Pandemic-related changes in postpartum depression and anxiety among breastfeeding mothers: a systematic review and meta-analysis

This systematic review and meta-analysis of 23 studies across 15 countries reveals that breastfeeding mothers experienced significantly higher levels of postpartum depression and anxiety during the COVID-19 pandemic compared to the pre-pandemic period, underscoring the critical need for sustained mental health support and flexible postpartum care services during public health emergencies.

The Gist

Imagine the world during the COVID-19 pandemic as a sudden, massive storm that knocked out the power grid for everyone. For new mothers who were breastfeeding, this storm didn't just bring rain; it washed away the ladders, bridges, and safety nets they usually relied on to climb out of the emotional valleys of early parenthood.

This paper is like a detective story where researchers gathered clues from 23 different investigations across 15 countries to answer one big question: How did this storm affect the mental health of breastfeeding mothers compared to how they felt before the storm hit?

Here is what the investigation found, broken down into simple terms:

1. The "Emotional Weather" Got Worse

Think of a mother's mental health as a weather report. Before the pandemic, the forecast was generally stable, with occasional cloudy days. The researchers found that during the pandemic, the "weather" for breastfeeding mothers turned significantly stormier.

• Depression: Using a standard "mood thermometer" called the EPDS, they found that mothers felt more down and heavy-hearted during the pandemic than before. It wasn't a hurricane for everyone, but the average temperature of sadness went up noticeably.
• Anxiety: Similarly, using an "anxiety meter" (GAD-7), they found that worry and nervousness spiked. It was as if the mothers were constantly standing on a tightrope, feeling more jittery than they did in the pre-pandemic days.

2. The "Support Ladder" Was Broken

Why did this happen? The paper suggests that breastfeeding is like a plant that needs regular watering from a support system. Usually, this system includes doctors, lactation consultants, and friends visiting in person.

• During the pandemic, lockdowns and social distancing rules cut the hoses. Mothers couldn't get their usual in-person help.
• They also faced new fears: "Will I get sick and pass it to my baby?" and "Can I even feed my baby safely?"
• Many also lost jobs or money, which is like trying to grow a garden while someone is stealing your water and tools.

3. The "Stress Meter" Was a Mixed Bag

When the researchers checked the "stress gauge" (PSS), the results were confusing, like a broken compass. Some studies showed stress went up, while others showed it stayed the same.

• The paper explains this might be because different countries had different "shields." For example, in the Netherlands, strong social safety nets might have kept stress levels steady, whereas in other places, the lack of support made stress harder to manage. Because the data was so messy, they couldn't combine it into one clear number.

4. The "Bond" Remained Strong

Here is the most surprising part of the story. Even though the mothers were feeling more depressed and anxious, the connection between the mother and the baby—the "bond"—didn't seem to break.

• Imagine a mother holding a baby in a shaking boat. Even though the boat is rocking violently (the pandemic stress), the mother's grip on the baby remained just as tight as it was in calm waters.
• One study even found that some mothers found a kind of "superpower" (called Post-Traumatic Growth) in the struggle, which actually helped them feel more connected to their babies.

5. The "Safety Net" Had Holes

The paper also noticed a problem with how the medical system was working. Before the pandemic, doctors checked mothers for depression about 74% of the time. During the peak of the pandemic, that number dropped to 22%.

• It's like a fire department that stopped checking smoke detectors because they were too busy putting out fires elsewhere. The mothers were suffering, but fewer people were checking to see if they needed help.

The Bottom Line

The researchers concluded that while the pandemic didn't break the bond between mothers and babies, it did make the mothers' emotional journey much harder. The "ladder" of support was removed, leaving many to climb alone.

What the paper says we should take away:
If another storm hits in the future, we need to make sure the "ladders" (support services) are still there, even if we can't climb them in person. We need flexible ways to check on mothers' mental health and keep the support flowing, because breastfeeding mothers are particularly vulnerable when the world stops turning normally.

Note: The paper explicitly states these findings are based on research that hasn't been fully peer-reviewed yet and should not be used to make immediate medical decisions, but they do highlight a clear pattern of increased distress.

Technical Summary

Technical Summary: Pandemic-related changes in postpartum depression and anxiety among breastfeeding mothers

Problem Statement
The COVID-19 pandemic introduced global disruptions to maternity care, breastfeeding support, and social networks. While existing systematic reviews have addressed perinatal mental health broadly, there is a lack of comprehensive synthesis specifically focusing on breastfeeding mothers, a population potentially more vulnerable due to their reliance on in-person lactation support and routine healthcare visits. This study aims to fill that gap by comparing maternal mental health outcomes (depression, anxiety, and stress) among breastfeeding mothers before and during the COVID-19 pandemic.

Methodology
This systematic review and meta-analysis adhered to PRISMA guidelines and was registered with PROSPERO (CRD42022354670).

• Search Strategy: The authors searched MEDLINE, EMBASE, AMED, Web of Science, WanFang Data, MedRxiv, WHO COVID-19 databases, and grey literature from inception to December 2023.
• Inclusion Criteria: Studies were included if they involved postnatal women (>18 years) breastfeeding infants (<18 months) during the pandemic, utilized validated mental health assessment tools (e.g., EPDS, GAD-7, STAI, PSS), and provided quantitative data comparing pre-pandemic and pandemic periods. Studies with fewer than 10 participants per group were excluded.
• Data Analysis: Two reviewers independently screened studies and extracted data. Risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist for cross-sectional studies and the Newcastle-Ottawa Scale (NOS) for cohort/case-control designs.
• Meta-Analysis: Random-effects meta-analyses were performed to calculate pooled standardized mean differences (SMDs) for outcomes where at least two studies reported comparable data. Heterogeneity was assessed using Cochrane's Q and I² statistics.

Key Results
Twenty-three studies from 15 countries (sample sizes ranging from 139 to 4,531) were included.

• Depression: Meta-analysis of 11 studies using the Edinburgh Postnatal Depression Scale (EPDS) revealed a statistically significant increase in depressive symptoms during the pandemic compared to the pre-pandemic period (SMD = 0.21, 95% CI 0.14 to 0.29).
• Anxiety: Meta-analysis of three studies using the Generalized Anxiety Disorder Scale (GAD-7) showed a significant increase in anxiety during the pandemic (SMD = 0.27, 95% CI 0.13 to 0.41). A pooled analysis of two studies using the State-Trait Anxiety Inventory (STAI) also suggested an increase in state anxiety (SMD = 0.35), though this showed marginal significance and high heterogeneity.
• Stress: Findings regarding perceived stress (PSS) were mixed and could not be pooled due to heterogeneity in reporting methods. Descriptive synthesis indicated non-significant differences in some cohorts (e.g., Netherlands, Poland) but varied results in others.
• Bonding and Other Outcomes: Limited evidence suggested that mother-infant bonding did not substantially decline despite increased psychological distress. Some studies indicated that childbirth-related stress was associated with post-traumatic growth, which in turn correlated with better bonding.
• Service Delivery: One study noted a significant reduction in postpartum depression screening rates during the pandemic (dropping from 74% pre-pandemic to 22–33% during peak/ongoing phases), despite similar attendance rates for postpartum visits.

Significance and Claims
The authors claim that breastfeeding mothers experienced a measurable increase in postpartum depression and anxiety symptoms during the COVID-19 pandemic globally. While the effect sizes for depression and anxiety were small to moderate, they represent a population-level shift in symptom burden.

The paper emphasizes that breastfeeding mothers are an underrepresented group in perinatal mental health research and that their specific vulnerabilities—particularly the disruption of lactation support and social networks—may have exacerbated mental health risks. The authors conclude that these findings highlight the necessity for maintaining breastfeeding support services, ensuring access to mental health screening, and developing flexible postpartum care models (such as telehealth) to prepare for future public health emergencies. The study acknowledges limitations, including the predominance of cross-sectional designs, potential residual confounding, and high heterogeneity across studies, cautioning against inferring direct causality.