6303_09_p754-762 8/3/06 1:35 PM Page 754

JOURNAL OF WOMENS HEALTH

Volume 15, Number 6, 2006
Mary Ann Liebert, Inc.

Association of Breastfeeding with Maternal

Depressive Symptoms

JENNIFER R. PIPPINS, M.D.,1 PHYLLIS BRAWARSKY, M.P.H.,2

REBECCA A. JACKSON, M.D.,3 ELENA FUENTES-AFFLICK, M.D., M.P.H.,4
and JENNIFER S. HAAS, M.D., M.S.P.H.2

ABSTRACT

Purpose: To identify risk factors for lack of breastfeeding initiation and duration of
1 month
among a racially diverse cohort of women. In particular, our interest was to examine depres-
sive symptoms during pregnancy as a potential risk factor for not initiating or continuing
breastfeeding.
Methods: Survey and medical record data from a cohort of pregnant women from the San
Francisco Bay area who delivered a singleton infant (n
1448) were analyzed to examine lack
of breastfeeding initiation and duration of
1 month.
Results: In this study, 5.6% of women did not initiate breastfeeding, and 11.1% of women
who initiated breastfeeding had a duration of breastfeeding of
1 month. There were no racial
or ethnic differences in initiation of breastfeeding after adjusting for demographic and clinical
characteristics. At 1 month postpartum, African American women were more likely than white
women to have a duration of breastfeeding lasting
1 month. Depressive symptoms during or
prior to pregnancy had no effect on initiation of breastfeeding even when symptoms were per-
sistent. Women with persistent depressive symptoms (symptoms at two time points, including
one prior to delivery) were more likely to have breastfeeding duration of
1 month (odds ra-
tio [OR] 1.77, 95% confidence interval [95% CI] 1.10-2.86), whereas depressive symptoms at a
single time point were not associated with breastfeeding duration of
1 month.
Conclusions: Addressing depressive symptoms experienced by women both during and af-
ter pregnancy may improve the duration of breastfeeding.

INTRODUCTION Healthy People 2010, the U.S. Department of

Health and Human Services set breastfeeding

B REASTFEEDING IS AN IMPORTANT,
yet unrealized
public health goal in the United States. In
goals of 75% during the early postpartum period,
50% at 6 months, and 25% at 1 year.1 In 2001, the

1Department of Medicine, Brigham and Womens Hospital, Department of Pediatrics, Massachusetts General Hos-

pital, Department of Medicine, Childrens Hospital Boston, and Harvard Medical School, Boston, Massachusetts.
2Division of General Medicine and Primary Care, Department of Medicine, Brigham and Womens Hospital, Boston,

Massachusetts.
3Departments of Obstetrics, Gynecology and Reproductive Sciences, and Epidemiology and Biostatistics, Univer-

sity of California, San Francisco, San Francisco, California.

4Departments of Pediatrics and Epidemiology and Biostatistics, University of California, San Francisco, San Fran-

cisco, California.
This work was supported by the National Institute of Child Health and Human Development (R01 HD37389).

754
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DEPRESSION AND BREASTFEEDING 755

prevalence of breastfeeding initiation ranged MATERIALS AND METHODS

from 65% to 70%, and the prevalence of breast-
feeding at 6 months ranged from 27% to 33%.2,3 Sample
Ethnic differences in breastfeeding rates between
Project Women and Infants Starting Healthy
African American and white women have been
(WISH) is a longitudinal cohort of pregnant wo-
well documented. In 1998, 45% of African Amer-
men in the San Francisco Bay area.34,35 Women
ican women breastfed in the early postpartum pe-
were enrolled in this observational study be-
riod compared with 68% of white women.1 De-
tween May 2001 and July 2002. Data were ob-
spite the upward trend in breastfeeding rates
tained from four telephone surveys, three during
among both white and African American women
pregnancy and one postpartum, and a chart re-
in recent years, a significant gap between the
view. This study includes subjects who com-
races persists. Closing this gap and, at the same
pleted the postpartum survey, which included
time, improving breastfeeding rates among all
questions about breastfeeding practice and in-
women are important public health goals.
struction. The mean gestational age at time of sur-
Past research has examined the role of socioe-
vey was 15.6 weeks for survey one, 26.1 weeks
conomic factors, maternal characteristics, and so-
for survey two, and 34.0 weeks for survey three.
cial and institutional support in influencing
The mean age of infants was 66.6 days for survey
breastfeeding decisions among women, with
four. Additional survey and chart review data in-
most prior work focused on white and African
cluded demographic characteristics, level of edu-
American women.422 Less is known about the
cational attainment, gestational age, parity,
role of maternal depression as a possible con-
chronic and pregnancy-related medical condi-
tributor to breastfeeding practices. Prior work ad-
tions, type of delivery, cigarette use, and depres-
dressing the relationship between depressive
sive symptoms.
symptoms and breastfeeding has focused pre-
Women were included in this analysis if they
dominantly on postpartum depression. Postpar-
self-identified their race/ethnicity as white,
tum depression has been shown to be associated
African American, Latina, or Asian, had infor-
with lower rates of breastfeeding in studies con-
mation on breastfeeding practices and depressive
ducted both abroad and in the United States, but
symptoms during pregnancy, and were inter-
these studies have been limited by a lack of racial,
viewed at least 30 days postpartum. This analy-
ethnic, and socioeconomic diversity.2329 A study
sis is based on 1448 women. The research proto-
of lower-income African American and white wo-
col was reviewed and approved by the
men found no association between postpartum
institutional review boards of the participating
depression and breastfeeding rates, but this may
institutions.
have been due to the studys small size and low
overall rates of breastfeeding.30
The possible effects of depressive symptoms Outcome variables
during pregnancy on breastfeeding have not been The outcome variables were breastfeeding ini-
adequately studied. Previous research has tiation and duration of breastfeeding at 1 month
demonstrated that many women make their de- postpartum. Both of these outcomes were defined
cisions about feeding methods during pregnancy, as dichotomous variables (e.g., yes/ no). These
well before delivery, which suggests that depres- variables were based on responses to questions
sive symptoms during pregnancy could be asso- in the postpartum survey that assessed whether
ciated with breastfeeding.9,31,32 A recent study or not the woman had ever breastfed her new-
did not show a statistically significant association born and whether the woman was currently
between maternal depressive symptoms either breastfeeding and asked women to recall the age
during or after pregnancy and breastfeeding du- of their baby when breastfeeding was discontin-
ration of at least 1 month, although there was a ued.
trend toward a decline in breastfeeding rates with
increasing depressive symptoms.33 The aim of
Independent variables
this study is to further examine the relationship
between maternal depressive symptoms and The main independent variables were depres-
breastfeeding among a racially diverse cohort of sive symptoms during or prior to pregnancy, as
women. well as in the postpartum period. Depressive
6303_09_p754-762 8/3/06 1:35 PM Page 756
756
symptoms were assessed by the short-form Cen-
ter for Epidemiologic Studies-Depression Scale
(CES-D), a screening tool consisting of 10 ques-
tions.36 The long form CES-D is considered to be
both reliable and valid, and the short form CES-
D has been shown to generate similar results to
those obtained through use of the long form.36
The short form has also demonstrated favorable
test characteristics, with an overall test-retest
score correlation of 0.71.36 Studies have generally
supported the reliability of both the short and
long form CES-D among various racial/ethnic
groups.3740 The CES-D has been used among re-
productive age women both during pregnancy
and in the postpartum period.4144 The first sur-
vey focused on symptoms experienced in the
month prior to pregnancy, and subsequent sur-
veys focused on symptoms experienced during
the week prior to survey administration. For the
initiation model, women were classified as hav-
ing depressive symptoms at either zero, one, or
two time points based on their responses to the
first three surveys, which were all conducted dur-
ing pregnancy and reflect symptoms either prior
to pregnancy (survey one) or during pregnancy
(surveys two and three). One hundred forty-nine
women did not complete both surveys two and
three, which resulted in the choice of two time
points, rather than three, as the upper limit of the
depression scale. If survey three was available, it
was used; if not, survey two was used. For the
duration model, women were classified as hav-
ing depressive symptoms at zero, one, or two or
more time points based on their responses to the
four surveys. The fourth survey reflects symp-
toms in the postpartum period. Again, if survey
three was available, it was used; if not, survey
two was used. Given the small number of women
(61) with depressive symptoms at three time
points, they were combined in the analysis with
the women who met criteria at two time points.
A woman was considered to have depressive
symptoms if her CES-D score was
10, the
threshold used for this short form.36
Other covariates included sociodemographic
characteristics, such as age (categorized in 5-year
intervals, except the oldest group included 11
years because of smaller sample size), race/eth-
nicity (white, Latina, African American, Asian),
level of educational attainment ( high school,
high school graduate or equivalent, some college,
college graduate), marital status (married or liv-
ing with a partner vs. other), and economic means
PIPPINS ET AL.
(subjects were asked if they ever lacked money
for food). Additional measures included parity
(nulliparous, parous), method of delivery (ce-
sarean section vs. other), breastfeeding instruc-
tion or preparation (yes/ no), smoking during
pregnancy or postpartum (yes/ no), presence of
a chronic disease during pregnancy (including
hypertension, asthma, thyroid disease, lung dis-
ease, anemia, arthritis, epilepsy, kidney disease,
liver disease, heart disease, cancer, and HIV), self-
reported health status postpartum (excellent or
good vs. fair or poor), and perceived stress (none,
some, high), which was measured using the
short-form Perceived Stress Scale.45,46
Data analysis
Multivariate logistic regression models were
built with variables shown in the literature to
be associated with breastfeeding or found to
be associated in bivariate analysis (p 
0.05).47,9,10,13,1521 To prevent overfitting of the
models resulting from the modest number of wo-
men who did not breastfeed, we limited the num-
ber of variables in final models by including only
those variables with a p  0.05 for both initiation
and duration, with the exception of three vari-
ables (age, lack of money for food, and depres-
sion [our variable of primary interest]). We tested
the interaction between depressive symptoms
and race/ethnicity in both models. Statistical
analyses were performed using SAS for Win-
dows, version 8.0 (SAS Institute, Inc., Cary, NC).
RESULTS
Response and retention rates
Of 2854 eligible women, 1809 (63%) enrolled in
the study. Postpartum surveys were available for
1480 of the 1648 women who subsequently de-
livered at one of the participating sites (90%).
Thirty-two women were excluded from this
analysis because of identification of race/ethnic-
ity as Native American (n  4), missing breast-
feeding data (n  1), missing CES-D score during
pregnancy (n  21), and a short (1 month) or
missing interval between delivery and the post-
partum interview (n  6). The total sample size
was 1448. Respondents and nonrespondents were
of similar age. Nonrespondents were more likely
than respondents to be Asian American and less
likely to be African American, Latina, or white.34
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DEPRESSION AND BREASTFEEDING 757

Description of the sample D short form criteria at multiple time points. Fac-
tors that were significantly associated with a lack
Overall, 5.6% of women did not initiate breast-
of breastfeeding initiation included lower educa-
feeding, and among those who initiated breast-
tional attainment, insufficient money for food, de-
feeding, 11.1% stopped by 1 month postpartum
livery by cesarean section, smoking during or af-
(Table 1). The cohort was racially diverse, com-
ter pregnancy, and chronic disease during
prising 35.8% Latinas, 14.3% Asian American wo-
pregnancy. Participation in breastfeeding in-
men, 16.6% African American women, and 33.2%
struction had a protective effect on breastfeeding
white women. The majority of women were 2435
initiation (OR 0.40, CI 0.24-0.65).
years of age, had completed high school or some
Before accounting for confounders, African
college, were married or lived with a partner, and
American women were also significantly more
reported having enough money for food. Most of
likely to have a breastfeeding duration of 1
the women were nonsmokers. With regard to de-
month. After adjustment for age, educational at-
pressive symptoms, 25.2% of women reported a
tainment, lack of money for food, marital status,
history of depressive symptoms during preg-
the receipt of breastfeeding instruction, cesarean
nancy and 14.0% in the postpartum period.
section, smoking status, and presence of chronic
In unadjusted analyses, women were more
disease, African American race was significantly
likely not to initiate breastfeeding if they were
associated with breastfeeding duration of 1
African American, less educated, or not married.
month (OR 1.86, CI 1.04-3.33) (Table 2). Rates of
Maternal health factors associated with a lack of
breastfeeding duration at 1 month among Asian
initiation included parity, a history of chronic dis-
and Latina women did not significantly differ
ease during pregnancy, delivery by cesarean sec-
from those of white women. Having depressive
tion, poor or fair postpartum health status, de-
symptoms at a single time point was not a sig-
pressive symptoms, and smoking. Women were
nificant risk factor for having a breastfeeding du-
also more likely to not initiate breastfeeding if
ration of 1 month, but having depressive symp-
they did not receive breastfeeding instruction or
toms at two time points was significantly
if they lacked money for food. In unadjusted
associated with breastfeeding for 1 month (OR
analyses, risk factors for a breastfeeding duration
1.77, CI 1.10-2.86). Other significant risk factors
of 1 month were similar to those for lack of ini-
included having a high school or partial college
tiation except that they also included younger age
education as compared with graduating from col-
and more stress during pregnancy. In addition,
lege and smoking during or after pregnancy.
several factors associated with lack of initiation
Older age, being married or living with a part-
were not significant risk factors in unadjusted
ner, participation in breastfeeding instruction,
analyses of duration 1 month. These included
and a lack of money for food were associated with
parity, lack of money for food, and mode of de-
a longer duration of breastfeeding. In both the ini-
livery.
tiation and the duration model, the interaction be-
tween race/ethnicity and depressive symptoms
Risk factors for not breastfeeding was not significant, suggesting that the role of de-
Before adjusting for confounders, African pressive symptoms on breastfeeding decisions
American women were significantly more likely does not differ between racial/ethnic groups.
to not initiate breastfeeding compared with white
women (odds ratio [OR] 3.52, 95% confidence in-
terval [CI] 1.91-6.48). However, after adjustment DISCUSSION
for age, educational attainment, lack of money for
food, marital status, the receipt of breastfeeding In this cohort of ethnically and socioeconomi-
instruction, cesarean section, smoking status, and cally diverse women, depressive symptoms dur-
presence of chronic disease, there were no sig- ing or prior to pregnancy were not found to be
nificant differences in breastfeeding initiation associated with breastfeeding initiation, even
rates between white women and either African among women who had persistent symptoms.
American, Latina, or Asian women (Table 2). De- Having a breastfeeding duration of 1 month,
pression during or prior to pregnancy was not however, was found to be significantly associated
significantly associated with a lack of breastfeed- with persistent depressive symptoms (occurring
ing initiation, even among women who met CES- at a minimum of two time points, with at least
6303_09_p754-762 8/3/06 1:35 PM Page 758

758 PIPPINS ET AL.

TABLE 1. ASSOCIATION OF MATERNAL, PREGNANCY, AND INFANT CHARACTERISTICS

WITHBREASTFEEDING INITIATION AND DURATION OF 1 MONTH

Duration less than 1

Did not initiate n of month
women
Total p who p
Characteristic n n % value initiated n % value

All 1448 81 5.6 1367 152 11.1

Age, years NS 0.001
1823 226 19 8.4 207 46 22.2
2429 444 22 5.0 422 50 11.9
3035 529 27 5.1 502 36 7.2
3647 249 13 5.2 236 20 8.5
Race/ethnicity 0.001 0.001
White 481 18 3.7 463 27 5.8
African American 241 29 12.0 212 48 22.6
Latina 519 28 5.4 491 56 11.4
Asian 207 6 2.9 201 21 10.5
Educational attainment 0.001 0.001
Less than high school 221 20 9.1 201 20 10.0
High school graduate 605 46 7.6 559 102 18.3
or some college
College graduate 622 15 2.4 607 30 4.9
Married or living with partner 0.001 0.001
Yes 1311 62 4.7 1249 119 9.5
No 137 19 13.9 118 33 28.0
Parity 0.005 NS
Nulliparous 650 24 3.7 626 70 11.2
Parous 798 57 7.1 741 82 11.1
Stress during pregnancy NS 0.001
No stress 255 14 5.5 241 14 5.8
Some stress 783 43 5.5 740 76 10.3
High stress 352 20 5.7 332 53 16.0
Chronic disease during 0.001 0.021
pregnancy
Yes 515 45 8.7 470 65 13.8
No 933 36 3.9 897 87 9.7
Breastfeeding instruction or 0.001 0.005
preparation
Yes 783 26 3.3 757 68 9.0
No 665 55 8.3 610 84 13.8
Episode of inadequate money 0.004 NS
for food, postpartum
Yes 136 15 11.0 121 8 6.6
No 1312 66 5.0 1246 144 11.6
Pregnancy-related depressive NS 0.004
symptoms
None 1024 52 5.1 972 93 9.6
At one time point 323 19 5.9 304 41 13.5
At two or more time points 101 10 9.1 91 18 19.8
Smoked during pregnancy 0.001 0.001
or postpartum
Yes 92 17 18.5 75 21 28.0
No 1356 64 4.7 1292 131 10.1
Cesarean section 0.013 NS
Yes 352 29 8.2 323 39 12.1
No 1096 52 4.7 1044 113 10.8
Postpartum health status 0.005 0.011
Excellent/good 1296 65 5.0 1231 128 10.4
Fair/poor 152 16 10.5 136 24 17.7
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DEPRESSION AND BREASTFEEDING 759

TABLE 2. FACTORS ASSOCIATED WITH LACK OF BREASTFEEDING INITIATION AND WITH DURATION 1 MONTH

Lack of initiation Duration 1 month

Adjusted ORa Adjusted ORa

Factor (95% confidence interval) (95% confidence interval)

Age (continuous) 1.02 (0.981.07) 0.96 (0.930.99)

Race
White Reference Reference
African American 1.48 (0.713.06) 1.86 (1.043.33)
Latina 0.64 (0.301.37) 1.33 (0.752.36)
Asian 0.64 (0.241.67) 1.51 (0.812.80)
Education
Less than high school 3.45 (1.418.44) 1.33 (0.642.74)
High school graduate or some college 2.37 (1.154.90) 2.48 (1.484.17)
College graduate or more Reference Reference
Married or living with partner
Yes 0.54 (0.291.02) 0.53 (0.320.89)
No Reference Reference
Breastfeeding instruction or preparation
Yes 0.40 (0.240.65) 0.66 (0.460.95)
No Reference Reference
Episode of insufficient money for food
postpartum
Yes 2.69 (1.335.42) 0.40 (0.180.88)
No Reference Reference
Depressive symptoms
None Reference Reference
At one time point 0.79 (0.441.41) 0.85 (0.531.36)
At two or more time points 0.93 (0.422.06) 1.77 (1.102.86)
Cesarean section
Yes 1.86 (1.123.10) 1.16 (0.771.77)
No Reference Reference
Smoked during pregnancy or postpartum
Yes 2.78 (1.415.51) 1.88 (1.033.41)
No Reference Reference
Chronic disease during
pregnancy
Yes 1.96 (1.213.16) 1.36 (0.941.97)
No Reference Reference
aAdjusted for all variables in table and age.

one time point occurring prior to delivery).
African Americans were more likely to have a
breastfeeding duration of 1 month.
The body of literature addressing depression
during pregnancy and breastfeeding is very lim-
ited. One study of low-income, primarily African
American women examined the relationship be-
tween depressive symptoms and various infant
healthcare practices, including breastfeeding.33
This large study by Chung et al. was similar to
ours in that it examined the persistence of de-
pressive symptoms. Its focus, however, was pri-
marily on postpartum depression, with only one
of the three surveys occurring during pregnancy.
Unlike our study, the Chung et al. study did not
find a significant association between depressive
symptoms and breastfeeding duration, even
when symptoms were persistent.33
Our study differs from prior work because we
found that there was a black-white disparity in
breastfeeding duration but no disparity in initia-
tion of breastfeeding. We defined breastfeeding
initiation as having evereven only once
breastfed; this lenient definition may have mini-
mized differences in initiation between racial
groups. In addition, the overall rates of breast-
feeding initiation and duration were high among
women in the WISH cohort; in such a population,
disparities may be less likely. Of note, the high
rate of breastfeeding initiation in the WISH co-
hort is comparable to the overall rate for the San
Francisco County population, which was 85% in
6303_09_p754-762 8/3/06 1:35 PM Page 760
760
2000 (www.mch.dhs.ca.gov/programs/bfp/breastfeed-
ing_tables.htm; accessed 11/17/05). This is signif-
icantly higher the national rate of 65%70% in
2001.2,3 In addition, the rate of breastfeeding ini-
tiation among African American women living in
San Francisco County in the year 2000 was 70%,
which is significantly higher than the 40%53%
range reported for national samples of African
American women in the year 2001. The observa-
tional nature of this study, which only assessed
breastfeeding in the postpartum survey after wo-
men had made their feeding decisions, makes it
unlikely that participation in the study influenced
the rates of breastfeeding. It is more likely that
the high breastfeeding rates in the WISH cohort
reflect regional differences, as is evidenced by the
high rates reported for the San Francisco County
area.
The finding that depressive symptoms during
or prior to pregnancy were not associated with
lower rates of breastfeeding initiation was some-
what surprising. Women who are affected by de-
pressive symptoms during pregnancy might lack
the resources to initiate breastfeeding. Indeed, the
literature suggests that postpartum depression is
associated with lower rates of breastfeeding.2325
Our findings suggest that one cannot extrapolate
from the data about postpartum depression and
breastfeeding when considering the possible ef-
fects of depressive symptoms during or prior to
pregnancy on breastfeeding initiation. There
could be several reasons for the difference in find-
ings. The definition used for depressive symp-
toms in this study was score of 10 on the short
form of the CES-D.36 Persistent symptoms were
defined as symptoms occurring at a minimum of
two time points. Use of a stricter definition might
allow the identification of a group of women with
more substantial depressive symptoms. In addi-
tion, the definitions we used for breastfeeding ini-
tiation and duration may have influenced our re-
sults. This definition of breastfeeding is similar to
that used in other studies examining depressive
symptoms and breastfeeding.24,33 It may be that
use of a more substantial definition of breast-
feeding (e.g., exclusive) might allow unmasking
of potential effects of depression during preg-
nancy. A study with a more conservative defini-
tion of breastfeeding (breastfeeding discontinua-
tion was defined as feeding more than 12 oz. of
formula daily) found a significant association be-
tween postpartum depression and breastfeeding
discontinuation.25
PIPPINS ET AL.
Our study has several limitations. Breastfeed-
ing initiation and duration in this sample were
high, and our findings may, therefore, not be gen-
eralizable to other populations. These results
should be confirmed in other settings. Informa-
tion about breastfeeding practices came from self-
report. As noted, our definition of breastfeeding
was broad and did not take into account differ-
ent patterns of breastfeeding (i.e., partial vs ex-
clusive). Information on maternal employment
status at the time of breastfeeding discontinua-
tion was not available. Finally, we had limited
power to detect a significant difference between
depressive symptoms and breastfeeding by
race/ethnicity.
This study highlights how little is known about
the effects of depressive symptoms during preg-
nancy on maternal behaviors, such as breast-
feeding. Further work is needed to determine if
more substantial or persistent depressive symp-
toms during or prior to pregnancy are associated
with a womans breastfeeding decision. Larger
studies with similar racial diversity are needed to
better explore the known racial disparities in
breastfeeding as well as the role of mental health
factors, including depressive symptoms.
CONCLUSIONS
In this large and racially diverse cohort of wo-
men with high rates of breastfeeding initiation,
depressive symptoms during or prior to preg-
nancy were not found to be significantly associ-
ated with breastfeeding initiation. Persistent de-
pressive symptoms, however, were associated
with breastfeeding duration of 1 month. Fur-
ther work is needed to explore the potential ef-
fects of maternal depressive symptoms during
pregnancy on both mothers and their children.
REFERENCES
1. U.S. Department of Health and Human Services.
Healthy people 2010, 2nd ed. With understanding
and improving health and objectives for improving
health. Washington, DC: U.S. Government Printing
Office, 2000.
2. Li R, Zhao Z, Mokdad A, Barker L, Grummer-Stawn
L. Prevalence of breastfeeding in the United States the
2001 National Immunization Survey. Pediatrics
2003;111:1198.
3. Ryan AS, Wenjun Z, Acosta A. Breastfeeding contin-
6303_09_p754-762 8/3/06 1:35 PM Page 761
DEPRESSION AND BREASTFEEDING
ues to increase into the new millennium. Pediatrics
2002;110:1103.
4. Forste R, Weiss J, Lippincott E. The decision to breast-
feed in the United States: Does race matter? Pediatrics
2001;108:291.
5. Li R, Grummer-Strawn L. Racial and ethnic dispari-
ties in breastfeeding among United States infants: Na-
tional Health and Nutrition Examination Survey,
19881994. Birth 2002;29:251.
6. Ertem IO, Votto N, Leventhal JM. The timing and pre-
dictors of the early termination of breastfeeding. Pe-
diatrics 2001;107:543.
7. Saunders-Goldson S, Edwards QT. Factors associated
with breastfeeding intentions of African-American
women at military health care facilities. Mil Med
2004;169:111.
8. Brownell K, Hutton L, Hartman J, Dabrow S. Barriers
to breastfeeding among African American adolescent
mothers. Clin Pediatr 2002;41:669.
9. Noble L, Hand I, Haynes D, McVeigh T, Kim M, Yoon
JJ. Factors influencing initiation of breastfeeding
among urban women. Am J Perinatol 2003;20:477.
10. Park YK, Meier ER, Song WO. Characteristics of
teenage mothers and predictors of breastfeeding ini-
tiation in the Michigan WIC Program in 1995. J Hum
Lact 2003;19:50.
11. Kugyelka JG, Rasmussen KM, Frongillo EA. Maternal
obesity is negatively associated with breastfeeding
success among Hispanic but not black women. J Nutr
2004;134:1746.
12. Humphreys AS, Thompson NJ, Miner KR. Intention
to breastfeed in low-income pregnant women: The
role of social support and previous experience. Birth
1998;25:169.
13. Sharps PW, El-Mohandes AA, Nabil El-Khorazaty M,
Kiely M, Walker T. Health beliefs and parenting atti-
tudes influence breastfeeding patterns among low-in-
come African-American women. J Perinatol 2003;
23:414.
14. Bentley ME, Dee DL, Jensen JL. Breastfeeding among
low income, African-American women: Power, be-
liefs and decision-making. J Nutr 2003;133:305S.
15. Kum-Nji P, Mangrem CL, Wells PJ, White P, Herrod
HG. Breastfeeding initiation: Predictors, attitudes,
and practices among blacks and whites in rural Mis-
sissippi. South Med J 1999;92:1183.
16. Kuan LW, Britto M, Decolongon J, Schoettker PJ,
Atherton HD, Kotagal UR. Health system factors con-
tributing to breastfeeding success. Pediatrics 1999;
104:e28.
17. Lu MC, Lange L, Slusser W, Hamilton J, Halfon N.
Provider encouragement of breastfeeding: Evidence
from a national survey. Obstet Gynecol 2001;97:290.
18. Schwartz JB, Popkin BM, Tognetti J, Zohoori N. Does
WIC participation improve breastfeeding practices?
Am J Public Health 1995;85:729.
19. Beal AC, Kuhlthau K, Perrin JM. Breastfeeding advice
given to African American and white women by
physicians and WIC counselors. Public Health Rep
2003;118:368.
761
20. Madden JM, Soumerai SB, Lieu TA, Mandl KD, Zhang
F, Ross-Degnan D. Effects on breastfeeding of changes
in maternity length-of-stay policy in a health mainte-
nance organization. Pediatrics 2003;111:519.
21. Heck KE, Schoendorf KC, Chavez GF, Braveman P.
Does postpartum length of stay affect breastfeeding du-
ration? A population-based study. Birth 2003;30:153.
22. Celi AC, Rich-Edwards JW, Richardson MK, Klein-
man KP, Gillman MW. Immigration, race/ethnicity,
and social and economic factors as predictors of
breastfeeding initiation. Arch Pediatr Adolesc Med
2005;159:255.
23. Henderson JJ, Evans SF, Straton JA, Priest SR, Haan
R. Impact of postnatal depression on breastfeeding
duration. Birth 2003;30:175.
24. Falceto OG, Giugliani ER, Fernandes CL. Influence of
parental mental health on early termination of breast-
feeding: A control study. J Am Board Fam Pract
2004;17:173.
25. Taveras E, Capra A, Braveman P, Jensvold N, Esco-
bar G, Lieu T. Clinician support and psychosocial risk
factors associated with breastfeeding discontinuation.
Pediatrics 2003;112:108.
26. Harlow BL, Cohen LS, Otto MW, Spiegelman D,
Cramer DW. Early life menstrual characteristics and
pregnancy experiences among women with and with-
out major depression: The Harvard study of moods
and cycles. J Affect Disord 2004;79:167.
27. Taj R, Sikander KS. Effects of maternal depression on
breast-feeding. J Pak Med Assoc 2003;53:8.
28. Galler JR, Harrison RH, Biggs MA, Ramsey F, Forde
V. Maternal moods predict breastfeeding in Barbados.
J Dev Behav Pediatr 1999;20:80.
29. Cooper PJ, Murray L, Stein A. Psychosocial factors as-
sociated with the early termination of breast-feeding.
J Psychosom Res 1993;37:171.
30. Jacobson SW, Jacobson JL, Frye KE. Incidence and
correlates of breast-feeding in socioeconomically dis-
advantaged women. Pediatrics 1991;88:728.
31. Houghton MD, Graybeal TE. Breast-feeding practices
of Native American mothers participating in WIC. J
Am Diet Assoc 2001;101:245.
32. Grossman LK, Larsen-Alexander JB, Fitzsimmons
SM, Cordero L. Breastfeeding among low-income,
high-risk women. Clin Pediatr (Phila) 1989;28:38.
33. Chung EK, McCollum KF, Elo IT, Lee HJ, Culhane JF.
Maternal depressive symptoms and infant health
practices among low-income women. Pediatrics
2004;113:523.
34. Haas JS, Fuentes-Afflick E, Stewart AL, et al. Pre-preg-
nancy health status and the risk of preterm delivery.
Arch Pediatr Adolesc Med 2005;159:58.
35. Haas JS, Jackson RA, Fuentes-Afflick E, et al. Changes
in the health status of women during and after preg-
nancy. J Gen Intern Med 2004;20:45.
36. Andresen EM, Malmgren JA, Carter WB, Patrick DL.
Screening for depression in well older adults: Evalu-
ation of a short form of the CES-D (Center for Epi-
demiologic Studies Depression Scale). Am J Prev Med
1994;10:77.
6303_09_p754-762 8/3/06 1:35 PM Page 762
762
37. Long Foley K, Reed PS, Mutran EJ, DeVellis RF. Mea-
surement adequacy of the CES-D among a sample of
older African-Americans. Psychiatry Res 2002;109:61.
38. Cheng ST, Chan AC. The Center for Epidemiologic
Studies Depression Scale in older Chinese: Thresholds
for long and short forms. Int J Geriatr Psychiatry
2005;20:465.
39. Callahan CM, Wolinsky FD. The effect of gender and
race on the measurement properties of the CES-D in
older adults. Med Care 1994;32:341.
40. Crockett LJ, Randall BA, Shen YL, Russell ST, Driscoll
AK. Measurement equivalence of the Center for Epi-
demiologic Studies Depression Scale for Latino and
Anglo adolescents: A national study. J Counsult Clin
Psychol 2005;73:47.
41. Marcus SM, Flynn HA, Blow FC, Barry KL. Depres-
sive symptoms among pregnant women screened in
obstetrics settings. J Womens Health 2003;12:373.
42. Holzman C, Eyster J, Tiedje LB, Roman LA, Seagull
E, Rahbar MH. A life course perspective on depres-
sive symptoms in mid-pregnancy. Matern Child
Health J 2006;7:1.
43. Seto M, Cornelius MD, Goldschmidt L, Morimoto K,
PIPPINS ET AL.
Day NL. Long-term effects of chronic depressive
symptoms among low-income childrearing mothers.
Matern Child Health J 2005;2:1.
44. NICHD Early Child Care Research Network.
Chronicity of maternal depressive symptoms, mater-
nal sensitivity, and child functioning at 36 months.
Dev Psychol 1999;35:1297.
45. Ware JE Jr. SF-36 health survey: Manual and inter-
pretation guide. Boston: The Health Institute, 1993.
46. Cohen S, Kamarch T, Mermelstein R. A global mea-
sure of perceived stress. J Health Soc Behav 1983;
24:385.
Address reprint requests to:
Jennifer S. Haas, M.D.
Division of General Medicine and Primary Care
Brigham and Womens Hospital
1620 Tremont Street
Boston, MA 02120-1613
E-mail: jhaas@partners.org