Perinatal depression and breastfeeding: a longitudinal investigation of the bidirectional relationship in Pakistan

PURPOSE: The relationship between perinatal depression and breastfeeding is complicated and reciprocal. While breastfeeding may protect against postpartum depression, perinatal depression can also reduce the likelihood of breastfeeding. Using longitudinal data from Pakistan, we examine the effect of (1) breastfeeding on postpartum depression, stratified by prenatal depression and (2) perinatal depression on breastfeeding. METHODS: Data were drawn from the Bachpan study in Pakistan at five timepoints: pregnancy, delivery, 3-, 6-, and 12-months postpartum. Breastfeeding (any and exclusive [EBF]) was assessed using 24-hour recall; depression was measured with the Structured Clinical Interview for DSM-5 (SCID). Marginal structural models accounted for the time-varying relationship between depression and breastfeeding to estimate risk ratios (RR) and 95% confidence intervals (CI). RESULTS: Among 1,014 postpartum individuals, weighted prevalence of any breastfeeding was 73.6% at delivery, 93.1% at 3-months, 86.1% at 6-months, and 73.0% at 12-months. EBF at 6-months was low (8.7%). Depression prevalence was 25.1% during the third trimester, 13.1% at 3-months, 10.8% at 6-months, and 15.7% at 12-months. Any breastfeeding was associated with a lower risk of postpartum depression (RR: 0.77; 95% CI: 0.51-1.03), though the CI included the null. In turn, perinatal depression reduced the likelihood of any breastfeeding (RR: 0.92; 95% CI: 0.84-0.99). EBF was similarly associated with a lower risk of postpartum depression (RR: 0.94; 95% CI: 0.68-1.20), though the CI also included the null. When stratified by prenatal depression, point estimates suggest that EBF may have a stronger association with lower depression risk among those without prenatal depression compared to those with prenatal depression (RR: 0.77 vs. RR: 1.03), though both CIs included the null. CONCLUSIONS: Results support a complex bidirectional relationship between breastfeeding and perinatal depression, where depression reduces breastfeeding likelihood and any breastfeeding shows possible protective associations with depression, though the benefits of EBF may differ by prenatal depression status.