greatest risk factors for the onset of postpartum depression. While waking frequently may be protective of babies and milk supply, sleep deprivation is a huge risk factor for postpartum depression, anxiety, and psychosis. Mindfully balancing the needs of baby and parent is something we need to get much better at talking about and teaching.
My Chest, My Choice
We seem to believe bodily autonomy matters but we can’t seem to accept the idea that bodyfeeding or pumping are huge issues of bodily autonomy and must be chosen freely with more education and less pressure. I wish the full phrase were “Breast/chest is best unless it is making you stressed, anxious or depressed, or unless you simply don’t want to do it.” I know. It isn’t as catchy.
Because of the lack of systemic support for new parents, especially in the United States, starting, continuing, or stopping breastfeeding must be an ongoing, personal, and informed choice supported by family, community, professionals, and society. Every parent’s mental and physical health needs, tolerances, goals, and desires are unique.
Preventing Feeding Challenges, Feeding Shame & Protecting Mental Health
Create a Postpartum Plan
Expecting parents should note their risk factors for perinatal mental health challenges, such as prior history of mood challenges or a traumatic birth, the amount of support they will have in the perinatal period, their personal sleep needs, when they plan to return to work, and their ability to manage lactation.
Once these factors are considered, expecting parents can make a postpartum plan. This plan includes the parents’ ideal and contingency plans for getting support and next steps if feeding doesn’t go well or if the parent is beginning to feel anxious or depressed. To build a postpartum plan, I suggest looking at the questions in this article or here.
In planning for adequate sleep, talk to other caregivers and people you trust about how to make changes to baby’s sleep if you experience a sleep crisis and research how to begin aligning with circadian rhythms again after the first few weeks, to protect your melatonin production and encourage a better circadian rhythm in infants. Breastfeeding families can practice bottle feeding once daily starting at two weeks so that the baby is acclimated and does not develop a bottle aversion.
Find and Connect with Lactation Support Before Giving Birth
- Find a local breastfeeding basics class. Bonus if they also teach bottle-feeding skills and mixing formula!
- Find out if your pediatrician offers an IBCLC and ask to meet them.
- Find an IBCLC who is covered by your insurance and have a pre-baby phone call. Alert them as soon as baby has arrived.
- Ask a friend or family member to gift you the price of an IBCLC home visit.
- Many WIC offices have staff with lactation training. They can help with getting formula and offer bottle-feeding support if necessary.
- Feeding challenge emergency? Go to your local children’s hospital ER and request to be seen by an IBCLC.
- Consider getting overnight support from a postpartum doula a few nights a week.
Get Support and Know You’re Not Alone
- Peer support for breastfeeding: La Leche League
- Peer support online for breastfeeding/bodyfeeding: The Leaky Boob Facebook group
- Quality bodyfeeding info in a pinch: KellyMom.com
- Evidence-based Facebook group for bodyfeeding AND formula feeding
- Exclusively Pumping Facebook group
- Formula Feeding: Fed is Best Facebook group
Feeling all the feels about feeding?
Text/Call PSI ask for the breastfeeding/chest feeding coordinator and get support within 48 hours. We can help you find local support too.
Need support immediately? Call the National Maternal Mental Health Hotline: 1-833-9-HELP4MOMS.
Look for a counselor or therapist with perinatal mental health training (PMH-C)
Talk to your doctor about medication if you are struggling. Medications for anxiety or depression, even short-term, can lift symptoms and give you time to find the right feeding plan and care team. Many medications for anxiety and depression are safe for breastfeeding/bodyfeeding.
If you are a worried family member or you are concerned about your safety or baby’s safety and can’t see a therapist right away, go to the emergency room for immediate care. If you are breastfeeding, you can bring your baby and another caregiver. There is no need to worry about your infant being taken from your care.
We do not prepare parents for the possibility of early feeding challenges – and we must. Most parents in the U.S. do not get any feeding education prior to birthing. Many families I volunteer with do not feel they were educated or supported enough to make an informed choice regarding lactation. One parent said:
“If I’d have known that breastfeeding problems could put someone like me on anti-anxiety meds, I might have just made a different decision. It was the shock and disappointment and feeling alone that did me in.”
It is unfair that bodyfeeding within our culture poses mental health risks when it is humanity’s biological norm. It is unfair that many parents who try to bodyfeed have such a challenging time that they develop postpartum anxiety or depression. It is unfair when a parent walks around in shame for feeding their child formula that has sustained billions of babies.
Let’s acknowledge individual feeding journeys rather than judge, and support fellow parents in finding a balance between baby’s needs and parent’s needs.
*The phrase bodyfeeding is used along with or alternatively to breastfeeding to include nonbinary and trans parents, those who have had mastectomies, dads and others who use supplemental nursing systems on their bodies. The phrases bodyfeeding parent and lactating parent are also used for gender inclusivity.
Moorea Malatt is a PMH-C (Perinatal Mental Health Certified) Lactation Counselor-Educator, attachment-informed sleep consultant and Postpartum Doula. She is a volunteer with Postpartum Support International.