Division of Epidemiology, College of Public Health, The Ohio State University, Ohio, United States of America.
Department of Psychology, The Ohio State University, Ohio, United States of America.
PLoS Med. 2021 Jan 11;18(1):e1003465. doi: 10.1371/journal.pmed.1003465. eCollection 2021 Jan.
Social support and relevant skills training can reduce the risk of postpartum depression (PPD) by reducing the impact of stressors. The 10-step program to encourage exclusive breastfeeding that forms the basis of the Baby-Friendly Hospital Initiative (BFHI) provides both, suggesting it may lessen depressive symptoms directly or by reducing difficulties associated with infant feeding. Our objective was to quantify the association of implementing Steps 1-9 or Steps 1-10 on postpartum depressive symptoms and test whether this association was mediated by breastfeeding difficulties.
We used data from a breastfeeding promotion trial of all women who gave birth to a healthy singleton between May 24 and August 25, 2012 in 1 of the 6 facilities comparing different BFHI implementations (Steps 1-9, Steps 1-10) to the standard of care (SOC) randomized by facility in Kinshasa, Democratic Republic of Congo. Depressive symptoms, a non-registered trial outcome, was assessed at 14 weeks via the Edinburgh Postnatal Depression Scale (EPDS). Inverse probability weighting (IPW) was used to estimate the association of BFHI implementations on depressive symptoms and the controlled direct association through breastfeeding difficulties at 10 weeks postpartum. A total of 903 mother-infant pairs were included in the analysis. Most women enrolled had previously given birth (76%) and exclusively breastfed at 10 weeks (55%). The median age was 27 (interquartile range (IQR): 23, 32 years). The proportion of women reporting breastfeeding difficulties at week 10 was higher in both Steps 1-9 (75%) and Steps 1-10 (91%) relative to the SOC (67%). However, the number of reported difficulties was similar between Steps 1-9 (median: 2; IQR: 0, 3) and SOC (2; IQR: 0, 3), with slightly more in Steps 1-10 (2; IQR: 1, 3). The prevalence of symptoms consistent with probable depression (EPDS score >13) was 18% for SOC, 11% for Steps 1-9 (prevalence difference [PD] = -0.08; 95% confidence interval (CI): -0.14 to -0.01, p = 0.019), and 8% for Steps 1-10 (PD = -0.11, -0.16 to -0.05; p < 0.001). We found mediation by breastfeeding difficulties. In the presence of any difficulties, the PD was reduced for both Steps 1-9 (-0.15; 95% confidence level (CL): -0.25, -0.06; p < 0.01) and Steps 1-10 (-0.16; 95% CL: -0.25, -0.06; p < 0.01). If no breastfeeding difficulties occurred in the population, there was no difference in the prevalence of probable depression for Steps 1-9 (0.21; 95% CL: -0.24, 0.66; p = 0.365) and Steps 1-10 (-0.03; 95% CL: -0.19, 0.13; p = 0.735). However, a limitation of the study is that the results are based on 2 hospitals randomized to each group.
In conclusion, in this cohort, the implementation of the BFHI steps was associated with a reduction in depressive symptoms in the groups implementing BFHI Steps 1-9 or 1-10 relative to the SOC, with the implementation of Steps 1-10 associated with the largest decrease. Specifically, the reduction in depressive symptoms was observed for women reporting breastfeeding difficulties. PPD has a negative impact on the mother, her partner, and the baby, with long-lasting consequences. This additional benefit of BFHI steps suggests that renewed effort to scale its implementation globally may be beneficial to mitigate the negative impacts of PPD on the mother, her partner, and the baby.
ClinicalTrials.gov NCT01428232.
社会支持和相关技能培训可以通过减轻压力源的影响来降低产后抑郁（PPD）的风险。促进纯母乳喂养的 10 步计划是“爱婴医院倡议”（Baby-Friendly Hospital Initiative，BFHI）的基础，它提供了这两者，这表明它可能直接减轻抑郁症状，或通过减少与婴儿喂养相关的困难来减轻抑郁症状。我们的目的是量化实施第 1-9 步或第 1-10 步与产后抑郁症状之间的关联，并检验这种关联是否通过母乳喂养困难来介导。
我们使用了一项母乳喂养促进试验的数据，该试验于 2012 年 5 月 24 日至 8 月 25 日期间在刚果民主共和国金沙萨的 6 家设施之一对所有分娩健康单胎婴儿的女性进行了随机分组，比较了不同的 BFHI 实施（第 1-9 步和第 1-10 步）与标准护理（SOC）。在 14 周时，通过爱丁堡产后抑郁量表（Edinburgh Postnatal Depression Scale，EPDS）评估抑郁症状，这是非注册的试验结局。采用逆概率加权（Inverse Probability Weighting，IPW）估计 BFHI 实施与抑郁症状的关联，以及通过产后 10 周时的母乳喂养困难进行的控制直接关联。共有 903 对母婴纳入分析。大多数纳入的女性之前有过分娩（76%），10 周时纯母乳喂养（55%）。中位年龄为 27 岁（四分位间距（Interquartile Range，IQR）：23，32 岁）。第 1-9 步（75%）和第 1-10 步（91%）的女性在第 10 周报告母乳喂养困难的比例高于 SOC（67%）。然而，第 1-9 步和 SOC 报告的困难数量相似（中位数：2；IQR：0，3），第 1-10 步略多（2；IQR：1，3）。SOC 的症状符合可能的抑郁（EPDS 评分>13）的患病率为 18%，第 1-9 步为 11%（PD = -0.08；95%置信区间（Confidence Interval，CI）：-0.14 至 -0.01，p = 0.019），第 1-10 步为 8%（PD = -0.11，-0.16 至 -0.05；p < 0.001）。我们发现了母乳喂养困难的中介作用。在存在任何困难的情况下，第 1-9 步（PD = -0.15；95%置信水平（Confidence Level，CL）：-0.25，-0.06；p < 0.01）和第 1-10 步（PD = -0.16；95% CL：-0.25，-0.06；p < 0.01）的 PD 均降低。如果在人群中没有出现母乳喂养困难，那么第 1-9 步（0.21；95% CL：-0.24，0.66；p = 0.365）和第 1-10 步（-0.03；95% CL：-0.19，0.13；p = 0.735）的可能抑郁患病率没有差异。然而，本研究的一个局限性是，结果基于随机分配到每组的 2 家医院。
总之，在本队列中，与 SOC 相比，实施 BFHI 步骤 1-9 或 1-10 与抑郁症状减少相关，实施 BFHI 步骤 1-10 与最大程度的抑郁症状减少相关。具体来说，在报告母乳喂养困难的女性中观察到抑郁症状的减少。产后抑郁对母亲、她的伴侣和婴儿都有负面影响，并产生长期后果。BFHI 步骤的这一额外益处表明，重新努力在全球范围内扩大其实施可能有助于减轻产后抑郁对母亲、她的伴侣和婴儿的负面影响。
ClinicalTrials.gov NCT01428232。
