Journal of Affective Disorders 200 (2016) 4550

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Breastfeeding and postpartum depression: Assessing the inuence of

breastfeeding intention and other risk factors
Carley J. Pope a,n, Dwight Mazmanian a, Michel Bdard b, Verinder Sharma c,d
a
Department of Psychology, Lakehead University, Thunder Bay, Ontario, Canada
b
Department of Health Sciences, Lakehead University, Thunder Bay, Ontario, Canada
c
Mood & Anxiety Program, Regional Mental Health Care, London, Ontario, Canada
d
Psychiatry and Obstetrics & Gynecology, Western University, London, Ontario, Canada

art ic l e i nf o a b s t r a c t

Article history: Background: Risk and protective factors for postpartum depression have been extensively studied, and in
Received 11 December 2015 recent studies an association between breastfeeding and maternal mood has been reported. The present
Accepted 11 April 2016 retrospective, cross-sectional study was conducted to evaluate the association between breastfeeding-
Available online 19 April 2016
related variables and postpartum depression (based on Edinburgh Postnatal Depression Scale threshold
Keywords: criteria) within the context of other known risk factors.
Breastfeeding Method: Breastfeeding information, demographic information, and scores on the Edinburgh Postnatal
Household income Depression Scale were examined from the Canadian Maternity Experience Survey. This survey contains
Postpartum depression data collected from 6421 Canadian mothers between October 2006 and January 2007, and 2848 women
Risk factors
between ve and seven months postpartum were included in the current analyses.
Social support
Results: In contrast to previous research, logistic regression analyses revealed that when considered
Stress
within the context of other risk factors, breastfeeding attempt and duration were not associated with
postpartum depression at ve to seven months postpartum. Although a relationship between the pre-
natal intention to combination feed and postpartum depression was observed, these variables were no
longer related once other potential risk factors were controlled for. Factors that were associated with
postpartum depression included lower income, higher perceived stress, lower perceived social support,
no history of depression, or no recent history of abuse.
Limitations: A clinical diagnostic instrument was not used and variable selection was restricted to data
collected as part of this survey.
Conclusion: These ndings suggest that the association between breastfeeding and postpartum de-
pression reported by previous researchers may in fact be due to alternative risk factors.
& 2016 Elsevier B.V. All rights reserved.

1. Introduction Due to the severe consequences and functional impairment

Postpartum depression is a serious mental health condition
that affects an estimated 1319% of women who have recently
given birth (OHara and McCabe, 2013). Postpartum depression is
characterized as a persistent low mood in new mothers, which is
often accompanied by feelings of sadness, worthlessness, and/or
hopelessness. While the clinical prole of postpartum depression
is similar to depression occurring at other times in a woman's life,
it may differ in some respects due to the profound physiological
changes occurring during pregnancy and the postpartum period
(Bloch et al., 2000; OHara and McCabe, 2013).
n
Correspondence to: Department of Psychology, Lakehead University, 955 Oliver
Road, Thunder Bay, ON, Canada P7B 5E1.
E-mail address: cpope@lakeheadu.ca (C.J. Pope).
associated with the disorder, potential risk and protective factors
for postpartum depression have been extensively studied. Risk
factors that have been identied in the literature include younger
age, lower level education, being single/divorced/separated, not
wanting the pregnancy, lower socioeconomic status/income, pri-
miparity, smoking, history of alcohol use, history of physical or
sexual abuse, the experience of birth and postpartum stressors,
history of depression and antidepressant use, residing in large
urban areas, plan to return to work in the early postpartum, and
poor social support (Dagher and Shenassa, 2012; OHara and
McCabe, 2013). As well, an association between breastfeeding and
maternal mood has been reported (Dias and Figueiredo, 2015;
Figueiredo et al., 2013).
Initially the relationship was conceptualized as postpartum
depression resulting in lower rates of breastfeeding initiation and
early cessation (Seimyr et al., 2004). More recently however,

http://dx.doi.org/10.1016/j.jad.2016.04.014
0165-0327/& 2016 Elsevier B.V. All rights reserved.
46 C.J. Pope et al. / Journal of Affective Disorders 200 (2016) 4550

reports indicated that while postpartum depression may reduce Table 1

rates of breastfeeding, not engaging in breastfeeding may increase Descriptive statistics of female participants and variables in the analysis.
the risk of postpartum depression. Additionally, there is some
Variable Mean (SD) Relative frequency
evidence that longer duration of breastfeeding may protect against
postpartum depression (Figueiredo et al., 2013). Some researchers, Mother's age (N 2848) 30.39 (5.11)
however, have not found an association between breastfeeding Education (N 2831)
and postpartum depression (Davey et al., 2011; McKee et al., Did not graduate high school 182 (6.4%)
Graduated high school 382 (13.4%)
2004). Some postsecondary 179 (6.3%)
While numerous studies have evaluated the association be- Completed postsecondary education 2088 (73.3%)
tween postpartum depression and breastfeeding (Dias and Fig- Marital Status (N 2847)
ueiredo, 2015), few studies (Davey et al., 2011; Nielsen Forman Married 2632 (92.4%)
Widowed, separated, or divorced 57 (2.0%)
et al., 2000; Borra et al., 2015) have looked at the rate of post-
Single 158 (5.6%)
partum depression in women who never initiated (or failed to Wanted pregnancy (N 2831)
initiate) breastfeeding or in women who made the decision pre- Yes 2649 (93.0%)
natally not to breastfeed and did not attempt to breastfeed. In No 182 (6.4%)
response, the current study aimed to add to this available research Household income (N 2703)
4 $10000$50000 944 (34.8%)
by assessing if: 1) women who did not attempt breastfeeding were $50000$100000 1194 (44.1%)
at greater risk of postpartum depression compared to women who $100000$150000 425 (15.7%)
attempted breastfeeding, and if intent to breastfeed inuenced $150000$200000 85 (3.1%)
this association; and 2) if breastfeeding duration was related to the 4 $200000 56 (2.1%)
Number of live births (N 2845) 1.80 (0.96)
experience of postpartum depressive symptoms.
Currently smoke (N 2849)
Yes 424 (14.9%)
No 2424 (85.1%)
2. Method Drank during pregnancy (N 2840)
Yes 283 (9.9%)
No 2557 (89.8%)
2.1. Procedure History of abuse (past two years) (N 2846)
Yes 304 (10.7%)
This study was a retrospective, cross-sectional design utilizing No 2542 (89.3%)
survey data derived as part of the Canadian Maternity Experiences Stress in the past year prior to delivery
(N 2840)
Survey (CMES; Public Health Agency of Canada, 2009). Permission
Not stressful 1213 (42.7%)
to access the CMES raw data-set was obtained from the Social Somewhat stressful 1267 (44.6%)
Sciences and Humanities Research Council, a division of the Gov- Very stressful 360 (12.7%)
ernment of Canada. The data was accessed through a Research History of depression or antidepressant use*
Data Centre and the research protocol was approved by a Uni- (N 2844)
Yes 432 (15.2%)
versity Research Ethics Board. No 2412 (84.8%)
Lived rurally (N 2748)
2.2. Participants Yes 462 (16.2%)
No 2286 (80.3%)
Social support availability (N 2839)
A sample of 8542 postpartum women, stratied by province
None of the time 40 (1.4%)
and territory, were identied based on their 2006 Canadian Cen- A little of the time 125 (4.4%)
sus survey responses, of which 6421 (78%) consented to complete Some of the time 283 (10.0%)
the survey. Eligible participants were birth mothers who were 15 Most of the time 912 (32.1%)
years of age and older, who had a singleton live birth in Canada, All of the time 1479 (52.1)
Had returned to work postpartum (N 2845) 314 (11.0%)
and who lived with their infant at the time of the interview. Birth
mothers were not eligible to participate in the survey if they were *
Prior to pregnancy.
under 15 years of age at the time of giving birth, or lived on a First
Nations reserve or in an institution at the time of data collection.
As well, mothers who had a multiple birth, a stillbirth, or had
experienced an infant death, were not eligible as the survey did sociocultural characteristics and depression scores, as well as in-
not focus on birth mothers who experienced those specic tention, initiation, and duration of breastfeeding were obtained
circumstances. from the raw survey data. Questions regarding feeding status were
For sample continuity, only women who were ve to seven similar to the denitions provided by the World Health Organi-
months postpartum were considered in this analysis (N 2848). zation (2008).
The mean age of women included in this analysis was 30.39
(SD 5.11). Tables 1 and 2 present descriptive statistics for the 2.4. Measures
women included in the analyses in this study.
Edinburgh Postnatal Depression Scale (EPDS; Cox et al., 1987).
2.3. Materials Postpartum depressive symptoms were measured based on the
women's scores on the EPDS, a scale widely-used to assess post-
Canadian Maternity Experiences Survey (CMES; Public Health partum depression and postpartum depression risk (Beck, 2001).
Agency of Canada, 2009). The CMES was developed and im- The EPDS is a 10 item self-report scale that asks women to report
plemented by the Public Health Agency of Canada in collaboration the extent to which they have experienced specic depressive
with Statistics Canada and data was collected between October 23, symptoms within the past seven days on a four point Likert-type
2006 and January 31, 2007. The survey was an initiative to acquire scale. The cut-off classications are based on literature which
representative pan-Canadian data on women's experiences during suggests that total scores of 09 indicate not depressed, 1012
pregnancy and the postpartum period. Demographics and indicate some depressive symptoms present, and 1330 are
 C.J. Pope et al. / Journal of Affective Disorders 200 (2016) 4550 47

Table 2 Correlational analysis (Pearson product-moment) was then

Descriptive statistics of depression and breastfeeding variables. used to determine if a linear relationship existed between duration
of exclusive or any (i.e., partial and exclusive) breastfeeding and
Variable Mean (SD) Relative Frequency
EPDS scores. Next, in order to assess whether there was an asso-
Edinburgh Postnatal Depression Scale score 5.19 (4.38) ciation between the duration of exclusive or any breastfeeding
(N 2817) between women who were depressed (EPDS 412) compared to
EPDS score4 12 203 (7.2%) women who were not depressed (EPDS scoreo10) a binary lo-
EPDS score 1012 (inclusive) 233 (8.3%)
EPDS scoreo 10 2381 (84.5%)
gistic regression was conducted. All analyses were weighted in
Breastfeeding intention (N 2838) accordance with guidelines issued by Statistics Canada to account
Exclusive breastfeeding 2187 (77.1%) for oversampling conducted in some geographic locations.
Combination feeding 383 (13.5%)
Exclusive formula feeding 269 (9.5%)
Breastfeeding attempt (N 2848)
Attempted to breastfeed 2589 (90.9%) 4. Results
Did not attempt to breastfeed 260 (9.1%)
Intended to breastfeed/Attempted 2169 (76.4%) As illustrated in Table 2, 203 (7.2%) women met EPDS threshold
breastfeeding criteria suggestive of depression (score412), 233 (8.3%) endorsed
Intended to combination feed/Attempted 366 (12.9%)
breastfeeding
scores suggestive of subclinical levels of depression (score 1012),
Intended to formula feed/Attempted 47(1.7%) and 2381 (84.5%) scored in a range indicating they were not
breastfeeding struggling with depression (score o10). Binary logistic regressions
Intended to breastfeed/Did not attempt to 18 (0.6%) were rst conducted to determine if main effects exist between
breastfeed
breastfeeding intent (analysis 1) or breastfeeding attempt (analysis
Intended to combination feed/Did not at- 17 (0.6%)
tempt to breastfeed 2) with EPDS depressive symptom categories (not depressed, de-
Intended to formula feed/Did not attempt 222 (7.8%) pressed). The analysis was then run once more with breastfeeding
to breastfeed intent and attempt, as well as their interaction along with vari-
Exclusive breastfeeding duration in weeks 13.49 ables related to a number of prominent postpartum depression
(N 2844) (11.77)
Any breastfeeding duration in weeks 20.66
risk factors, included in the equation (analysis 3). The results of
(N 2844) (13.21) each set of analyses can be found in Table 3. As can be seen from
the table, the univariate binary logistic regression results indicate
Note. EPDS Edinburgh Postnatal Depression Scale. that, compared to intent to exclusively breastfeed, intent to com-
bination feed decreased the risk for meeting EPDS threshold cri-
indicative of a greater number/ severity of depressive symptoms, teria for depression at a level that was statistically signicant (2
which may indicate postpartum depression (the EPDS total score (1)9.53, p o.01). No signicant relationship was found compar-
ranges from 0 to 30; Cox et al., 1987). A cut-off score of 4 12 on the ing women who did and did not attempt to breastfeed with
EPDS yields satisfactory sensitivity (84.293.9%) and specicity meeting EPDS threshold criteria for depression (2 (1)1.23, ns).
(75.276.7%; Dennis, 2004). The Cronbach's alpha coefcient is When considering all risk factors, the analysis was signicant
reported to be .87 .88 (Dennis, 2004). and accounted for approximately 22% of the variance in explaining
EPDS scores412 (Nagelkerke R Squared). As can be seen from the
table, when examined in the context of the other postpartum
3. Statistical analysis depression risk factors, breastfeeding intention (entered as a
continuous variable) was no longer associated with meeting EPDS
IBM SPSS (version 22) was used to perform all statistical ana- threshold criteria for depression. Moreover, the binary logistic
lyses. Women were stratied into three groups based on their regression results indicated that some, but not all, other risk fac-
EPDS score, using the cut-off scores suggested by Cox et al. (1987). tors included in the analysis were statistically signicant in pre-
Although categorizing a dimensional entity may impose restric- dicting risk of postpartum depression in this sample. In particular,
tions on the information obtained (Streiner, 2002), doing so im- when controlling for the other variables in the analysis, lower
proved the clinical relevance and interpretability of the results. household income (2 (1) 22.50, p o.001), higher perceived level
Specically, the aim in this particular investigation was to explain of stress (2 (1) 28.71, p o.001), and lower social support (2
which breastfeeding variables would predict EPDS scores (primary (1)77.99, p o.001) signicantly predicted meeting EPDS
outcome) suggestive of clinical levels of postpartum depression (in threshold criteria for depression in this sample. As well, contrary
the absence of a clinical diagnostic interview). A categorical ap- to what would be expected based on existing literature, we found
proach allowed for reduced ambiguity that may result from not that no history of abuse (2 (1) 4.05, p o.05) or no history of
clearly delineating between levels of depression indicative of a depression (2 (1) 26.92, p o.001) signicantly predicted meet-
clinical syndrome and subclinical levels of depressive sympto- ing EPDS threshold criteria for depression in this sample. In other
mology by comparing women who were almost certainly not de- words, contrary to what has been reported in the previous lit-
pressed (EPDSo 10) to women whose symptom endorsement erature, having a history of abuse or depression reduced the risk
would strongly suggest the presence of postpartum depression for postpartum depression in this sample. However, compared to
(EPDS 412; Tuohy and McVey, 2008). Those women scoring 1012 the other signicant risk factors in this analysis (po .001), the
(inclusive) on the EPDS (suggestive of subclinical levels of de- signicance level for the history of abuse variable was just within
pressive symptoms) were not included in this analysis to permit the acceptable range (p .05).
an extreme group approach to prevent misclassication (Preacher Correlation analysis then was conducted to determine if a lin-
et al., 2005). Due to the categorical nature of the outcome measure ear association existed between duration of exclusive or any
and the variations expected in sample size for each condition, a breastfeeding and EPDS scores in this sample. Results of this
statistical method which does not require the assumption of nor- analysis showed that duration of exclusive breastfeeding is asso-
mality, binary logistic regression analysis, was employed to test for ciated with EPDS scores at a level that is statistically signicant
a relationship between breastfeeding attempt and postpartum (r(2812)  0.05, p o.05). This suggests that shorter duration of
depression. exclusive breastfeeding increased the risk for postpartum
48 C.J. Pope et al. / Journal of Affective Disorders 200 (2016) 4550

Table 3
Logistic Regression of breastfeeding intent, attempt, and postpartum depression risk factors with depressive symptoms (EPDS 412).

95% condence
Interval for OR

Analysisa Variable B OR Sig. Lower Upper

1 Intent (intend to exclusively breastfeed)

Intend to exclusively formula feed  0.44 0.65 .159 0.35 1.19
Intended to combination feed 0.57 1.77 .002* 1.23 2.53
2 Breastfeeding Attempt (attempted)
Did not attempt breastfeed  0.32 0.73 .268 0.42 1.28
3 Mother's age 0.03 1.03 .165 0.99 1.07
Education  0.02 0.98 .807 0.86 1.13
Marital status (married)
Never married  0.42 .66 .284 0.31 1.41
Widowed, separated, or divorced 0.21 1.23 .649 0.51 2.98
Wanted pregnancy  0.24 0.79 .502 0.40 1.57
Household income  0.18 0.84 o .001** 0.78 0.90
Number of live births 0.11 1.12 .211 0.94 1.32
Currently smoke  0.03 0.97 .889 0.61 1.54
Drank during pregnancy  0.05 0.95 .850 0.57 1.60
History of abuse (past 2 years)  0.47 0.63 .044* 0.40 0.99
Level of stress past year 0.66 1.94 o .001** 1.52 2.46
History depression/antidepressantsb  1.01 0.36 o .001** 0.25 0.53
Live rurally 0.43 1.54 .096 0.93 2.57
Level of social support  0.69 0.50 o .001** 0.43 0.59
Time returned to work postpartum 0.03 1.03 .081 1.00 1.07
Breastfeeding intentc 0.07 1.07 .745 0.71 1.63
Breastfeeding attemptc  0.59 0.55 .514 0.09 3.27
Interaction intent & attemptc 0.45 1.57 .363 0.59 4.17

Note. OR Odds Ratio. Operational denition for signicant risk variables: Level of stress past year [The amount of stress in their life during the 12 months before the index
baby was born (1 not stressful, 2 somewhat stressful, 3 very stressful)]; History depression/antidepressants [Ever been prescribed anti-depressants or been diagnosed
with depression prior to pregnancy (0 no, 1 yes)]; History of abuse (past 2 years) [Experienced verbal, sexual, or physical abuse in the past two years (0 no, 1 yes)];
Level of social support [availability of support when she needed it since the birth of the index baby (1 none of the time, 2 a little of the time, 3 some of the time, 4 most
of the time, 5 all of the time)].
a
Analysis 1, 2, and 3 Ns were 2600, 2608, and 2347, respectively.
b
prior to pregnancy.
c
When entered as either continuous or categorical variables, breastfeeding variables were not signicant in analysis 3, continuous values are presented.
*
p o .05.
**
po .001.

depression. However, the effect size of this association is negli-
gible. No association between any breastfeeding engagement and
EPDS scores was found (r(2812)  0.02, ns).
In order to assess if there was an association between the
duration of exclusive or any breastfeeding between women who
were depressed (EPDS 412) compared to women who were not
depressed (EPDS score o10) a binary logistic regression was
conducted. Neither duration of exclusive breastfeeding (2 (1)
0.53, ns), nor any breastfeeding (2 (1) 0.12, ns), signicantly
predicted meeting EPDS threshold criteria for depression.
5. Discussion
The primary purpose of this study was to determine if women
who did not attempt to breastfeed were at an increased risk for
postpartum depression. As well, we sought to determine if pre-
natal intention to breastfeed inuenced the association between
breastfeeding and postpartum depression. The results of this
study, derived from a large population-based sample, failed to
support ndings of previous literature (Figueiredo et al., 2013;
Seimyr et al., 2004) that suggested an association between
breastfeeding and postpartum depression. Specically, when other
risk factors were considered, breastfeeding attempt or intention to
breastfeed did not reduce the risk for postpartum depression. As
well, previous research has suggested a dose response effect of
breastfeeding with postpartum depression (Hahn-Holbrook et al.,
2013). That is, women who breastfeed more or for longer periods
of time were reported to be at a reduced risk for postpartum
depression (Thome et al., 2006; Ystrom, 2012). In this study, we
examined the dose response effect in two ways: rst, by examin-
ing duration of exclusive breastfeeding, and second, by examining
duration of any breastfeeding. Correlational analysis revealed that
duration of exclusive breastfeeding was negatively associated with
scores on the EPDS. However, the effect size of this association was
negligible, suggesting that this association is unlikely to translate
into clinically relevant observations. This assertion was further
supported by the binary logistic regression that did not show a
signicant association between duration of exclusive breastfeed-
ing, comparing women who were not depressed to women who
were depressed using EPDS threshold criteria. Further, in contrast
with other research, the results of the present study did not reveal
an association between duration of any breastfeeding and risk of
postpartum depression when examined by correlational analysis
or binary logistic analysis. Thus, the results of the current study
align with that of the prospective study by Bogen et al. (2001) who
also failed to nd an association between breastfeeding intention,
initiation, or duration and postpartum depressive symptoms
measured at 2 and 12 weeks postpartum.
The large sample size used in the current investigation, per-
mitted detection of even small differences (Streiner, 2003).
Moreover, the use of an extreme group approach, which excluded
individuals endorsing subclinical levels of depression from the
analysis, upwardly biased estimates of standardized effect size.
This increased the likelihood of detecting a signicant difference
between groups (Preacher et al., 2005). Thus, while non-signicant
ndings do not assure that no association exists, when viewed in
light of the considerably large sample size and method of
 C.J. Pope et al. / Journal of Affective Disorders 200 (2016) 4550
categorization that encouraged differences to be detected, the re-
sults of this study strongly suggest breastfeeding status does not
act as a standalone risk factor for the experience of postpartum
depression.
As part of this investigation the association of other factors
(previously identied in existing literature as risk factors for
postpartum depression) were also examined. Interestingly, not all
of the risk factors identied in previous research were found to be
signicant risk factors for postpartum depression in this sample. In
particular, when considering all potential risk factors in the ana-
lysis, mothers age, education level, marital status, smoking and
drinking status were not found to be signicantly associated with
depression status. Nor were an unwanted pregnancy, urban living,
number of previous live births, or the time postpartum the mother
returned to work. This suggests that when other risk factors are
considered, these specic factors may not in fact put women at
increased risk for postpartum depression. However, in agreement
with the previous literature, lower household income, higher
perceived stress, and lower perceived social support were found to
be signicantly related to depression status.
In contrast with previous research no history of depression or
antidepressant use increased the risk of endorsing EPDS score412
and not endorsing the experience of abuse in the past two years
increased the risk of endorsing an EPDS score412. These ndings
are counterintuitive to what would be hypothesized based on the
existing research (Meltzer-Brody et al., 2013) and may be a result
of the broad way these variables were classied. It is also notable
that some of the risk factors identied in the current investigation
are similar to factors that have been found by previous researchers
to predict a more chronic course of postpartum depression. Spe-
cically, lower family income, less perceived social support, and
stressful life circumstances (Pope et al., 2013, 2014; Vliegen et al.,
2014) are implicated in more chronic postpartum depression.
Thus, the current investigation may have captured women with a
more persistent form of postpartum depression. Finally, we in-
cluded a large number of risk factors identied in the empirical
literature. Interestingly, the results of the current study suggest
that even with the inclusion of many empirically supported risk
factors, there is still a very large proportion of variance un-
accounted for (approximately 78%). However, in binary logistic
regression an equivalent statistic to R-squared does not exist, so
this estimate is based on a pseudo R square value (Tabachnick and
Fidell, 2014). Based on this estimate it appears that even when we
consider a number of empirically supported risk factors, the fac-
tors leading to postpartum depression are still largely unknown.
More recent research points at potential underlying or mediating
biological mechanisms, such as alterations in hormonal levels,
inammation, and genetic predisposition (Skalkidou et al., 2012).
The role of these biological variables was not assessed in the
current study as information pertaining to these particular vari-
ables was not available.
The results of this study should be interpreted within the
connes of its strengths and limitations. The large population-
based sample of postpartum women used is a notable strength of
this investigation. A larger sample size promotes more precise
estimates of the magnitude of an association and the ability to
detect small but statistically signicant associations that may be
overlooked when smaller sample sizes are used. Larger sample
sizes have a reduced potential for producing false-positive results
than do smaller samples and allow for covariates to be assessed in
a manner that encourages more interpretable results (Hackshaw,
2008). The sizable number of mothers included in this sample also
allowed for the inclusion of multiple covariates without the risk of
over-tting (models with too many variables for the number of
observations; Babyak, 2004).
The ndings of this study should be viewed in light of the
49
following considerations. The measure of postpartum depression
taken in this sample was not a clinical diagnostic instrument.
However, currently there is no gold standard for measuring post-
partum depression (Vliegen et al., 2014) and the EPDS is the most
commonly used screening instrument in research for assessing
depression throughout the perinatal period (Hewitt et al., 2009).
As well, administering clinical interviews to a population-based
sample comes with obvious practical restraints, as such interviews
require specialized training and much more time to administer. In
addition, some episodes of postpartum depression may have been
missed, as depressive symptoms occurring before or after 57
months postpartum were not considered in the current in-
vestigation. The method by which the data was derived also re-
sulted in a few limitations. In particular, the questions used to
obtain data in this research were developed for the purposes of
the CMES. Thus, the current study was restricted to the use of data
collected as part of this survey. For instance, the CMES asked if
women had a history of antidepressant use or a diagnosis of de-
pression before pregnancy but did not ask women about anti-
depressant use or diagnosis of depression during pregnancy or the
postpartum period. As well, information pertaining to potential
serious medical condition for the infant was not available.
It would be ideal if future research could attempt to replicate
the results of this study with other large population-based sam-
ples. It would also be interesting to see if similar results are seen
when considering other time points during the postpartum period
and when using a prospective design. While the current study did
not look at course of treatment, the observation that the risk
factors identied in this sample may suggest a more chronic
course of depression brings light to the need for more research
regarding the course of postpartum depression. Further, research
investigating the factors that increase the risk of earlier versus
later onset of the disorder as well as factors that may predict a
longer course is also needed. This information may be valuable in
guiding clinical decision making regarding: 1) which women re-
quire more careful monitoring, 2) the length of time women
should be monitored for as informed by research and risk factors,
and 3) which women are at risk of a more chronic course as this
may be particularly important when considering pharmacological
interventions.
6. Conclusions
The results of this study suggest that breastfeeding status alone
may not be a signicant risk factor for postpartum depression.
Thus, if a relationship does exist, it is more complicated than the
way the relationship is currently conceptualized. Moreover, while
breastfeeding status did not predict postpartum depression in this
study, support was found for the role of other previously reported
risk factors. The results of this study suggest that future research
should seek to better understand the inuence that nancial dif-
culties, higher perceived stress, and limited social support have
on the clinical prognosis of depression in new and expecting
mothers.
Role of funding source
V. Sharma has received grant support from, participated on scientic advisory
boards for, or served on the speakers bureaus of AstraZeneca, Bristol-Myers Squibb,
Cephalon, Eli Lilly, Janssen, Lundbeck, the Ontario Mental Health Foundation, Pzer,
Servier, and the Stanley Foundation. C.J. Pope gratefully acknowledges nancial
support from the Canadian Institutes of Health Research.
Acknowledgments
Dr. Karen McQueen is thanked for her helpful comments. The authors are
grateful to the Public Health Agency of Canada and Statistics Canada for compiling
50 C.J. Pope et al. / Journal of Affective Disorders 200 (2016) 4550
the data and making it available for empirical exploration. The Maternity Experi-
ences Survey was developed and implemented by the Public Health Agency of
Canada in collaboration with Statistics Canada. The survey can be accessed through
Research Data Centres located across Canada. For more information please contact
the: Maternal and Infant Health Section of the Health Surveillance and Epide-
miology Division at the Public Health Agency of Canada cpss@phac-aspc.gc.ca. The
work reported here is based on a Masters thesis submitted by the rst author in
partial fulllment of the requirement for the degree of Master of Arts in Clinical
Psychology. This research was presented at the 76th annual conference of the
Canadian Psychological Association in Ottawa, Ontario on 5 June 2015.
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