An evaluation of a prenatal individualised mixed management intervention addressing breastfeeding outcomes and postpartum depression: A ramdomised controlled trial

A systematic review of the benefits of breastfeeding against postpartum depression in low-middle-income countries

BACKGROUND

The positive impact of breastfeeding against postpartum depression has been increasingly reported. However, no studies have systematically and critically examined current evidence on breastfeeding practices' influences on postpartum depression in LMICs.

AIM

To review the influence of breastfeeding on postpartum depression in LMICs.

METHODS

We searched original research in English published over the last ten years (2012 - 2022) within 8 databases: EBSCOhost, EMBASE, Pubmed, Sage Journals, Science Direct, APA PsycArticles, Taylor & Francis, Google Scholar, and citation tracking. The risk of bias assessment used The Newcastle Ottawa Scale and The Modified Jadad Scale. We followed the PRISMA statement after the protocol had been registered on the PROSPERO. The review included 21 of 11015 articles.

RESULTS

Of 21 articles, 16 examined breastfeeding practices, 2 each investigated breastfeeding self-efficacy and breastfeeding education, and 1 each assessed breastfeeding attitude and breastfeeding support. 3 randomized control trials and 5 cohorts revealed that breastfeeding decreased the EPDS scores. However, 4 cross-sectional studies indicated that breastfeeding is nonsignificantly associated with postpartum depression.

CONCLUSION

This review indicated that breastfeeding may alleviate or prevent postpartum depression. Our findings indicated that integrating breastfeeding-related programs and policies into postpartum depression prevention may benefit public health.

REGISTRATION

PROSPERO (CRD42022315143).

Effect of Breastfeeding Education Program and Nurse-led Breastfeeding Online Counseling System (BMUM) for Mothers: A Randomized Controlled Study

BACKGROUND

Breastfeeding is very important for maternal and infant health. With first pregnancies, many pregnant people face obstacles to achieving their breastfeeding goals.

RESEARCH AIMS

We aimed to investigate the outcomes of a breastfeeding education program and nurse-led online breastfeeding counseling system (BMUM) on breastfeeding self-efficacy, attitudes about breastfeeding, breastfeeding problems, breastfeeding frequencies and postpartum depression.

METHODS

This study was a randomized controlled trial. Participants were randomly assigned to the intervention group (n = 36), or control group (n = 36). Assessments were conducted during pregnancy, between 32- and 37-weeks gestation, and on postpartum Day 1, Week 1, Week 3, and 6 months.

RESULTS

The means of the Breastfeeding Self-Efficacy-Short Form scores, and the Infant Feeding Attitude Scale (IIFAS) scores were similar between the groups at the first assessment (p = 0.733). IIFAS scores in the intervention group were significantly higher in the follow-up measurements on postpartum Day 1, Week 1, Week 3, and 6 months compared to scores in the control group (p = 0.006; p = 0.000; p = 0.002; p = 0.001) Edinburgh Postpartum Depression Scale (EPDS) scores were similar between the two groups at 1 week (p = 0.678). EPDS scores were significantly higher in the control group on Day 1 and at 3 and 6 months postpartum (p = 0.000; p = 0.038; p = 0.042). There was no statistically significant difference in breastfeeding problems between the two groups (p > 0.05 across breastfeeding problems examined). The mean values of breastfeeding frequency were similar between groups on Day 1, and significantly higher in the intervention group on follow-up measurements.

CONCLUSION

The results of this intervention appear to promote positive attitudes toward breastfeeding and decrease feelings of postpartum depression. However, further randomized controlled trials are needed to support our outcomes.

Breastfeeding and Postpartum Depression: A Review of Relationships and Potential Mechanisms

PURPOSE OF REVIEW

Postpartum depression (PPD) and breastfeeding are important, interrelated health factors. It is established that women who breastfeed exclusively have lowered likelihood of developing significant PPD. Yet, many questions remain around what factors are involved. The purpose of this review is to provide updated information about the relationship between PPD and breastfeeding.

RECENT FINDINGS

Both psychological and physiological factors have emerged as important moderators and mechanisms of the relationship between postpartum depression and breastfeeding. Breastfeeding self-efficacy, self-compassion, and engagement with the infant during feeding all modify or mediate the relationship, and a complex dynamic relationship among cortisol, oxytocin, progesterone, and estrogen is involved. Importantly, recent intervention studies suggest psychosocial interventions may impact both breastfeeding and mood. Providers and researchers should recognize the interrelationship between the breastfeeding and PPD and apply this understanding to patient care through integrated education and care for both mood and breastfeeding enhancement.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Efficacy of behavioral interventions to improve maternal mental health and breastfeeding outcomes: a systematic review

BACKGROUND

Despite extensive benefits and high intentions, few mothers breastfeed exclusively for the recommended duration. Maternal mental health is an important underlying factor associated with barriers and reduced rates of breastfeeding intent, initiation, and continuation. Given evidence of a bidirectional association between maternal mental health and breastfeeding, it is important to consider both factors when examining the efficacy of interventions to improve these outcomes. The purpose of this manuscript is to review the literature on the efficacy of behavioral interventions focused on both maternal mental health and breastfeeding outcomes, examining the intersection of the two.

METHODS

This systematic review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Studies were selected if they were available in English, used primary experimental design, and used a behavioral intervention type to examine maternal mental health and breastfeeding outcomes. Articles were identified from PubMed, CINAHL, Embase, and PsycINFO from database inception to 3 March 2022. Study quality was assessed using the Cochrane Risk of Bias tool. Results were synthesized by intervention success for 1. Mental health and breastfeeding, 2. Breastfeeding only, 3. Mental health only, and 4. No intervention effect. PROSPERO CRD42021224228.

RESULTS

Thirty interventions reported in 33 articles were identified, representing 15 countries. Twelve studies reported statistically significant positive effect of the intervention on both maternal mental health and breastfeeding; most showing a decrease in self-report depressive and/or anxiety symptoms in parallel to an increase in breastfeeding duration and/or exclusivity. Common characteristics of successful interventions were a) occurring across pregnancy and postpartum, b) delivered by hospital staff or multidisciplinary teams, c) offered individually, and d) designed to focus on breastfeeding and maternal mental health or on breastfeeding only. Our results are not representative of all countries, persons, experiences, circumstances, or physiological characteristics.

CONCLUSIONS

Interventions that extend the perinatal period and offer individualized support from both professionals and peers who collaborate through a continuum of settings (e.g., health system, home, and community) are most successful in improving both mental health and breastfeeding outcomes. The benefits of improving these outcomes warrant continued development and implementation of such interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021224228.