Pone 0251419

PLOS ONE
RESEARCH ARTICLE
Early exclusive breastfeeding cessation and

postpartum depression: Assessing the
mediating and moderating role of maternal
stress and social support
Md Jahirul Islam ID1,2*, Lisa Broidy1,3, Kathleen Baird4, Mosiur Rahman5, Khondker
Mohammad Zobair6
1 Griffith Criminology Institute, Mt Gravatt, Brisbane, Queensland, Australia, 2 Skills for Employment
a1111111111
Investment Program (SEIP) Project, Finance Division, Ministry of Finance, Dhaka, Bangladesh,
a1111111111 3 Department of Sociology, University of New Mexico, Albuquerque, NM, United States of America, 4 Faculty
a1111111111 of Health, School of Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales,
a1111111111 Australia, 5 Department of Population Science and Human Resource Development, University of Rajshahi,
a1111111111 Rajshahi, Bangladesh, 6 Department of International Business and Asian Studies, Griffith University,
Brisbane, Queensland, Australia
* mdjahirul.bd@gmail.com
OPEN ACCESS
Citation: Islam MJ, Broidy L, Baird K, Rahman M,

Abstract
Zobair KM (2021) Early exclusive breastfeeding
cessation and postpartum depression: Assessing Background
the mediating and moderating role of maternal Early termination of exclusive breastfeeding (EBF) and postpartum depression (PPD) are
stress and social support. PLoS ONE 16(5):
e0251419. https://doi.org/10.1371/journal.
both recognized as global health problems. Recent literature reviews demonstrate a notable
pone.0251419 link between PPD and breastfeeding outcomes, however, the underlying mechanisms link-
Editor: Yukiko Washio, Christiana Care/University
ing the two remain unclear.
of Delaware, UNITED STATES
Received: August 14, 2020

Objectives
Accepted: April 26, 2021
The aim of the study is to: 1) explore the comparative risk for PPD among new mothers who
terminated EBF before the 6-month mark, compared to those who did not; and 2) test
Published: May 17, 2021
whether maternal stress and social support operate to mediate and/or moderate the rela-
Peer Review History: PLOS recognizes the tionship between EBF and PPD.
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author Methods
responses alongside final, published articles. The
Between October 2015 and January 2016, a cross-sectional study was carried out among
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0251419 426 new mothers of Bangladesh who were six months postpartum.
Copyright: © 2021 Islam et al. This is an open

access article distributed under the terms of the
Results
Creative Commons Attribution License, which Based on the multivariate logistic regression model, non-exclusively breastfeeding mothers
permits unrestricted use, distribution, and
were 7.58-fold more likely to experience PPD (95% CI [3.94, 14.59]) than exclusively breast-
reproduction in any medium, provided the original
author and source are credited. feeding mothers. Additionally, maternal stress and social support not only partially mediate
the relationship between EBF and PPD but also substantially moderate this relationship.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting Specifically, the odds of PPD are significantly higher among mothers who had early EBF
Information. interruption in conjunction with increased stress levels and limited social support.
PLOS ONE | https://doi.org/10.1371/journal.pone.0251419 May 17, 2021 1 / 19

PLOS ONE Early exclusive breastfeeding termination and postpartum depression
Funding: The authors received no specific funding Conclusions

for this work.
Current evidence suggests that concurrent screening for EBF difficulties and maternal
Competing interests: NO authors have competing
stress are important red flags that might hint at complications even before mother’s screen
interests.
positive for PPD. Support and care from family members can provide assistance in over-
coming this issue.
Introduction
Postpartum depression (PPD) is widely acknowledged as a significant public health issue,
affecting 3–19% of women worldwide [1,2]. PPD typically occurs within one month following
childbirth with symptoms that may include feelings of extreme sadness, guilt, low self-worth,
and hopelessness [3]. Evidence suggests that PPD can lead to long-lasting deleterious effects
on both mothers and their children, including impaired mother-infant interaction [2,4,5], par-
enting stress [6], infant attachment problems [7], maternal death due to suicide [8] and chil-
dren’s poor cognitive and physical development [2,4]. In addition, PPD involves significant
economic costs, both in terms of healthcare expenditures and lost work productivity [9]. There
is also mounting evidence that it is associated with early interruption of exclusive breastfeeding
(EBF) [7,10,11].
The association between PPD and the early interruption or termination of exclusive breast
feeding is notable because of the well-established short- and long-term health benefits of
breastfeeding. Citing these benefits, the World Health Organization (WHO) strongly recom-
mends EBF with no additional food types other than required medicines, vitamins, and miner-
als in the first six months of an infant’s life [12]. Evidence suggests that exclusively breastfed
babies have 15 times greater likelihood of survival in the first six months of life than non-exclu-
sively breastfed children [13]. While the promotion of breastfeeding is a global priority for
improving child mortality and morbidity, the prevalence of breastfeeding during the first few
weeks postpartum dramatically declines in both developed and developing countries, and EBF
during an infant’s first six months is rare [14,15]. Given that PPD is a known correlate of early
termination of EBF, early identification of mothers at-risk for both PPD and EBF termination
is a significant global health priority [16]. However, research has yet to fully articulate the
mechanisms that might link PPD with the early cessation of EBF, which complicates efforts to
develop targeted interventions with women at risk for PPD and EBF.
Complicating our understanding of the links between EBF and PPD is a lack of clarity
around the direction of the relationship between the two. A range of studies have illustrated
that early EBF interruption is associated with increased risk of PPD [7,17,18], while other
recent studies have indicated that PPD occurs prior to discontinuation of EBF [11,19,20]. At
the same time, several studies suggest no association [21–24]; or conversely find that breast-
feeding mothers are at higher risk for PPD [25]. Because of the inconsistent and insufficient
evidence, the nature of this association and the mechanisms underlying it remain unclear
[10,26,27]. It may be that early termination of EBF and PPD only become comorbid under spe-
cific conditions. Here, we suggest that social support and maternal stress are among the plausi-
ble mechanisms that might account for the link between EBF termination and PPD.
The nexus between EBF and women’s postpartum mental health may be driven by a num-
ber of psychosocial and biological influences [11]. Earlier studies suggests that breastfeeding
mothers appear to be calmer, less anxious, and less stressed [28,29]. Because of increased social
and educational awareness regarding the established health benefits of breastfeeding, many

women intend to breastfeed prenatally and also feel an intense social pressure to do so. Moth-
ers experiencing breastfeeding difficulties report culpability and loneliness, which ultimately
leads feelings of worthlessness and defeat [29,30]. The psychological displeasure due to the
inability to breastfeed increases maternal anxiety and stress levels and other postpartum
adjustment issues [18,27,29]. Social support is among the most crucial resources for navigating
the stressors of early motherhood, with benefits to both mother and child [31,32]. Those with
high social support are less likely to terminate EBF and report less PPD [33,34]. Alternatively,
women with limited social support who experience stress and anxiety around EBF are at
increased risk of PPD [7,35–37].
Given this literature, we see two possible pathways through which maternal stress and social
support might influence the link between EBF and PPD. First, maternal stress and limited
social support may be associated with both early termination of EBF and PPD, thereby mediat-
ing the relationship between the two. In other words, accounting for the association of mater-
nal stress and decreased social support with both EBF and PPD would reduce the relationship
between these two postpartum outcomes. In addition to this mediating model in which stress
and social support act as intervening mechanisms explaining the link between EBF and PPD,
it may also be the case that maternal stress and limited social support exaggerate any link
between early termination of EBF and PPD, creating a moderating effect. In other words, EBF
has a stronger impact on PPD when it interacts with high maternal stress or low social support,
thereby moderating the direct relationship between EBF on PPD. Exploring these potential
mediation and moderation effects of perceived stress and social support on the link between
EBF and PPD is crucial for identifying key pathways and processes, and for improving guid-
ance for the formulation of effective intervention strategies.
Research on the links between EBF and PPD has been predominantly carried out in high-
income countries, with varying definitions of EBF. Less is known about the influence of EBF
on maternal mental health outcomes in low- and middle-income countries. In the South Asian
region, only two recent studies from Pakistan [38] and Bangladesh [11] investigated the influ-
ence of PPD on EBF outcomes. In our previous study, it was revealed that mothers who experi-
enced postpartum depressive symptoms exhibited a lower likelihood of EBF than those who
reported no such symptoms [11]. However, no studies were found in South Asia exploring
how or why there is a significant association between early termination of EBF on the develop-
ment of PPD. Specifically, we know of no other studies from South Asia that have investigated
the influence of maternal stress and social support on the association between EBF and PPD.
In response, this study aims to: 1) explore the comparative risk for PPD among new mothers
who terminated EBF before the 6-month mark, compared to those who did not; and 2) test
whether maternal stress and social support operate to mediate and/or moderate the link
between EBF and PPD. We hypothesized that non-exclusive breastfeeding is linked with
higher risk of PPD and that maternal perceived stress and limited social support modify the
relationship between EBF and PPD.
Materials and methods

Study population
The current study is drawn from a much larger project, which mainly investigates maternal
and child health before, during and after pregnancy in Bangladesh. This extensive dataset was
used to produce several research outcomes exploring the correlates and changing pattern of
intimate partner violence (IPV) before, during, and after pregnancy [39,40], the influence of
IPV on experiencing PPD [41], maternal healthcare services [42] and suicidal ideation [8], psy-
chosocial factors of EBF [11], and the influence of childhood maltreatment on EBF behaviours

[43]. As described previously [11,41], a population-based cross-sectional survey of new moth-

ers was carried out between October 2015 and January 2016 in two Upazilas (sub-districts) of
the Chandpur district of Bangladesh. Virtually all mothers in Bangladesh rely on government
health clinics for their maternal and child health needs [44]. For this study, four hundred and
twenty-six new mothers who visited government-sponsored community immunization clinics
to receive vaccinations for their babies constitute the sampling frame. Married women of
reproductive age (15–49 years) with a child of six months or younger were included in the
study. It is important to note here that, given socio-cultural norms around marriage and par-
enthood (key markers of adulthood) in Bangladesh, the ethics board determined that, for this
study, married women aged 15 or older could agree to participate without parental consent.
Data collection
Detailed data collection procedures have been reported previously [11,41]. A multistage ran-
dom sampling design was applied for drawing the sample from selected immunization clinics.
Stage by stage, two Upazilas, 10 Unions (5 Unions per Upazila), and 80 immunization clinics
(8 clinics per Union) were chosen randomly to conduct the study. Union-wide immunization
clinic lists were obtained from the Upazila Health Centre to select immunization clinics. Once
Unions were chosen randomly, starting with the second immunization clinic on the list, every
third clinic was selected for the research.
If eligible to participate, women were invited to participate in a face-to-face survey. Because
several survey questions were relatively technical and hard to understand by the respondents
with limited literacy, a closed-form interviewer-administered questionnaire was utilized rather
than using a self-administered questionnaire. At each of the selected immunization clinics,
interviewers approached every woman who visited the clinic and asked each of the eligible
mothers to take part in the study. Attaining the desired sample size of 426, a total of 453
women were approached.
Human participation protection

The project received ethical approval from the National Research Ethics Committee of the
Bangladesh Medical Research Council (BMRC/NREC/2013-2016/305) and Griffith University
Human Research Ethics Committee (CCJ/41/14/HREC). Taking the cultural context and sen-
sitivity of the study into account, verbal informed consent was taken from every participant
after informing them of the purpose of the study, the confidential nature of the interview, and
their right to withdraw from the interview at any stage without consequences. As per our
approved ethics agreements, verbal informed consent was collected from all participants, but
not formally documented in order to ensure respondents’ anonymity and to avert any legal
consequences.
Measures
PPD. The main outcome variable in the current study was PPD. The Bangla version of the
Edinburgh Postpartum Depression Scale (EPDS-B) was applied to ascertain postpartum
depressive symptoms among new mothers [45]. The EPDS comprises 10 four-point Likert
scale statements (0–3) concerning women’s feelings of enjoyment, stress, fear and anxiety (see
Appendix for a full list of items). A sum score ranges from 0–30 with higher total scores speci-
fying higher depressive symptoms. The validation of the EPDS-B suggests a cut-off score of
�10, sensitivity 89% and specificity 87% [46]. Using this cut-off score, postpartum mothers
were categorized as either non-depressed (score <10 = 0) or depressed (score �10 = 1). The
Cronbach’s α for this scale in this study was .90.

EBF. The breastfeeding practice was classified as EBF using the WHO’s definition: “up to
six months of age, the infant receives only breast milk without any additional liquids or solids
—not even water—except oral rehydration solution, or drops/syrups of vitamins, minerals, or
medicines” [47, p.2]. Accordingly, each postpartum mother was asked if she had ever breastfed
her infant, if she was continuing breastfeeding, and if so, whether any additional food was fed
to her infant in the past [8]. The feeding behaviour was classified as either EBF (= 1) if a baby
was breastfed only since birth, or non-EBF (= 0) if a child was fed anything other than
breastmilk.
Maternal perceived stress

Maternal perceived stress was assessed using the 10-item Cohen’s Perceived Stress Scale (PSS)
on a 0 (never) to 4 (very often) Likert scale [48]. This scale measures perceived stress by asking
postpartum mothers about their feelings and thoughts during the previous month in relation
to such things as level of stress and the ability to cope with situations and handle personal
problems during the last month (see Appendix for a full list of scale items). After reverse scor-
ing for some items, total scores range from 0–40 with higher total scores indicate higher levels
of stress. The Bangla version of PSS has been validated in Bangladesh [43]. The PSS does not
have predefined cut-off values as it is not a diagnostic instrument [49]. Following a study in
Pakistan [50], this study uses 20 as the cut-off score to classify women as either low stress
(score <20 = 0) or a high stress (score �20 = 1) (Cronbach’s α = .93).
Social support
Social support was assessed using Chan et al.’s (2011) 10-item scale [51]. The Likert scale
scored as 1 (strongly disagree) to 4 (strongly agree) asking mothers whether they have people
they can talk to and rely on (see Appendix for full list of items). A higher score indicates greater
self-reported social support. The total score was classified into two groups: the lowest tertile
was coded as limited social support (= 0), and the higher two tertles were coded together as
high social support (= 1) (Cronbach’s α = .90).
Control variables
A range of control variables were included in this study that have been theoretically and empir-
ically linked to PPD [2,52] and EBF [53,54]. Maternal age was classified into adolescence,
young adulthood, and adulthood (14–18 years = 0, 19–24 years = 1, or 25 years and over = 2).
Educational level was categorized according to the country’s formal education system: no edu-
cation (0 years = 0), primary (1–5 years = 1), and secondary and higher (6 years or more = 2).
Family monthly income was categorized based on the national average (BDT 8500, ~ 109
USD) as � BDT 8500 (= 0) versus >BDT 8500 (= 1). Place of residence was grouped as rural
(= 0) versus urban (= 1). Reproductive attributes, such as parity (primiparous = 0, multipa-
rous = 1), pregnancy intention (unintended = 0, intended = 1), mode of birth (caesarean = 0,
vaginal = 1), and obstetric complications (no = 0, yes = 1) were also taken into account.
Prior depression. Each woman was asked if she had suffered from any of the PPD symp-
toms around the time of pregnancy, referred to herein as prior depression (categorized as:
score <10 = no = 0 and score �10 = yes = 1). We control for prior depression since it increases
the odds of PPD [41].
Childhood sexual abuse (CSA). CSA was determined by any of the following acts before
age 15: forced to have sexual intercourse, or forced to touch someone or be touched, kiss,
undress or perform any other sexual acts against her will by anyone (0 = no, 1 = yes). We con-
trol for CSA since it is associated with maternal stress [55].

Statistical analysis
Data analysis was performed by using SPSS version 24.0 for Windows (SPSS Inc., Chicago, IL,
USA). Descriptive statistics for mothers’ socio-demographic, reproductive, and psychosocial
characteristics and EBF outcomes were calculated. To assess the distributions of PPD by rele-
vant covariates, bivariate analysis was performed using cross tabulation. The χ2 test was
adopted to evaluate the differences in PPD rates by mothers’ psychosocial characteristics. We
set the level of significance for all analyses at p < .05 (two-tailed). The unadjusted associations
between the outcome and other variables were assessed through odds ratios and correspond-
ing 95% confidence intervals (CI). The multicollinearity was tested by variance inflation fac-
tors (VIF), all of which were below the standard cut-off score of 2.5.
Adjusted odds ratios (AOR) and 95% CI were estimated by using multivariate logistic
regression models to compare the strength of the relationship between each of the confounders
and PPD. First, three adjusted multivariate logistic regression models were designed—one sep-
arate model for early termination of EBF, maternal perceived stress, and social support to eval-
uate the independent influence of each on PPD (Table 2, Model 1–3). All the confounders
were introduced simultaneously into the logistic regression models. Another set of multivari-
ate models were designed to explore whether maternal stress and social support mediate and/
or moderate any association between the early termination of EBF and PPD. In the first occa-
sion (mediation), maternal stress and social support were introduced into the model to assess
if the association between EBF termination and PPD was attenuated once maternal stress and
social support were taken into consideration (Table 2, Model 4). In the second occasion
(moderation), an interaction term for maternal stress and EBF was introduced to investigate
whether higher levels of stress exaggerate the association between EBF termination and PPD.
Additionally, another interaction term for social support and EBF was introduced to deter-
mine whether limited social support exaggerates the association between of EBF termination
on PPD.
Results
Breastfeeding outcomes
Fig 1 portrays the frequency distribution of various feeding practices among respondents.
Within the total sample, 47 women introduced bottle or formula feeding (11.0%), 193 women
continued mixed feeding (45.3%), and the remaining 186 women exclusively breastfed their
babies at any point until the age of six months (43.7%). Fig 1 also depicts the feeding practice-
wise frequency distribution of the incidence of PPD among the respondents. In practice, the
incidence of PPD was highest among mixed feeding mothers (58.3%) and lowest among exclu-
sively breastfeeding mothers (8.6%).
Fig 2 depicts the EBF and PPD rates by maternal postpartum age in the sample. The preva-
lence of EBF was approximately 71.0% in the first month, whereas the rate dramatically
declined to 29%in the sixth month. Moreover, 23.0% of new mothers at month 1 and 40.0% of
women at month 6 experienced PPD. The figure clearly demonstrates a steady reduction in
EBF and a fairly dramatic shift in PPD at about 4 months postpartum.
General characteristics
Table 1 provides descriptive data for the sample and evaluates differences in rates of PPD as a
function of several psychosocial characteristics. Most mothers were between 19 and 24 years of
age (43.9%), had received either secondary or higher level of education (67.4%), and were liv-
ing in rural areas (68.5%) at the time of the survey. A large number of respondent’s average

Fig 1. Frequency distribution of different feeding practices and the incidence of corresponding postpartum depression rate
among postpartum women in Bangladesh (N = 426).
https://doi.org/10.1371/journal.pone.0251419.g001
Fig 2. Rates of exclusive breastfeeding and PPD by maternal postpartum age.


Table 1. General characteristics of the participants by the occurrence of postpartum depression and their unadjusted associations (N = 426).
Characteristics n (%) Postpartum depression Crude OR (95% CI)
(%) p-value
Low stress 183 (43.0) 11.5 < .001 1.00
High stress 243 (57.0) 53.1 8.73 (5.19–14.68) �
Social support
High 282 (66.2) 20.2 < .001 1.00
Limited 144 (33.8) 64.6 7.20 (4.60–11.27) �
Breastfeeding practices
Exclusive breastfeeding 240 (56.3) 56.8 < .001 1.00
Not exclusive breastfeeding 186 (43.7) 8.6 13.43 (7.58–23.81) �
Maternal age
14–18 106 (24.9) 36.8 .35 1.00
19–24 187 (43.9) 31.6 0.79 (0.48–1.31)
� 25 133 (31.2) 39.1 1.10 (0.65–1.87)
Maternal education
No formal education 35 (8.2) 62.9 < .001 1.00
Primary 104 (24.4) 48.1 0.55 (0.25–1.20)
Secondary and higher 287 (67.4) 27.2 0.22 (0.11–0.46) �
Family monthly income, BDT
�8500 (~ 109 USD) 163 (38.3) 52.1 < .001 1.00
>8500 263 (61.7) 24.7 0.31 (0.20–0.46) �
Place of residence
Rural 292 (68.5) 37.3 .17 1.00
Urban 134 (31.5) 30.6 0.74 (0.48–1.15)
Parity
Primiparous 175 (41.1) 30.3 .08 1.00
Multiparous 251 (58.9) 38.6 1.45 (0.96–2.19)
Pregnancy intention
Unintended 107 (25.1) 43.9 .03 1.00
Intended 319 (74.9) 32.3 0.61 (0.39–0.95) ��
Obstetric complications
No 357 (83.8) 33.9 .20 1,00
Yes 69 (16.2) 42.0 1.41 (0.84–2.39)
Mode of childbirth
Caesarean section 131 (30.8) 25.2 .004 1.00
Spontaneous Vaginal 295 (69.2) 39.7 1.95 (1.23–3.09) ��
Prior depression
No 312 (73.2) 22.4 < .001 1.00
Yes 114 (26.8) 70.2 8.13 (5.03–13.16) �
Childhood sexual abuse
No 364 (85.4) 33.0 0.02 1.00
Yes 62 (14.6)) 48.4 1.91 (1.11–3.28) ��
Total 35.2
Here
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p< 0.001
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p< 0.01
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p< 0.05.
https://doi.org/10.1371/journal.pone.0251419.t001

monthly income was below the national average (38.3%). Regarding reproductive characteris-
tics, around a quarter of the pregnancies were reported as unintended, 16.2% had experienced
obstetric complications, and just over two-thirds of women had spontaneous vaginal births
(69.2%). Concerning women’s mental health, about one-third of them reported to have limited
social support (33.8%), and nearly one in nine women reported that they were victims of sex-
ual abuse before 15 years of age (14.6%). While approximately one in four women (26.6%) had
previous depressive symptoms, more than one in three women (35.2%) had PPD symptoms.
Exclusive breastfeeding and postpartum depression: Bivariate associations

Table 1 demonstrates the results of bivariate analysis performed to assess the distributions of
PPD by relevant covariates. The experience of PPD was notably more common among respon-
dents who had no formal education, a low income, and limited social support. Postpartum
mothers were more likely to experience PPD if they also reported unplanned pregnancies and
gave spontaneous birth. As anticipated, postpartum mothers who had not exclusively breastfed
were significantly more likely to report PPD. Moreover, mothers who had a history of depres-
sion, higher levels of maternal perceived stress, and limited social support showed a signifi-
cantly greater likelihood of PPD. Findings reported in Table 1 depict unadjusted associations
between PPD and a range of relevant covariates. Noticeably, no significant association was
observed in the bivariate analysis for maternal age, place of residence, parity, and obstetric
complications.
Exclusive breastfeeding and postpartum depression: Multivariate

association
Results reported in Table 2 demonstrate the findings of multivariate analyses examining the
link between EBF and PPD controlling for all covariates. First, early termination of EBF was
examined (Table 2, Model 1), then social support and maternal stress separately (Table 2,
Model 2 & 3). Model 1 demonstrates that EBF was significantly associated with PPD, meaning
that women who terminated EBF early had a 9.68-fold higher risk (95% CI [5.16–18.16]) of
experiencing PPD than women who continued EBF during the first six months postpartum.
The odds of PPD were higher for mothers who experience maternal stress and for those who
report limited social support. Whether the association between EBF and PPD was partially
mediated by maternal stress and social support was also investigated in this study. Results in
Model 4 show that both maternal stress and limited social support significantly elevated the
odds of PPD. Most importantly, the inclusion of maternal stress and social support in the
model considerably decreased the association between early termination of EBF and PPD.
This suggests that part of the reason early termination of EBF is associated with PPD is due to
the related influence of both maternal stress and social support. In the full model, women with
early cessation of EBF were 6.93-fold more likely (95% CI [3.54, 13.57]) to also experience
PPD compared to those who were exclusively breastfeeding. Though not full mediation, this is
a notable reduction from the base model that showed early cessation of EBF to increase the
odds of PPD by 9.68 (95% CI [5.16–18.16]).
Moderating effect of maternal stress and social support

In addition to evidence that maternal perceived stress and social support partially mediate the
link between early termination of EBF and PPD, we found strong support for an interactive
effect. A strong interaction effect between EBF and maternal stress on PPD outcomes was
observed in the binary regression model (Fig 3). Overall, women who had high levels of mater-
nal stress and early termination of EBF were 17.22 times more likely to experience PPD (95%

Table 2. Logistic regression Adjusted odds ratios (AOR) with Confidence Interval (CI) for the relationship between EBF and PPD among postpartum women in
Bangladesh (N = 426).
Independent variable Postpartum Depression, AOR (95% CI)
Model 1 Model 2 Model 3 Model 4 (Full model)
Breastfeeding practices
Exclusive breastfeeding 1.00 1.00 1.00 1.00
Not exclusive breastfeeding 9.68 (5.16–18.16) � 8.49 (4.43–16.26) � 7.61 (3.95–14.65) � 6.93 (3.54–13.57) �
Social support
High - 1.00 - 1.00
Limited - 3.63 (2.04–6.45) � - 2.95 (1.63–5.34) �
Low stress - - 1.00 1.00
High stress - - 4.20 (2.16–8.13) � 3.41 (1.72–6.78) �
-2 log likelihood 375.15 355.53 355.63 342.64
R2 (Cox & Snell) .34� .37� .37� .39�
2 � � �
R (Nagelkerke) .47 .51 .51 .54�
Model χ2 177.58 197.20 197.10 210.10
Overall model prediction rate 78.6% 82.2% 81.5% 82.6%
Here
�
p< 0.001.
Model 1: Influence of EBF controlling for age, education, place of residence, family monthly income, parity, pregnancy intention, obstetric complications, mode of
childbirth, childhood sexual abuse, and prior depression WITHOUT maternal stress and social support.
Model 2: Influence of EBF controlling for the above covariates AND social support WITHOUT maternal stress.
Model 3: Influence of EBF controlling for the above covariates AND maternal stress WITHOUT social support.
Model 4: Influence of EBF controlling for the above covariates AND maternal stress & social support.
https://doi.org/10.1371/journal.pone.0251419.t002
CI [5.97, 49.64]) compared to women who exclusively breastfed and had low levels of maternal
stress. Additionally, women who had low levels of maternal stress and did not continue EBF
were still 5.43-fold more likely to experience PPD (95% CI [1.71, 17.25]) compared to women
who had low levels of maternal stress and continued EBF.
We also found a robust interaction effect between EBF and social support on PPD in the
logistic regression model (Fig 4). On balance, women who exclusively breastfed and had lim-
ited social support were 18.91 times more likely to experience PPD (95% CI [7.73, 46.29]) com-
pared to women with EBF and high social support.
Discussion
The primary objective of this study was to begin to unpack the link between early termination
of exclusive breastfeeding and PPD among new mothers. In addition to establishing a relation-
ship between EBF termination and PPD, we sought to test whether maternal stress and social
support mediate or moderate this relationship. The findings of the current study reinforce
mounting evidence that non-exclusive breastfeeding is significantly associated with PPD. Fur-
thermore, we extend this literature by examining the contributions of maternal stress and
social support to this relationship. Findings indicate that maternal stress and social support are
associated with EBF and PPD and that this partly accounts for significant association between
EBF and PPD. Furthermore, this relationship is exaggerated when maternal stress is high and
social support is limited. These findings have important implications for prevention and early
intervention with maternal mental health and breastfeeding practices.

Fig 3. Combined effect of EBF and maternal perceived stress on postpartum depression. Controlling for maternal age, maternal
education, place of residence, family monthly income, parity, pregnancy intention, obstetrical complications, mode of childbirth, social
support, childhood sexual abuse, and previous depressive symptoms; Here � p < 0.001, �� p < 0.01; MS = Maternal stress; EBF = Exclusive
breastfeeding.
The current research enhances the maternal mental health literature by providing evidence
of the comorbidity between early cessation of EBF and PPD outcomes, even after adjusting for
a range of potential covariates including previous depressive symptoms, obstetric complica-
tions, etc. Specifically, even when we account for maternal stress and limited social support
during the first 6 months postpartum, mothers who had an early interruption of EBF were
6.93-fold more likely to also experience PPD than those who had exclusively breastfed their
infants. In spite of contradictory findings in the literature, particularly on the direction of this
association, our results reinforce earlier studies linking early cessation of EBF with PPD
[7,17,18,56]. However, important questions of directionality remain and our data, unfortu-
nately, are not fine-grained enough to offer conclusions about the direction of this association.
Beyond the association between EBF cessation and PPD, our results reveal that maternal
perceived stress considerably exaggerates these effects. Women who reported early interrup-
tion of EBF and high levels of maternal stress were significantly more likely to exhibit depres-
sive symptoms than those who exclusively breastfed and had low levels of maternal stress. A
growing number of studies provide empirical evidence that EBF reduces PPD through several
psychological and biological processes directly or indirectly associated with maternal stress
[24,57]. Breastfeeding improves maternal psychological well-being not only by regulating
maternal-infant sleep and wake patterns [58] but also enhancing mothers’ self-efficacy and
perceptions of maternal adequacy by improving mothers’ emotional involvement with their
infant [26] and mother-infant interaction [59]. Exclusive breastfeeding mothers usually sleep
an average of 40–45 minutes longer and report less sleep interruption compared to mothers of
formula-fed infants [58]. Previous studies show that inadequate or interrupted sleep experi-
enced by new mothers due to formula supplementation during the first few month’s

Fig 4. Combined effect of EBF and social support on postpartum depression. Controlling for maternal age, maternal education, place of
residence, family monthly income, parity, pregnancy intention, obstetric complications, mode of childbirth, childhood sexual abuse, previous
depressive Symptoms and maternal stress; Here � p< 0.001; SS = Social Support, EBF = Exclusive Breastfeeding.
postpartum leads to increased maternal stress and fatigue [28,60,61]. Consequently, increased
levels of maternal stress and anxiety may interfere with the physiological process of milk pro-
duction or maintaining milk production [28,62,63]. In the delayed lactation process, mothers
may erroneously conclude that they are incapable of producing adequate breastmilk, leading
to early termination of breastfeeding [63,64]. EBF difficulties may generate feelings of embar-
rassment and discomfort among women presuming that they will be judged by others for not
properly protecting and caring their developing infants, aggravating levels of stress among
mothers, which may ultimately contribute to the development of PPD [36,65,66].
An alternative explanation may be that lactation attenuates neuroendocrine and beha-
vioural responses to physical and psychological stress and may act to ameliorate maternal
mood [28,67]. In particular, two lactation inducing hormones—oxytocin and prolactin—are
reported to have mood-alleviating effects that may promote feelings of nurturance and relaxa-
tion [67]. Also, lactation attenuates cortisol stress responses by reducing levels of stress hor-
mone and enhancing sleep [68]. The stress associated with EBF difficulties and sleep
deprivation can alter the synthesis and release of prolactin and oxytocin, and interfere with
milk secretion and maintaining milk production [62]. This is consistent with evidence suggest-
ing that persistent sleep deprivation and EBF difficulties are significant predictors for the
development of PPD [55].
Consistent with other literature [34,41,69], results of this study also implicate social support
deficits in the relationship between EBF and PPD. The odds of PPD are significantly higher
among mothers with limited social support who terminated exclusive breastfeeding. This is in
line with existing literature suggesting that the increased likelihood of EBF is seen among

mothers who report higher social support compared with those who report limited social sup-
port [11,70,71]. Previous research shows a linier relationship between greater quality of social
support, and stress management and coping [72]. In distress situations, social support buffers
the detrimental effects of stressful events by enhancing self-efficacy, leading to fewer depressive
symptoms [31,32]. Several studies also have portrayed that quality support from family is sig-
nificantly connected with better adjustment to and healing from severe diseases, and with
healthier neuroendocrine functioning and good mood [73–76]. As such, mothers lacking
social support will have a harder time enduring the challenges linked with EBF along with the
emotional toll connected with a sense of guilt and inadequacy due to early discontinuation of
EBF, exaggerating links between EBF termination and PPD.
Our findings are consistent with other research showing that, compared to mothers without
depressive symptoms, mothers with symptoms of postnatal depression are more likely to pro-
vide the supplementary formula to their infants in the first year of life [77]. In a large study of
women evaluated between 8 and 12 weeks postpartum, it has been established that exclusively
breastfeeding mothers had lower levels of depressive symptoms compared to partial breast-
feeding mothers [17]. This finding is supported by Ystrom (2012), who also found that, at six
months postpartum, both partially breastfeeding as well as exclusively bottle-feeding were
associated with higher levels of depressive symptoms in postpartum women when compared
to those who solely breastfeed their infants [18]. While our data do not allow us to interrogate
the causal mechanisms at play here, we can speculate links between the high levels of depres-
sion symptoms and poor feeding outcomes that future research can explore. Postpartum
depression might cause negative effects on maternal self-esteem and cognition, which can
interrupt breast feeding intentions [77]. Furthermore, women with depressive symptoms may
not engage or interact with their baby, they may spend less time experiencing skin—to—skin,
not enjoy touching their baby, which in turn may affect their lactation and decrease their milk
supply which leads to an increase in their lack of confidence in their own ability to breastfeed.
This can then lead to further dissatisfaction and disappointment in relation to their infant
feeding practices and increases the likelihood that they rely more on formula feeding and less
on breast feeding.
Various professional organizations recommend screening for depression during perinatal
and postpartum healthcare visits [78]. However, our work suggests that concurrent screening
for problems related to EBF, parenting stress, and social support deficits are also important red
flags that might hint at complications even before mother’s screen positive for PPD. Screening
for these issues may occur early postpartum, at 2–3 months, and finally at 4–6 months. Of
course, it remains an important empirical question to determine the most appropriate window
for screening and intervention. In this regard, evidence-based policies and guidelines need to
be developed by professional organisations, and specialised training should be introduced for
midwives, obstetricians, and family workers to identify mothers with EBF difficulties, stress
exposure, social disengagement, and depressive symptoms and offer proper support to them.
Mother-infant psychotherapy [79], cognitive-behavioural therapy [80], and a ‘Nurse-Family
Partnership program’ or ‘Home visitation program’ [81–83] were found to be effective in
improving maternal mental health as along with family functioning and related social sup-
ports. In low- and middle-income countries, well-established referral pathways and support
organisations need to be set up before introducing a screening program [84].
Strengths and limitations

The important features of this particular research are the large sample size (N = 426) and the
inclusion of a range of key confounders. This was the first known research of its kind in South

Asian region to explore the association between EBF cessation and PPD in a community-
based sample of postpartum mothers. Moreover, it is one of the few studies to assess the medi-
ating and moderating influences of maternal perceived stress on the relationship between EBF
and PPD outcomes. Surveying mothers within six months postpartum helped us to signifi-
cantly minimize the potential recall bias regarding their experience of EBF and maternal men-
tal health. Most importantly, the study results are internationally comparable because of the
application of widely recognized standardized instruments for this study. Despite these
strengths, the results from this study need to be interpreted in light of several limitations. First,
the cross-sectional design of this study restricts us from establishing the exact temporal associ-
ation between the discontinuation of EBF and PPD outcomes. The current study demonstrates
only the strong association between these two significant public health issues. Second, an over-
estimation of the rate of EBF may result due to the inclusion of women of postpartum ages
between one and six months, because the EBF prevalence is significantly high in the first cou-
ple of postpartum months, and then gradually declines. Third, information was obtained
through self-report which is subject to some biases. However, the potential recall bias of the
respondents is minimized as they were surveyed within six months postpartum. Finally, lim-
ited time and budget restrict us from collecting data regarding several confounders, such as
the family history of axis I or II disorders, maternal medications use, gestational age, health sta-
tus of the infant, and difficult infant temperament. Despite such limitations, the research is
timely as this particular research adds to the extant literature on the influences of EBF on PPD
in low- and middle-income countries.
Conclusion
Despite high profile campaigns to raise awareness of the importance of EBF and to promote
the social acceptability of breastfeeding in Bangladesh, the rate of EBF was found to be only
32% at 4–5 months postpartum [85]. The low prevalence of EBF and its relationship with
maternal mental health outcomes underscore the urgency of recognizing both of them as a
notable public health issue in Bangladesh. This study reinforces the necessity of early detection
and effective treatment of depressed mothers with EBF complications, stress exposure, or lim-
ited social support not only to offer need-based support but also to improve EBF outcomes.
Since the pathway of the relationship between EBF and PPD remains unclear, longitudinal
studies assessing the direction of the association between PPD outcomes and breastfeeding are
needed to get a relatively better understanding of the dynamics and process.
Supporting information
S1 Data.
(SAV)
S1 Appendix.
(DOCX)
Author Contributions
Conceptualization: Md Jahirul Islam.
Data curation: Md Jahirul Islam, Lisa Broidy.
Formal analysis: Md Jahirul Islam.
Investigation: Md Jahirul Islam.

Methodology: Md Jahirul Islam.

Project administration: Md Jahirul Islam.
Supervision: Lisa Broidy, Kathleen Baird.
Visualization: Md Jahirul Islam.
Writing – original draft: Md Jahirul Islam.
Writing – review & editing: Md Jahirul Islam, Lisa Broidy, Kathleen Baird, Mosiur Rahman,
Khondker Mohammad Zobair.
References
1. O’hara MW, McCabe JE. Postpartum depression: current status and future directions. Annual Review
of Clinical Psychology. 2013; 9:379–407. https://doi.org/10.1146/annurev-clinpsy-050212-185612
PMID: 23394227
2. Gelaye B, Rondon MB, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and
child outcomes in low-income and middle-income countries. The Lancet Psychiatry. 2016; 3(10):973–
82. https://doi.org/10.1016/S2215-0366(16)30284-X PMID: 27650773
3. Craig M, Howard L. Postnatal depression. Clinical Evidence (Online) 2009; 1407. PMID: 19445768
4. Stein A, Pearson RM, Goodman SH, Rapa E, Rahman A, McCallum M, et al. Effects of perinatal mental
disorders on the fetus and child. The Lancet. 2014; 384(9956):1800–19. https://doi.org/10.1016/S0140-
6736(14)61277-0 PMID: 25455250
5. Milgrom J, Ericksen J, McCarthy R, Gemmill AW. Stressful impact of depression on early mother–infant
relations. Stress and health. 2006; 22(4):229–38.
6. Kan ML, Feinberg ME, Solmeyer AR. Intimate Partner Violence and Coparenting Across the Transition
to Parenthood. Journal of Family Issues. 2012; 33(2):115–35.
7. Dias CC, Figueiredo B. Breastfeeding and depression: A systematic review of the literature. Journal of
Affective Disorders. 2015; 171:142–54. https://doi.org/10.1016/j.jad.2014.09.022 PMID: 25305429
8. Islam MJ, Broidy L, Mazerolle P, Baird K, Mazumder N, Zobair KM. Do maternal depression and self-
esteem moderate and mediate the association between intimate partner violence after childbirth and
postpartum suicidal ideation? Archives of Suicide Research. 2019:1–24. https://doi.org/10.1080/
13811118.2019.1655507 PMID: 31462186
9. Ammerman RT, Chen J, Mallow PJ, Rizzo JA, Folger AT, Van Ginkel JB. Annual direct health care
expenditures and employee absenteeism costs in high-risk, low-income mothers with major depression.
Journal of Affective Disorders. 2016; 190:386–94. https://doi.org/10.1016/j.jad.2015.10.025 PMID:
26546774
10. Dennis CL, McQueen K. The relationship between infant-feeding outcomes and postpartum depres-
sion: a qualitative systematic review. Pediatrics. 2009; 123(4):e736–e51. https://doi.org/10.1542/peds.
2008-1629 PMID: 19336362
11. Islam MJ, Baird K, Mazerolle P, Broidy L. Exploring the influence of psychosocial factors on exclusive
breastfeeding in Bangladesh. Archives of Women’s Mental Health. 2017; 20(1):173–88. https://doi.org/
10.1007/s00737-016-0692-7 PMID: 27838781
12. World Health Organization (WHO). Exclusive Breastfeeding for six months best for babies everywhere.
Geneva: World Health Organization (WHO); 2011.
13. Black RE, Allen LH, Bhutta ZA, Caulfield LE, De Onis M, Ezzati M, et al. Maternal and child undernutri-
tion: global and regional exposures and health consequences. The lancet. 2008; 371(9608):243–60.
https://doi.org/10.1016/S0140-6736(07)61690-0 PMID: 18207566
14. Chalmers B, Levitt C, Heaman M, O’Brien B, Sauve R, Kaczorowski J. Breastfeeding rates and hospital
breastfeeding practices in Canada: A national survey of women. Birth. 2009; 36(2):122–32. https://doi.
org/10.1111/j.1523-536X.2009.00309.x PMID: 19489806
15. Al-Sahab B, Lanes A, Feldman M, Tamim H. Prevalence and predictors of 6-month exclusive breast-
feeding among Canadian women: A national survey. BMC Pediatrics 2010; 10(1):20–9. https://doi.org/
10.1186/1471-2431-10-20 PMID: 20377899
16. Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, et al. Breastfeeding in the 21st
century: epidemiology, mechanisms, and lifelong effect. The Lancet. 2016; 387(10017):475–90.

17. Thome M, Alder EM, Ramel A. A population-based study of exclusive breastfeeding in Icelandic
women: is there a relationship with depressive symptoms and parenting stress? International Journal of
Nursing Studies. 2006; 43(1):11–20. https://doi.org/10.1016/j.ijnurstu.2004.10.009 PMID: 16326160
18. Ystrom E. Breastfeeding cessation and symptoms of anxiety and depression: a longitudinal cohort
study. BMC pregnancy and childbirth. 2012; 12(1):36. https://doi.org/10.1186/1471-2393-12-36 PMID:
22621668
19. Chiu H-C, Wang H-Y, Hsiao J-C, Tzeng I-S, Yiang G-T, Wu M-Y, et al. Early breastfeeding is associated
with low risk of postpartum depression in Taiwanese women. Journal of Obstetrics and Gynaecology.
2020; 40(2):160–6. https://doi.org/10.1080/01443615.2019.1603216 PMID: 31215282
20. Silva CS, Lima MC, Sequeira-de-Andrade LAS, Oliveira JS, Monteiro JS, Lima NMS, et al. Association
between postpartum depression and the practice of exclusive breastfeeding in the first three months of
life. Jornal de Pediatria 2017; 93(4):356–64. https://doi.org/10.1016/j.jped.2016.08.005 PMID:
28034730
21. Farı́as-Antúnez S, Santos IS, Matijasevich A, de Barros AJD. Maternal mood symptoms in pregnancy
and postpartum depression: association with exclusive breastfeeding in a population-based birth
cohort. Social Psychiatry and Psychiatric Epidemiology. 2020; 55:635–43. https://doi.org/10.1007/
s00127-019-01827-2 PMID: 31897581
22. Hahn-Holbrook J, Haselton MG, Schetter CD, Glynn LM. Does breastfeeding offer protection against
maternal depressive symptomatology?: A prospective study from pregnancy to 2 years after birth.
Archives of women’s mental health. 2013; 16(5):411–22. https://doi.org/10.1007/s00737-013-0348-9
PMID: 23749095
23. Pope CJ, Mazmanian D, Bédard M, Sharma V. Breastfeeding and postpartum depression: Assessing
the influence of breastfeeding intention and other risk factors. Journal of Affective Disorders. 2016;
200:45–50. https://doi.org/10.1016/j.jad.2016.04.014 PMID: 27126139
24. Ahn S, Corwin EJ. The association between breastfeeding, the stress response, inflammation, and
postpartum depression during the postpartum period: Prospective cohort study. International journal of
nursing studies. 2015; 52(10):1582–90. https://doi.org/10.1016/j.ijnurstu.2015.05.017 PMID: 26143358
25. Alder E, Bancroft J. The relationship between breast feeding persistence, sexuality and mood in post-
partum women. Psychological Medicine. 1988; 18(2):389–96. https://doi.org/10.1017/
s0033291700007935 PMID: 3399590
26. Nishioka E, Haruna M, Ota E, Matsuzaki M, Murayama R, Yoshimura K, et al. A prospective study of
the relationship between breastfeeding and postpartum depressive symptoms appearing at 1–5 months
after delivery. Journal of Affective Disorders. 2011; 133(3):553–9. https://doi.org/10.1016/j.jad.2011.04.
027 PMID: 21705090
27. Gregory EF, Butz AM, Ghazarian SR, Gross SM, Johnson SB. Are unmet breastfeeding expectations
associated with maternal depressive symptoms? Academic pediatrics. 2015; 15(3):319–25. https://doi.
org/10.1016/j.acap.2014.12.003 PMID: 25906701
28. Mezzacappa ES, Katkin ES. Breast-feeding is associated with reduced perceived stress and negative
mood in mothers. Health Psychology. 2002; 21(2):187–93. PMID: 11950109
29. Sisk PM, Lovelady CA, Dillard RG, Gruber KJ. Lactation counseling for mothers of very low birth weight
infants: effect on maternal anxiety and infant intake of human milk. Pediatrics. 2006; 117(1):e67–e75.
https://doi.org/10.1542/peds.2005-0267 PMID: 16396850
30. Palmér L, Carlsson G, Mollberg M, Nyström M. Severe breastfeeding difficulties: Existential lostness as
a mother—Women’s lived experiences of initiating breastfeeding under severe difficulties. International
Journal of Qualitative Studies on Health and Well-being. 2012; 7(1):10846. https://doi.org/10.3402/qhw.
v7i0.10846 PMID: 22312409
31. Haslam DM, Pakenham KI, Smith A. Social support and postpartum depressive symptomatology: The
mediating role of maternal self-efficacy. Infant Mental Health Journal. 2006; 27(3):276–91. https://doi.
org/10.1002/imhj.20092 PMID: 28640472
32. Haga SM, Ulleberg P, Slinning K, Kraft P, Steen TB, Staff A. A longitudinal study of postpartum depres-
sive symptoms: multilevel growth curve analyses of emotion regulation strategies, breastfeeding self-
efficacy, and social support. Archives of women’s mental health. 2012; 15(3):175–84. https://doi.org/10.
1007/s00737-012-0274-2 PMID: 22451329
33. Beydoun HA, Beydoun MA, Kaufman JS, Lo B, Zonderman AB. Intimate partner violence against adult
women and its association with major depressive disorder, depressive symptoms and postpartum
depression: systematic review and meta-analysis. Social Science & Medicine. 2012; 75(6):959–75.
https://doi.org/10.1016/j.socscimed.2012.04.025 PMID: 22694991
34. Beck CT. State of the Science on postpartum depression: What nurse researchers have contributed—
Part 1. The American Journal of Maternal/Child Nursing. 2008; 33(2):121–6.

35. Borra C, Iacovou M, Sevilla A. New Evidence on Breastfeeding and Postpartum Depression: The
Importance of Understanding Women’s Intentions. Matern Child Health Journal. 2015; 19(4):897–907.
https://doi.org/10.1007/s10995-014-1591-z PMID: 25138629
36. Leung SSK, Martinson IM, Arthur D. Postpartum depression and related psychosocial variables in
Hong Kong Chinese women: findings from a prospective study. Research in nursing & health. 2005; 28
(1):27–38.
37. Kendall-Tackett KA, Cong Z, Hale TW. The effect of feeding method on sleep duration, maternal well-
being and postpartum depression. Clinical Lactation. 2011; 2(2):22–6.
38. Rahman A, Hafeez A, Bilal R, Sikander S, Malik A, Minhas F, et al. The impact of perinatal depression
on exclusive breastfeeding: a cohort study. Maternal & child nutrition. 2016; 12(3):452–62. https://doi.
org/10.1111/mcn.12170 PMID: 25682731
39. Islam MJ, Mazerolle P, Broidy L, Baird K. Exploring the prevalence and correlates associated with inti-
mate partner violence during pregnancy in Bangladesh. Journal of interpersonal violence. 2017. https://
doi.org/10.1177/0886260517730029 PMID: 29294908
40. Islam MJ, Broidy L, Mazerolle P, Baird K, Mazumder N. Exploring intimate partner violence before, dur-
ing, and after pregnancy in Bangladesh. Journal of interpersonal violence. 2018:0886260518775753.
https://doi.org/10.1177/0886260518775753 PMID: 29792129
41. Islam MJ, Broidy L, Baird K, Mazerolle P. Intimate partner violence around the time of pregnancy and
postpartum depression: The experience of women of Bangladesh. PloS one. 2017; 12(5):e017621.
https://doi.org/10.1371/journal.pone.0176211 PMID: 28472056
42. Islam MJ, Broidy L, Baird K, Mazerolle P. Exploring the associations between intimate partner violence
and delayed entry to prenatal care: Evidence from a cross-sectional study in Bangladesh. Midwifery.
2017; 47:43–55. https://doi.org/10.1016/j.midw.2017.02.002 PMID: 28237897
43. Islam MJ, Mazerolle P, Broidy L, Baird K. Does the type of maltreatment matter? Assessing the individ-
ual and combined effects of multiple forms of childhood maltreatment on exclusive breastfeeding
behavior. Child Abuse & Neglect. 2018; 86:290–305. https://doi.org/10.1016/j.chiabu.2018.10.002
PMID: 30391785
44. Khan NN. Maternal and child health in Bangladesh: a critical look at the policy and the sustainable
development goals. Asian Journal of Medical and Biological Research. 2017; 3(3):298–304.
45. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edin-
burgh Postnatal Depression Scale. The British Journal of Psychiatry. 1987; 150(6):782–6. https://doi.
org/10.1192/bjp.150.6.782 PMID: 3651732
46. Gausia K, Fisher C, Algin S, Oosthuizen J. Validation of the Bangla version of the Edinburgh Postnatal
Depression Scale for a Bangladeshi sample. Journal of Reproductive and Infant Psychology 2007; 25
(4):308–15.
47. UNICEF, WHO. Nurturing the Health and Wealth of Nations: The Investment Case for Breastfeeding.
New York, USA: UNICEF and WHO, 2017.
48. Cohen S, Kamarck T, Mermelstein R. A Global Measure of Perceived Stress. Journal of health and
social behavior. 1983; 24(4):385–96. https://doi.org/10.2307/2136404 PMID: 6668417
49. White RS, Jiang J, Hall CB, Katz MJ, Zimmerman ME, Sliwinski M, et al. Higher Perceived Stress Scale
Scores Are Associated with Higher Pain Intensity and Pain Interference Levels in Older Adults. Journal
of the American Geriatrics Society. 2014; 62(12):2350–6. https://doi.org/10.1111/jgs.13135 PMID:
25516031
50. Shah M, Hasan S, Malik S, Sreeramareddy CT. Perceived stress, sources and severity of stress among
medical undergraduates in a Pakistani medical school. BMC Medical Education. 2010; 10(1):2–. https://
doi.org/10.1186/1472-6920-10-2 PMID: 20078853
51. Chan KL, Brownridge DA, Tiwari A, Fong DY, Leung WC, Ho PC. Associating pregnancy with partner
violence against Chinese women. Journal of interpersonal violence. 2011; 26(7):1478–500. https://doi.
org/10.1177/0886260510369134 PMID: 20495098
52. Fisher J, Mello MCd, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of com-
mon perinatal mental disorders in women in low-and lower-middle-income countries: a systematic
review. Bulletin of the World Health Organization. 2012; 90(2):139–49. https://doi.org/10.2471/BLT.11.
091850 PMID: 22423165
53. James JP, Taft AJ, Amir LH, Agius P. Does intimate partner violence impact on women’s initiation and
duration of breastfeeding? Breastfeeding Review. 2014; 22(2):11–9. PMID: 25109096
54. Wallenborn J, Masho S. Intimate Partner Violence and the Effects on Breastfeeding Outcomes. Journal
of women’s health. 2015; 24(4):47.
55. Kendall-Tackett KA, Cong Z, Hale TW. Depression, sleep quality, and maternal well-being in postpar-
tum women with a history of sexual assault: A comparison of breastfeeding, mixed-feeding, and

formula-feeding mothers. Breastfeeding Medicine. 2013; 8(1):16–22. https://doi.org/10.1089/bfm.2012.

0024 PMID: 23249130
56. Figueiredo B, Canario C, Field T. Breastfeeding is negatively affected by prenatal depression and
reduces postpartum depression. Psychological Medicine. 2014; 44(5):927–36. https://doi.org/10.1017/
S0033291713001530 PMID: 23822932
57. Dennis CL, McQueen K. Does maternal postpartum depressive symptomatology influence infant feed-
ing outcomes? Acta Paediatrica. 2007; 96(4):590–4. https://doi.org/10.1111/j.1651-2227.2007.00184.x
PMID: 17391475
58. Doan T, Gardiner A, Gay CL, Lee KA. Breast-feeding Increases Sleep Duration of New Parents. The
Journal of Perinatal & Neonatal Nursing. 2007; 21(3):200–6. https://doi.org/10.1097/01.JPN.
0000285809.36398.1b PMID: 17700096
59. Field T, Diego MA, Hernandez-Reif M, Figueiredo B, Ascencio A, Schanberg S, et al. Prenatal dysthy-
mia versus major depression effects on maternal cortisol and fetal growth. Depression and Anxiety.
2008; 25(6):E11–E6. https://doi.org/10.1002/da.20307 PMID: 17587221
60. Gay CL, Lee KA, Lee S-Y. Sleep patterns and fatigue in new mothers and fathers. Biological Research
for Nursing. 2004; 5(4):311–8. https://doi.org/10.1177/1099800403262142 PMID: 15068660
61. Heinrichs M, Neumann I, Ehlert U. Lactation and stress: protective effects of breast-feeding in humans.
Stress. 2002; 5(3):195–203. https://doi.org/10.1080/1025389021000010530 PMID: 12186682
62. O’Brien M, Buikstra E, Hegney D. The influence of psychological factors on breastfeeding duration.
Journal of Advanced Nursing. 2008; 63(4):397–408. https://doi.org/10.1111/j.1365-2648.2008.04722.x
PMID: 18727767
63. Holland ML, Thevenent-Morrison K, Mittal M, Nelson A, Dozier AM. Breastfeeding and Exposure to
Past, Current, and Neighborhood Violence. Maternal and Child Health Journal. 2017; 22(1):82–91.
https://doi.org/10.1007/s10995-017-2357-1 PMID: 28766093
64. Kendall-Tackett KA. Violence against women and the perinatal period: The impact of lifetime violence
and abuse on pregnancy, postpartum, and breastfeeding. Trauma, Violence & Abuse. 2007; 8(3):344–
53. https://doi.org/10.1177/1524838007304406 PMID: 17596350
65. Rodrı́guez MA, Valentine J, Ahmed SR, Eisenman DP, Sumner LA, Heilemann MV, et al. Intimate Part-
ner Violence and Maternal Depression During the Perinatal Period: A Longitudinal Investigation of Lati-
nas. Violence against women. 2010; 16(5):543–59. https://doi.org/10.1177/1077801210366959 PMID:
20388930
66. Wang S-Y, Jiang X-Y, Jan W-C, Chen C-H. A comparative study of postnatal depression and its predic-
tors in Taiwan and mainland China. American journal of obstetrics and gynecology. 2003; 189(5):1407–
12. https://doi.org/10.1067/s0002-9378(03)00673-2 PMID: 14634578
67. Pope CJ, Mazmanian D. Breastfeeding and Postpartum Depression: An Overview and Methodological
Recommendations for Future Research. Depression Research and Treatment. 2016; 2016:4765310.
https://doi.org/10.1155/2016/4765310 PMID: 27148457
68. Figueiredo B, Dias CC, Brandão S, Canário C, Nunes-Costa R. Breastfeeding and postpartum depres-
sion: state of the art review. Jornal de Pediatria 2013; 89(4):332–8. https://doi.org/10.1016/j.jped.2012.
12.002 PMID: 23791236
69. Faisal-Cury A, Menezes PR, d’Oliveira AFPL, Schraiber LB, Lopes CS. Temporal relationship between
intimate partner violence and postpartum depression in a sample of low income women. Maternal and
child health journal. 2013; 17(7):1297–303. https://doi.org/10.1007/s10995-012-1127-3 PMID:
22935913
70. Bai Y, Middlestadt S, E., Peng C-YJ, Fly AD. Predictors of continuation of exclusive breastfeeding for
the first six months of life. Journal of Human Lactation. 2010; 26(1):26–34. https://doi.org/10.1177/
0890334409350168 PMID: 19910521
71. Tenfelde S, Finnegan L, Hill PD. Predictors of breastfeeding exclusivity in a WIC sample. Journal of
Obstetric, Gynecologic, & Neonatal Nursing. 2011; 40(2):179–89.
72. Schwarzer R, Knoll N. Functional roles of social support within the stress and coping process: A theoret-
ical and empirical overview. International Journal of Psychology. 2007; 42(4):243–52.
73. Brandão T, Brites R, Hipólito J, Pires M, Nunes O. Dyadic coping, marital adjustment and quality of life
in couples during pregnancy: an actor–partner approach. Journal of Reproductive and Infant Psychol-
ogy. 2020; 38(1):49–59. https://doi.org/10.1080/02646838.2019.1578950 PMID: 30755030
74. Martins A, Canavarro MC, Pereira M. The relationship between dyadic coping and dyadic adjustment
among HIV-serodiscordant couples. AIDS Care. 2020:1–10. https://doi.org/10.1080/09540121.2020.
1781760 PMID: 32545995

75. Rusu PP, Nussbeck FW, Leuchtmann L, Bodenmann G. Stress, dyadic coping, and relationship satis-
faction: A longitudinal study disentangling timely stable from yearly fluctuations. PloS one. 2020; 15(4):
e0231133. https://doi.org/10.1371/journal.pone.0231133 PMID: 32271854
76. DeLongis A, Capreol M, Holtzman S, O’Brien T, Campbell J. Social support and social strain among
husbands and wives: a multilevel analysis. Journal of Family Psychology. 2004; 18(3):470. https://doi.
org/10.1037/0893-3200.18.3.470 PMID: 15382972
77. Henderson JJ, Evans SF, Straton JAY, Priest SR, Hagan R. Impact of Postnatal Depression on Breast-
feeding Duration. Birth. 2003; 30(3):175–80. https://doi.org/10.1046/j.1523-536x.2003.00242.x PMID:
12911800
78. American College of Obstetricians and Gynecologists. ACOG Committee opinion no. 343: Psychosocial
risk factors: perinatal screening and intervention. Obstetrics and Gynecology. 2006; 108(2):469–77.
https://doi.org/10.1097/00006250-200608000-00046 PMID: 16880322
79. Huang R, Yang D, Lei B, Yan C, Tian Y, Huang X, et al. The short-and long-term effectiveness of
mother–infant psychotherapy on postpartum depression: A systematic review and meta-analysis. Jour-
nal of Affective Disorders. 2020; 260:670–9. https://doi.org/10.1016/j.jad.2019.09.056 PMID: 31550613
80. Le H-N, Perry DF, Stuart EA. Randomized controlled trial of a preventive intervention for perinatal
depression in high-risk Latinas. Journal of Consulting and Clinical Psychology. 2011; 79(2):135–41.
https://doi.org/10.1037/a0022492 PMID: 21319897
81. Bair-Merritt MH, Jennings JM, Chen R, Burrell L, McFarlane E, Fuddy L, et al. Reducing Maternal Inti-
mate Partner Violence After the Birth of a Child: A Randomized Controlled Trial of the Hawaii Healthy
Start Home Visitation Program. Archives of pediatrics & adolescent medicine. 2010; 164(1):16–23.
https://doi.org/10.1001/archpediatrics.2009.237 PMID: 20048237
82. Taft AJ, Small R, Hegarty KL, Watson LF, Gold L, Lumley JA. Mothers’ AdvocateS in the Community
(MOSAIC)-non-professional mentor support to reduce intimate partner violence and depression in
mothers: A cluster randomised trial in primary care. BMC public health. 2011; 11(1):178–. https://doi.
org/10.1186/1471-2458-11-178 PMID: 21429226
83. Olds DL, Robinson J, Pettitt L, Luckey DW, Holmberg J, Ng RK, et al. Effects of home visits by parapro-
fessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics. 2004; 114(6):1560–
8. https://doi.org/10.1542/peds.2004-0961 PMID: 15574615
84. WHO. Responding to intimate partner violence and sexual violence against women: WHO clinical and
policy guidelines. Geneva: World Health Organization; 2013.
85. National Institute of Population Research and Training (NIPORT), Mitra and Associates, ICF Interna-
tional. Bangladesh Demographic and Health Survey 2014. Dhaka, Bangladesh and Rockville, Mary-
land, USA: NIPORT, Mitra and Associates, and ICF International; 2016.

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PLOS ONE

Early exclusive breastfeeding cessation and

Citation: Islam MJ, Broidy L, Baird K, Rahman M,

Received: August 14, 2020

Copyright: © 2021 Islam et al. This is an open

PLOS ONE | https://doi.org/10.1371/journal.pone.0251419 May 17, 2021 1 / 19

Funding: The authors received no specific funding Conclusions

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Materials and methods

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[43]. As described previously [11,41], a population-based cross-sectional survey of new moth-

Human participation protection

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Maternal perceived stress

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Fig 2. Rates of exclusive breastfeeding and PPD by maternal postpartum age.

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Exclusive breastfeeding and postpartum depression: Bivariate associations

Exclusive breastfeeding and postpartum depression: Multivariate

Moderating effect of maternal stress and social support

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PLOS ONE | https://doi.org/10.1371/journal.pone.0251419 May 17, 2021 11 / 19

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Strengths and limitations

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Methodology: Md Jahirul Islam.

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PLOS ONE | https://doi.org/10.1371/journal.pone.0251419 May 17, 2021 16 / 19

PLOS ONE | https://doi.org/10.1371/journal.pone.0251419 May 17, 2021 17 / 19

formula-feeding mothers. Breastfeeding Medicine. 2013; 8(1):16–22. https://doi.org/10.1089/bfm.2012.

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