Breastfeeding Among Women with Severe Mental Illness
by Anne Eglash MD, IBCLC, FABM
What are barriers to breastfeeding among women with severe mental illness?
Severe mental illness (SMI) is defined as psychiatric illness that impact a person’s daily functioning, requiring ongoing mental health services. According to the authors of this week’s systematic review, approximately 2.8% of pregnant women have pre-existing severe mental illness and/or develop severe post-partum psychiatric illness. Suicide is among the leading causes of direct maternal death in the first year postpartum, along with homicide and drug overdose.
Women with SMI are also at higher risk for poorer pregnancy outcomes such as gestational diabetes, prematurity, low birth weight, growth restriction and admission to neonatal intensive care. These risks are modified by the benefits of breastfeeding.
The aims of this systematic review were to evaluate evidence for infant feeding outcomes among women with SMI, experiences of breastfeeding support among women with SMI, interventions to support infant feeding in this population, and health care provider attitudes towards infant feeding among women with SMI.
The systematic review included 18 studies, of which 11 were cohort, 2 cross-sectional, 1 case series, 1 case-control, 2 qualitative, and 1 quasi-experimental study. The 18 studies included a total of 446,393 individuals, some of whom were controls. The studies took place in the USA, UK, Australia, Greece, Norway, Israel, and the Netherlands.
Only 2 studies evaluated breastfeeding rates and found that women with SMI had lower breastfeeding rates than controls.
What else? See the question!
- A key barrier for infant feeding decisions and support among women with SMI is inaccurate advice from healthcare providers.
- Breastfeeding support is lacking in inpatient psychiatric units.
- Women with current or a history of eating disorders were more concerned about their infants overeating as compared to women without eating disorders.
- Taking psychotropic medication has been documented as a barrier to breastfeeding.
- Women with SMI have less intention to breastfeed.
See the Answer
There are many benefits of breastfeeding to women and their infants but meeting the recommended 6 months of exclusive breastfeeding is likely to be more challenging for women with severe mental illness (SMI). This is the first systematic review that aims to examine evidence of (a) infant feeding outcomes in women with SMI and the factors associated with this, (b) the experiences of infant feeding and infant feeding support for women with SMI, (c) interventions for supporting infant feeding among these women and (d) health care professionals' attitudes toward supporting infant feeding in women with SMI. Mixed methods systematic review was carried out using the principles of Joanna Briggs Institute's (JBI) 'convergent integrated' methodology. CINAHL, PsycINFO, Medline and MIDIRS were used to search literature between 1994 and 2022. The quality of selected articles was assessed using JBI critical appraisal tools and thematic synthesis was undertaken to obtain findings. Eighteen papers were included in the final review. Women with SMI were less likely to initiate and continue breastfeeding than women without SMI. Several challenges with breastfeeding were highlighted, and while these were often linked to women's mental health difficulties, inconsistent advice from health care professionals and poor support with breastfeeding further compounded these challenges. This review highlights that policy and practice need to take into account the individual challenges women with SMI face when planning, initiating and maintaining breastfeeding. Education and training for health care professionals are needed to enable them to provide tailored infant feeding support to women with SMI, which reflects their individual needs.
Overall, the few studies in this systematic review were difficult to compare when evaluating infant feeding outcomes among women with SMI. Sadly, there were no studies that investigated interventions to support breastfeeding in women with SMI.
Women with SMI did not have lower intention to breastfeed. Intention to breastfeed aligned with similar demographic factors among women without SMI, such as education, socioeconomic status, race, age, etc.
Healthcare providers need more training regarding lactation and mental illness. There is an abundance of free, up to date resources for medications during lactation which demonstrates that very few medications are contraindicated during lactation. Nevertheless, women with SMI receive inappropriate advice, leading to premature weaning, or not taking needed psychiatric medications. With suicide being a top cause for postpartum mortality, evidence-based education among healthcare providers could save lives.
I have encountered advice from healthcare providers that women with SMI should not breastfeed because they won’t get enough sleep. It is true that sleep is important for people at risk for psychosis, such as bipolar disorder, but there is no evidence that breastfeeding women sleep less than women who formula feed.
Because this systematic review indicates that women with SMI are a high-risk group for low breastfeeding rates and lack of adequate support, I suggest that all women with SMI have a pre-conception or prenatal visit with a lactation consultant or breastfeeding medicine specialist to discuss infant feeding and to establish care for ongoing support.