Presented at the Society for Maternal Fetal Medicine, Las Vegas, NV, February 2019.

Alison Goulding, Karen Grewen, Samantha Meltzer-Brody, Brenda Pearson, Alison Stuebe

Objective: We sought to examine the association between traumatic birth and measures of mood and parenting stress through 12 months postpartum.

Study Design: We conducted a secondary analysis of participants in the Mood, Mother and Infant (MMI) Study. Women intending to breastfeed were recruited in the 3rdtrimester for a longitudinal cohort study, oversampling for women with current/past depression or anxiety.  A structured clinical interview was performed at baseline to assess for history or current diagnosis of major depressive or anxiety disorders. Baseline anxiety and depression symptoms were measured using the Beck Depression Inventory (BDI) and the Spielberger State-Trait Anxiety Inventory (STAI). Mood was measured at baseline and monthly with the Edinburgh Postnatal Depression Scale (EPDS), and at 2, 6, and 12 months postpartum with the BDI, STAI, and Parenting Stress Index (PSI). Maternal post-traumatic stress disorder (PTSD) symptoms were assessed at 2 months postpartum using the modified Perinatal PTSD Questionnaire (PPQ); birth PTSD was defined using the established threshold of PPQ score ≥ 19. We used repeated measures analysis to quantify the association between birth PTSD and postpartum mood and parenting stress through 12 months postpartum, adjusting for prenatal PPD risk and mood symptoms.

Results: Data were available from 209 women, of whom 15 (7.2%) had birth PTSD. Compared to women without birth PTSD, these women had higher prenatal STAI-Trait (mean 45.1 vs. 33.6, p=0.01) and BDI (mean 18.4 vs. 8.6, p<0.01) scores. In repeated measures analysis adjusting for prenatal STAI-Trait score, BDI score and PPD risk status, we found that birth PTSD was independently associated with higher postpartum EPDS (group p=0.03, group x time p=0.01), BDI (group p<0.0001), state anxiety (group p=0.002, group x time p=0.01) and PSI (group p=0.002) scores through 12 months postpartum.

Conclusions: In our sample, 7% of women had birth PTSD. A traumatic birth experience was associated with postpartum anxiety and depression symptoms and parenting stress, independent of prenatal risk. These findings support efforts to minimize traumatic experiences during childbirth, and to provide additional support to women who endorse PTSD symptoms following birth.

Presented at the Academy of Breastfeeding Medicine International Conferece, November 2018

Alison Stuebe, Roger Mills-Koonce, Samantha Meltzer‐Brody, Brenda Pearson, Karen Grewen

Background: Maternal-infant bonding is a commonly-cited benefit of breastfeeding.

Objective: We sought to quantify associations between breastfeeding intensity and attachment security at 12 months.

Methods:
We analyzed mother-infant pairs in an ongoing longitudinal cohort study. Women intending to breastfeed were recruited in the 3rd trimester of pregnancy for an ongoing longitudinal study. Psychiatric history was assessed via Structured Clinical Interview, with oversampling of women with a history or current diagnosis of major depressive disorder or anxiety disorders. Infant feeding was assessed monthly, with a 7-day recall of feeding at breast, expressed milk, or breastmilk substitutes. Breastfeeding intensity was calculated as the proportion of milk feedings that were at breast at each assessment. Attachment security was assessed at 12 months using the Ainsworth Strange Situation Paradigm (SSP). We used repeated measures analysis to quantify the extent to which at-breast feeding intensity was associated with attachment. Because infant sex has been reported to modify the effects of maternal behavior on socio-emotional development, we further stratified by infant sex.

Results:
Among 96 mother-infant pairs for whom SSP coding had been completed, 12/45 boys (26.7%) and 17/51 girls (33.3%) were insecurely attached. When we analyzed boys and girls together, we found no association between at-breast feeding intensity and secure attachment (p=0.50). However, the association differed by infant sex (p for interaction =0.03). Higher breastfeeding intensity was associated with secure attachment among girls (p= 0.01). Among boys, breastfeeding intensity was not associated with secure attachment (p=0.21).

Conclusions:
In an ongoing longitudinal cohort study, we found that the association between at-breast feeding intensity and secure attachment varied by infant sex. These findings suggest that stratified analyses by infant sex should be considered in studies of breastfeeding and socioemotional development.

Presented at the Breastfeeding and Feminism International Conference, Chapel Hill, NC, March 21-23, 2018

Wouk K¹, Tucker CM¹, Pence BW², Meltzer-Brody S³, Zvara B¹, and Stuebe AM^1,4

Background: Major medical organizations in the U.S. recommend exclusive breastfeeding for six months, with continued breastfeeding through the first year “or longer as mutually desired by the woman and her infant.” Few studies have explored the role of maternal emotions in breastfeeding outcomes. Dr. Barbara Fredrickson’s broaden-and-build theory of positive emotions suggests that experiences of positive emotions lead to adaptive benefits by broadening one’s thought-action repertoire, allowing the accrual of personal and social resources to improve health and well-being.

Aims/Purpose: To estimate the association between maternal positive emotions during infant feeding at two months and time to any and exclusive breast milk feeding cessation and overall maternal evaluation of breastfeeding at 12 months. Continue reading →

Presented at the Society for Maternal Fetal Medicine Annual Meeting, Dallas, TX, February 2018.

Alison M. Stuebe1,3, Samantha Meltzer-Brody2, Brenda Pearson2, Cheryl Walker2, Karen Grewen2

1Department of Obstetrics and Gynecology, 2Department of Psychiatry, 3Department of Maternal and Child Health,
Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina

Objective: Perinatal depression (PND) affects 1 in 8 women, making it the most common complication of childbirth. Hypothalamic Pituitary Adrenal (HPA) axis dysregulation has been implicated in the pathogenesis of PND, indexed by a blunted Cortisol (CRT) response to Adrenocorticotropic Hormone (ACTH). We hypothesized PND would be associated with dysregulated stress reactivity during lab stressors, indexed by loss of expected associations between ACTH and CRT.

Study Design: Women intending to breastfeed were recruited in the 3rd trimester for an ongoing longitudinal study. Past or current major depressive disorder or anxiety disorders were assessed via Structured Clinical Interview at enrollment; women with a history or current diagnosis of depression or anxiety were classified as high risk. At two months postpartum, dyads attended a lab visit. Following peripheral IV placement, women breastfed their infants and then participated in the Trier Social Stress Test (TSST), a standardized social stressor that includes a speech task and a math task. Blood samples for ACTH and CRT were collected prior to feeding, 10 minutes after feeding, during the speech and math tasks, and at 10, 20 and 30 minutes of recovery. We used repeated measures analysis to quantify associations between risk status and CRT and ACTH during the TSST, and we used linear regression to quantify the extent to which high risk status modified associations between ACTH at time j and cortisol at time j+1. P values <0.05 were considered statistically significant.

Results: ACTH and CRT data were available for 114 women, of whom 69 were high risk for PND and 45 were low risk. In repeated measures analysis (figure), high risk women had higher ACTH levels during the speech and math tasks (p<.05) and lower CRT levels during the recovery (p<.05) than low risk women. When we quantified associations between ACTH at time j and CRT at time j+1, we found that risk status modified this association: higher ACTH during the speech and math tasks, as well as during recovery, was associated with higher CRT among low-risk women, but not among high risk women (p for interaction < .05, figure).

Conclusion: We found a blunted association between ACTH and CRT among women with a history or current diagnosis of depression or anxiety. These findings support our hypothesis that the HPA axis is dysregulated in perinatal depression.

Presented at the Academy of Breastfeeding Medicine Annual Meeting. Atlanta, GA, November 2017.

Alison M. Stuebe1,3, Bharathi Zvara3, Samantha Meltzer-Brody2, Brenda Pearson2, Cheryl Walker2, Karen Grewen2

1Department of Obstetrics and Gynecology, 2Department of Psychiatry, 3Department of Maternal and Child Health,
Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina

Background: Adverse childhood experiences are associated with mood disorders and difficulties with early caregiving behaviors. We sought to quantify associations among moderate/severe childhood trauma (MSCT), depression symptoms and breastfeeding intensity.

Methods: Women intending to breastfeed were recruited in the 3rd trimester of pregnancy for an ongoing longitudinal study. Past or current major depressive disorder or anxiety disorders were assessed via Structured Clinical Interview. Trauma history was quantified using the Childhood Trauma Questionnaire. MSCT was quantified using CTQ subscale scores (abuse: emotional≥13, physical≥10, sexual≥8; neglect: emotional≥15, physical≥10).  During monthly interviews, mood was assessed via the Edinburgh Postnatal Depression Scale, and breastfeeding intensity in the past 7 days was assessed via a feeding questionnaire. Mean breastfeeding intensity and EPDS scores over the first 6 months and from birth to 12 months were used to calculate cumulative breastfeeding intensity (CBI) and cumulative EPDS (CEPDS). We used Wilcoxon rank sum tests to quantify the association between MSCT and CBI, and we used linear regression to model associations between CBI and CEPDS. P values <.05 were considered statistically significant.

Results: Among 162 women who had completed data collection, 41 (25.8%) had a history of MSCT. MSCT was associated with lower CBI in the first 6 months postpartum (median vs 0.77 [0.39-0.91] vs [IQR]: 0.87, [0.71-0.97]).  MSCT modified associations between CEPDS and CBI: Among women with MSCT, higher EPDS scores were associated with lower CBI (p for interaction <.01, whereas among women without MSCT, mood scores were not associated with breastfeeding intensity. In the MSCT trauma group, exclusive breastfeeding for 6 months was associated with a 4.4-point reduction in predicted CEPDS score, compared with never breastfeeding.

Conclusions: Among women with a history of MSCT, targeted strategies to reduce mood symptoms and support greater breastfeeding intensity may have synergistic effects on maternal health, wellbeing and early caregiving behavior.

Presented at the Academy of Breastfeeding Medicine Annual Meeting. Atlanta, GA, November 2017.

Alison M. Stuebe1,3, Samantha Meltzer-Brody2, Brenda Pearson2, Cheryl Walker2, Karen Grewen2

1Department of Obstetrics and Gynecology, 2Department of Psychiatry, 3Department of Maternal and Child Health,
Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina

Background: During breastfeeding, oxytocin facilitates milk let down. Oxytocin has also been implicated in maternal behavior and perinatal mood disorders. We sought to quantify the association between maternal mood symptoms, antidepressant use, and oxytocin levels during breastfeeding.

Methods: Women intending to breastfeed were recruited in the 3rd trimester of pregnancy for an ongoing longitudinal study, oversampling for women at high risk of depression or anxiety. At two and six months postpartum, dyads attended a lab visit. Following peripheral IV placement, women breastfed, with blood samples collected at baseline, 1, 4, 7, 10 minutes of feeding, and after 10-minute postfeed rest. Oxytocin levels were determined by enzyme immunoassay with extraction. Maternal depressive symptoms were quantified using the Beck Depression Inventory II ( score ≥11 defined as mild symptoms). Maternal medication use was reported via questionnaire. We used repeated measures analysis to quantify OT during breastfeeding among women with and without depressive symptoms and using or not using antidepressants. P values <.05 were considered statistically significant.

Results: Of 138 women who breastfed at the 2-month study visit, 88 were without symptoms and were not taking antidepressants, 17 were without symptoms and taking antidepressants, 23 were symptomatic and not taking antidepressants, and 10 were symptomatic and taking antidepressants.  In repeated measures analysis, we found a significant group * time interaction (p=.01):  At 2 months, OT levels were similar among women not taking antidepressants, regardless of symptoms, whereas women taking antidepressants had lower OT levels after the first few minutes of feeding. At 6 months, OT levels were similar among women without symptoms, and lower among women with symptoms (p = 0.02).

Conclusions: Both depression symptoms and antidepressant use are associated with differences in OT levels during breastfeeding.

Kathryn Wouk, Bharathi Zvara, Christine Tucker, Samantha Meltzer-Brody, Brian Pence, and Alison M. Stuebe

Presented at the Nutrition and Nurture in Infancy and Childhood (MAINN) Conference, Monday 12th – Wednesday 14th June 2017, Grange Over Sands, Cumbria, UK

Perinatal depression affects approximately one in eight women during pregnancy and the first year postpartum (Gaynes et al. 2005). Untreated perinatal depression is associated with numerous adverse outcomes including early breastfeeding cessation (Dias & Figueiredo 2014) and serious child social and emotional developmental concerns (Stein et al. 2014). Research shows that individuals can reduce depression symptoms and build personal resources, such as social support and mindfulness, by increasing experiences of positive emotions (Fredrickson et al. 2008). However, the role of positive emotions in breastfeeding and perinatal mental health has not yet been explored.

The objective of this study was to determine the extent to which women’s experiences of positive emotions during infant feeding are associated with postpartum depression and anxiety symptoms. This research is grounded in Barbara Fredrickson’s Broaden-and-Build theory of positive emotions, which posits that experiences of positive emotions trigger upward spirals that improve mental health and wellbeing (Fredrickson 2004). Applied in a variety of intervention contexts, this theory has demonstrated that cultivation of positive emotions through a loving-kindness meditation intervention leads to improved psychosocial outcomes, such as reduced depression symptoms (Fredrickson et al. 2008) and increased life satisfaction (Johnson et al. 2011). While it has not yet been tested in a perinatal population, the Broaden-and-Build theory suggests that positive emotions experienced during infant feeding may broaden the scope of a mother’s thoughts and actions, allowing her to build resources to cope with mental health challenges. Continue reading →