The role of maternal depression symptoms and foeto-maternal attachment in predicting exclusive breastfeeding: A multi-site prospective study

Background: Previous research shows that 61% of children younger than six months, in low-and middle-income countries (LMICs) are not exclusively breastfed. While data on the role of pre- and postnatal depression on breastfeeding exclusivity is mixed, foeto-maternal attachment might foster breastfeeding exclusivity. Thus, we tested the potential mediating role of foeto-maternal attachment and postnatal depression in the relationship between maternal prenatal depression and exclusive breastfeeding. Methods: Data were collected as part of a prospective, cross-cultural project, Evidence-for-Better-Lives-Study, which enrolled N=1208 expectant mothers, in their third trimester of pregnancy across eight sites, from LMICs. Of the whole sample, N=1185 women (Mage=28.32, SD=5.77) completed Computer-Aided-Personal-Interviews on prenatal depressive symptoms, foeto-maternal attachment and socio-economic status. N=1054 women provided follow-up data at 3-6 months after birth, about postnatal depressive symptoms, exclusive breastfeeding and infant health indicators. Path analysis was used to assess parallel mediation. Results: In the whole sample, the effect of prenatal depression on breastfeeding exclusivity was completely mediated by postnatal depression, while foeto-maternal attachment did not mediate the relationship. The full mediation effect was replicated individually in Pakistan and Sri Lanka.Conclusion: The study results indicate that prenatal depression symptoms contributed to the development of depressive symptoms after birth, negatively affecting the probability of exclusive breastfeeding. Future research should explore this in early prevention interventions, increasing the chances of healthy child development in LMICs. Considering the mixed results around the sites, it is important to better understand the relationship between maternal depression, foeto-maternal attachment and breastfeeding behavior in each site’s socio-cultural context. Abbreviations: LMICs, low- and middle-income countries