doi:10.1111/j.1440-1754.2008.01336.

ORIGINAL ARTICLE

Breastfeeding duration and postpartum psychological adjustment:

Role of maternal attachment styles
Ipek Akman,1 M. Kemal Kuscu,2 Ziya Yurdakul,1 Nihal zdemir,3 Mine Solakoglu,4 Lale Orhon,2
Aytl Karabekiroglu2 and Eren zek1
1
Division of Neonatology, Department of Paediatrics, and Departments of 2Psychiatry, 3Paediatrics and 4Public Health, Marmara University Medical School,
Istanbul, Turkey

Aim: Depressive and anxiety symptoms are common in new mothers. The aim of this study is to explore the link between postpartum
psychological adjustment and feeding preferences of the mothers.
Methods: Sixty mothers and newborns were enrolled in this prospective, longitudinal study. Maternal depressive symptoms were screened
by the Edinburgh Postpartum Depression Scale (EPDS), and maternal anxiety level was assessed by the State-Trait Anxiety Inventory at 1 month
postpartum. The Multidimensional Scale of Perceived Social Support was used for the assessment of maternal social support. The Adult
Attachment Scale was used to determine the attachment style of the mother. Infants were examined and evaluated at 1 and 4 months of life.
Results: All mothers started breastfeeding their infants postpartum; 91% and 68.1% continued exclusive breastfeeding at 1 and 4 months,
respectively. The rst-month median EPDS score of mothers who breastfeed at the fourth month was statistically signicantly lower than those
who were not breastfeeding (6 and 12, respectively) (P = 0001). The rst-month median EPDS score of mothers with secure attachment was
lower than the median score of mothers with insecure attachment (5 and 9, respectively) (P < 0001). Exclusive breastfeeding rate was not
statistically different among mothers with secure and insecure attachment styles. The median state and trait anxiety scores and social support
scores of mothers were not different between groups according to breastfeeding status.
Conclusions: This study has shown an association between higher EPDS scores and breastfeeding cessation by 4 months after delivery.

Key words: attachment style; breastfeeding; postpartum depression.

The World Health Organization recommends exclusive breast-
feeding for the first 6 months of life because of the numerous
benefits of breastfeeding for the mother and the child.1
However, previous studies have reported that young maternal
age, lower educational attainment, low social class and maternal
depressive disorder increase the risk of early termination of
breastfeeding.2,3 After adjustment of confounding factors, early
cessation of breastfeeding was found to be significantly associ-
ated with postnatal depression.2,46
Postpartum depressive or anxiety symptoms are common
maternal experiences effecting 1020% of new mothers.79 It is
often under diagnosed causing significant morbidity for the
entire family and deleterious effects on child care.10 In the post-
partum period, mothers might often feel anxious and present
Key Points
1 There is an association between higher EPDS scores and breast-
feeding cessation by 4 months after delivery.
2 There is an association with insecure adult attachment style and
postpartum depression.
3 There is a tendency of exclusive breastfeeding in mothers
who had a secure attachment style but this is not statistically
signicant.
Correspondence: Dr Ipek Akman, evre Sok, 54/6 06680 ankaya, Ankara,
Turkey. Fax: 090 216 3250323; email: ipekakman@yahoo.com
mild mood changes while they are trying to adapt to their new
roles as main care givers. These symptoms often do not reach to
a clinical significance and most of the time, require no specific
treatment other than maternal education and support. However,
high levels of depressive symptoms may contribute to poor child
outcomes from infancy to adolescence. Compared with well
women, depressed mothers were found to be less sensitively
attuned to their infants and were less affirming.11 Therefore,
there is a need for resources devoted to supporting new mothers
and routine screening and treatment for postpartum depression.
Attachment styles are emotional patterns that reflect mother
and infant reciprocal relationship. Adult attachment styles are a
prominent marker of personal construction of early childhood
experiences, which are closely related to the caregiving content.12
In an earlier meta-analysis, it was demonstrated that if mothers
attachment styles were secure, the caregiving behaviours were
more responsive and positive.13 Mothers anxiety level, maternal
attachment style and enviromental psychological (marital dissat-
isfaction, etc.) or non-psychological factors can contribute to
maternal psychological adoptation and create a contextual risk
for motherinfant diad in the early postpartum period.
In this study, we aimed to examine the psychological adjust-
ment of the mothers during early postpartum months and
describe the effect of maternal depressive symptoms, anxiety
levels, availability of social support and maternal attachment
styles on breastfeeding discontinuation for the first 4 months of
life.

Journal of Paediatrics and Child Health 44 (2008) 369373 369

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Journal compilation 2008 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Maternal depression and breastfeeding duration
Materials and Methods
The study population comprised a cohort of 60 mothers who
gave birth at Marmara University Hospital between June and
December 2005 and their infants who had an uneventful pre-
natal, perinatal and postnatal course. Mothers and newborns
with medical problems that needed hospitalisation were
excluded from the study. None of the mothers had any obstetric
complications in their previous pregnancies. Mothers were
asked to sign an informed consent before participation in the
study. The study was approved by Marmara University Ethical
Committee.
Perinatal records were reviewed and newborns were exam-
ined in the first week, the first and fourth months of life. All
mothers received short introductory information and encour-
agement to breastfeed from doctors and nurses during initial
hospital stay and subsequent follow-up appointments. A com-
plete dietary history was obtained and growth parameters of
infants were assessed during these visits. For analysis of data, we
grouped mothers into two according to the status of exclusively
breastfeeding at the fourth month.
Maternal evaluations were done by two research assistants
from psychiatry department. Each interview was evaluated with
a consultant psychiatrist. An initial assessment interview was
developed to assess the context of pregnancy and postpartum
experience of caregiving in the first week of postpartum period.
The interview included questions about the demographic char-
acteristics of mothers, medical and personal adversity before and
after childbirth, quality of living circumstances, quality and
quantity of social support network, problems and life events
related to pregnancy, daily life including instrumental, personal
and family life, and life adversity before the childbirth. The
initial interviews were carried out in a separate room in the
inpatient newborn unit. In the first month of the follow-up,
mothers were instructed to fill the Edinburgh Postpartum
Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI),
Adult Attachment Scale (AAS) and Multidimensional Scale of
Perceived Social Support (MSPSS) during their visits to
newborn outpatient clinic. Mothers who had difficulties under-
standing the content of the questionnaires were assisted by
research assistants. Mothers who had an EPDS score >13 were
evaluated with a semistructured interview on postpartum
depression to confirm the postpartum depression. Mothers who
experienced a postpartum depression were invited to the psy-
chiatry clinic for further intervention and follow-up.
Edinburgh Postpartum Depression Scale
The EPDS is a 10-item scale developed to measure the depres-
sive symptoms during postpartum period.14 The scale focuses on
specific depressive symptoms of postpartum period. The Turkish
validation is done by Engindeniz et al.15
Adult Attachment Scale
The AAS is a Likert-type 18-item self-report scale developed by
Collins and Read based on Hazan and Shavers Attachment
Style Measure.16,17 It assesses three adult attachment styles,
namely secure, avoidant and ambivalent styles. The AAS was
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Ipek Akman et al.
translated into Turkish and validated by Alp (IE Alp, unpub-
lished data, 1998). Because of the response rates in Turkish
population, avoidant and ambivalent styles were clustered as
insecure attachment style in this study.
State-Trait Anxiety Inventory
The STAI is a 40-item questionnaire measuring state (20 items)
and trait (20 items) anxiety.18 The STAI assesses how respon-
dents feel right now (state) and how respondents generally feel
(trait) on a 4-point Likert scale, indicating experience of a sig-
nificant amount of anxiety symptom. The total score for trait
and state anxiety ranges from 20 to 80. The STAI has good
internal consistency and testretest reliability.19
Multidimensional Scale of Perceived
Social Support
The MSPSS is a self-report measure of perceived social support
which is composed of 12 items, with four items comprising each
of three sources of social support (family, friends and significant
others).20 It was translated into Turkish and its validity and
reliability was provided by Eker and Arkar.21
Statistical analysis
The SPSS 10.0 for Windows (SPSS Inc., Chicago, IL, USA) was
used for data analysis. The differences in dichotomous variables
were analysed by c2 test, and the differences in continues vari-
ables were analysed by independent t-test when the sample was
distributed normally and by MannWhitney U-test when the
distribution was not normal.
Results
Demographic characteristics of the study group are shown in
Table 1. There was no statistically significant difference among
infant and maternal characteristics. All mothers had uneventful
prenatal and postnatal course. None of them were on any medi-
cation that would require discontinuation of breastfeeding.
Thirty-seven of 60 mothers were multiparous and 32 mothers
had breastfed their infants before. The median duration of
breastfeeding was 12 months (interquartile range (IQR) 618)
in the previous pregnancies.
All mothers, enrolled to the study, started breastfeeding their
infants postpartum; 91% and 68.1% continued breastfeeding
at first and fourth months, respectively. The EPDS scores of
mothers who discontinued breastfeeding before 4 months were
statistically significantly higher than those who were not. The
state and trait anxiety scores and social support scores were not
different between groups (Table 2).
It was found that 13.6% of mothers were at high risk for
depression (EPDS 13). Among mothers who had an EPDS
score of 13 (n = 8), 87.5% (n = 7) have discontinued breast-
feeding at 4 months. There was a statistically significant differ-
ence between the feeding preferences of mothers at high risk
of depression (P < 0.01). The median EPDS score of mothers
with secure attachment 538 was lower than the median EPDS
score of mothers with insecure attachment 9,512 and this was
Journal of Paediatrics and Child Health 44 (2008) 369373
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Ipek Akman et al. Maternal depression and breastfeeding duration

Table 1 Demographic characteristics of study population

Characteristics Exclusive breastfeeding at the fourth month P

Yes (n = 42) No (n = 18)

Birth weight (g) 3461 633 3357 356 0.4

Sex of the baby
Male/female 18/24 7/11 0.2
Maternal age (year) 29.9 4.8 28.6 6.1 0.4
Maternal parity
Primiparous/multiparous 16/26 7/11 0.3
Mothers education
<8 years 8 6 0.1
>8 years 34 12
Working status
Housewife 23 10 1
Works outside the house 19 8

Table 2 Postpartum psychological state of mothers and feeding preference at the fourth month

Psychological state Exclusive breastfeeding Discontinued exclusive breastfeeding P score

Median Interquartile range Median Interquartile range

EPDS 6.0 48 12.0 613 0.002

State anxiety score 41.0 3347 43.0 3451 0.4
Trait anxiety score 37.0 3246 36.0 3049 0.7
Social support score 75.0 63.779.2 73.5 6576 0.3

EPDS, Edinburgh Postpartum Depression Scale.

Table 3 Postpartum psychological evaluation and attachment styles

Secure attachment Insecure attachment P

Median Interquartile range Median Interquartile range

EPDS 5 38 9 512 <0.001

State anxiety 41 31.549.5 44 37.551.0 0.3
Trait anxiety 35 3144.5 40 34.550.0 0.8
Social support 76 67.781.0 72 57.576.09 0.02

EPDS, Edinburgh Postpartum Depression Scale.

statistically significant (Table 3). Mothers with secure attach-
ment style seemed to have higher exclusive breastfeeding rate,
but this pattern showed no statistical significance (Table 4).
Discussion
This study has shown an association between higher maternal
EPDS scores and cessation of exclusive breastfeeding by
4 months after delivery. Postpartum depression is a serious,
common and treatable condition, and clinicians recognition of
this condition may contribute to breastfeeding continuation and
prevention of adverse effects on mothers and infants.
The promotion and support of beastfeeding should be a
national public health priority especially in developing coun-
tries. Most mothers initiate breastfeeding in hospital, but the
rate of exclusive breastfeeding at 6 months is relatively low in
many countries. Henderson et al. have reported that 57% of the
patients were breastfeeding at 6 months and there is a signifi-
cant negative impact of postpartum depression on breastfeed-
ing duration.22 Ertem et al. have shown that only 59.3% of a

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Journal compilation 2008 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Maternal depression and breastfeeding duration
Table 4 Attachment style of the mothers and feeding preference at the
fourth month
Attachment style Exclusively breastfeeding at the fourth month
Yes No Total
n % n % n %
Secure 26 72 10 28 36 100
Insecure 15 65 8 35 23 100
P > 0.05.
socio-economically advantaged patient population from Turkey
was breastfeeding at 4 months.23 Similiarly, all mothers in our
study initiated breastfeeding; however, 91% and 68.3% of them
were exclusively breastfeeding at 1 month and 4 months,
respectively. Our study focused on middle-income families and
76.7% of the mothers had more than 8 years of education; thus,
our results may not be expanded to a more socio-economically
disadvantaged population in Turkey.
Studies have found higher risk of breastfeeding discontinua-
tion in mothers who lack support from family and friends,
insufficient prenatal breastfeeding education and who return to
work full-time.2426 Our study had a small sample size, but was
composed of a relatively homogenous population without any
ethnic or major cultural differences. All participants had been
followed at the same obstetric clinic and delivered in the same
hospital. They also received the same pre- and postnatal breast-
feeding education programme. Thus, in this study we were not
able to investigate the social and cultural factors or lactation
education affecting breastfeeding duration, but focused on the
psychological state of the mother in the early postpartum
weeks. Taveras et al. have shown that mothers with higher
depressive symptom scores were more likely to discontinue
breastfeeding at 12 weeks.3 Other studies have also shown that
postpartum depressive symptomology of mother predicted a
reduced preference of breastfeeding at later ages.2,5,20 Similiarly,
we have found that EPDS scores of mothers who continued
exclusive breastfeeding for 4 months were lower than those of
the ones who started formula feeding. The majority of mothers
in our study did not have evidence of severe mental disorder
and were mostly in the normal range of functioning. However,
13.6% were found to be at high risk for postpartum depression
by EPDS. EPDS is a validated screening instrument for post-
partum depression.14 It is necessary to screen new mothers for
postpartum depression because most of them do not recognise
their problem as depression.9 Twenty per cent of cases with
severe postpartum depression become chronic and delayed
treatment is the greatest factor in the development of chronic
depression.27
In our study we found a significant association with insecure
adult attachment style and postpartum depression. There was
a tendency of exclusive breastfeeding in mothers who had a
secure attachment style, but this was not statistically significant.
Mothers attachment style which is often a result of earlier
childhood experience of mothers in their own motherinfant
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Ipek Akman et al.
diad constructs a continum in adult life. Attachment style is not
only an important predictor of postpartum depressive states, but
also has an impact on several motherinfant diad adversities.28
We believe that this finding could improve our insight in the
patterns of adverse child-care events such as the early discon-
tinuation of breastfeeding. Early recognition of attachment
styles could contribute to the preventive interventions for post-
partum motherinfant interaction.
New mothers need support from family members and friends
to adjust themselves to their new role as a mother. In our study
exclusive breastfeeding rates of first-time mothers and multi-
parae were similar at 4 months. This may be achieved by the
support from family members of the new mothers. However,
social support scores of mothers who were exclusively breast-
feeding were not statistically different than the mothers who
discontinued breastfeeding in this study.
Cultural issues and family members have an influencial role
in breastfeeding initiation. Personal emotional styles and post-
partum emotional adjustment have an impact on the breasfeed-
ing duration on individula level. However, the support from
paediatricians and nurses during the postpartum hospitalisation
and postdischarge period is very crutial for breastfeeding con-
tinuation.21 Earlier recognition of maternal emotional needs and
risks could contribute to this effort. Studies with interventions
to prolong breastfeeding duration of mothers with depressive
symptoms are necessary.
References
1 American Academy of Pediatrics Work Group on Breastfeeding.
Breastfeeding and the use of human milk. Pediatrics 2005; 115:
496506.
2 Cooper PJ, Murray L, Stein A. Psychosocial factors associated with the
early termination of breastfeeding. J. Psychosom Res. 1993; 48:
90101.
3 Taveras EM, Capra AM, Braveman PA, Jensvold NG, Escobar GJ, Lieu
TA. Clinician support and psychosocial risk factors associated with
breastfeeding discontinuation. Pediatrics 2003; 112: 10815.
4 Falceto OG, Giugliani ER, Fernandes CL. Inuence of parenteral mental
health on early termination of breastfeeding: a case control study.
J. Am. Board Fam. Pract. 2004; 17: 17383.
5 Galler JR, Harrison RH, Biggs MA, Ramsey F, Forde V. Maternal moods
predict breastfeeding in Barbados. J. Dev. Behav. Pediatr. 1999; 20:
807.
6 Hellin K, Waller G. Mothers mood and infant feeding: prediction of
problems and practices. J. Reprod. Infant Psychol. 1994; 10: 3951.
7 Danac AE, Dinc G, Deveci A, Sen FS, Icelli I. Postnatal depression in
Turkey: epidemyelogical and cultural aspects. Soc. Psychiatry
Psychiatr. Epidemiol. 2002; 37: 1259.
8 Horowitz JA, Goodman JH. Identifying and treating postpartum
depression. J. Obstet. Gynecol. Neonatal Nurs. 2005; 34: 26473.
9 Siedman D. Postpartum psychiatric illness: the role of the
pediatrician. Pediatr. Rev. 1998; 19: 12831.
10 Cogill SR, Caplan HL, Alexandra H, Robson KM, Kumar R. Impact of
maternal postnatal depression on cognitive development of young
children. Br. Med. J. (Clin. Res. Ed) 1986; 292: 11657.
11 Hall LE, Farel AM. Maternal stresses and depressive symptoms:
correlates of behaviour problems in young children. Nurs. Res. 1998;
37: 15661.
12 George C, Solomon J. Representational mental models of
relationships: link between caregiving and attachment. Infant Ment.
Health J. 1996; 17: 198216.
Journal of Paediatrics and Child Health 44 (2008) 369373
2008 The Authors
Ipek Akman et al.
13 van Ijzendoorn M. Adult attachment representations, parental
responsiveness, and infant attachment: a meta-analysis on the
predictive validity of the Adult Attachment Interview. Psychol. Bull.
1995; 117: 387403.
14 Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression:
development of the Edinburgh Postnatal Depression Scale. Br. J.
Psychiatry 1987; 150: 7826.
15 Engindeniz AN, Kuey L, Kultur S. Edinburg post-partum depression
inventory. Study of validity and reliability in Turkish sample. In:
Psychiatric Spring Symposiums Book. Ankara: Psychiatry Association
Publication, 1997; 512.
16 Collins NL, Feeney BC. A safe haven: An attachment theory
perspective on support seeking and caregiving in intimate
relationships. J. Pers. Soc. Psychol. 2000; 78: 105373.
17 Hazan C, Shaver P. Romantic love conceptualized as an attachment
process. J. Pers. Soc. Psychol. 1987; 52: 51124.
18 Spielberger CD, Gorsuch RC, Lushene RE, Vagg PR, Jacobs GA.
Manual for the State Trait Anxiety Inventory. Palo Alto, CA: Consulting
Psychologists Press, 1983.
19 Barnes LLB, Harp D, Jung WS. Reliability generalization of scores on
the Spielberger State-Trait Anxiety Inventory. Edu. Psychol. Meas.
2002; 62: 60318.
20 Zimet GD, Dahlen NW, Zimet SG, Farley GK. The multidimensional
scale of perceived social support. J. Pers. Assess. 1988; 52: 3041.
Journal of Paediatrics and Child Health 44 (2008) 369373
2008 The Authors
Journal compilation 2008 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Maternal depression and breastfeeding duration
21 Eker D, Arkar H. ok Boyutlu Alglanan Sosyal Destek leginin faktr
yaps, geerlik ve gvenirligi. Trk Psikoloji Dergisi. 1995; 34: 4555.
22 Henderson JJ, Evans SF, Straton JA, Priest SR, Hagan R. Impact of
postnatal depression on breastfeeding duration. Birth. 2003; 30:
17580.
23 Ertem IO, Aknc Z, Ulukol B, Baskan-Gulnar S. Socioeconomically
advantaged infants attending university well-child clinic in Ankara: are
they breast-feeding optimally? Turk J Pediatr 2001; 43: 22330.
24 Losch M, Dungy CI, Russell D, Dusdieker LB. Impact of attitudes on
maternal decisions regarding infant feeding. J. Pediatr 1995; 126:
50714.
25 Piper S, Parks PL. Predicting the duration of lactation: evidence from a
national survey. Birth 1996; 23: 712.
26 Ertem IO, Votto N, Leventhal JM. The timing and predictors of the
early termination of breastfeeding. Pediatrics 2001; 107: 5438.
27 Forman DN, Videbech P, Hedegaard M, Salvig JD, Secher NJ.
Postpartum depression: identication of women at risk. BJOG 2000;
107: 121017.
28 Belsky J, Fearon RM. Infantmother security, contextual risk, and early
development: a moderational analysis. Dev Psychopathol. 2002; 14:
293310.
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