IMPACT OF THE INABILITY TO BREASTFEED ON POSTPARTUM DEPRESSION

Background : Depression is one of the major public health problems, which occurs twice as often in women than men during the fertile period. Depression or anxiety during pregnancy, stress from recent life events, a lack of social support, and a history of prior depression are all good predictors of postpartum depression. Providing expert breastfeeding support to women who plan to breastfeed is critical, as is providing caring support to women who want to breastfeed but are unable to do so. Objective : To determine women who have an inability to breastfeed that causes postpartum depression through the application of journal review descriptions. Methods: This review was carried out on case studies related to an inability to breastfeed and postpartum depression. The type of research is descriptive, which is a research method with the main objective of making an objective description or description of a situation. Results: The findings of this study's five case studies on the relationship between breastfeeding and postpartum depression were mixed. Regardless of the length of breastfeeding, EPDS scores showed a partial correlation that is substantially positively associated with physical stress, pain, lack of care, and pressure to quit from another person, even after adjusting for maternal age and education. Not exclusively breastfed, was twice as likely to develop postpartum depression. Conclusion: The inability to breastfeed due to difficulty and pain during breastfeeding is one of the reasons for the mother not to provide exclusive breastfeeding so that the mother cannot receive the psychological benefits of breastfeeding where the mother can increase the risk of postpartum depression.


INTRODUCTION
Depression is a significant public health issue that affects twice as many women as men during their reproductive years. Depression or anxiety during pregnancy, stress from life events, social support, and a history of prior depression are all good predictors of postpartum depression providing expert breastfeeding support to women who want to breastfeed as well as caring support to women who want to breastfeed but are unable is critical. 1,2 Depression or anxiety during pregnancy, stressful life activities, social support, and a prior history of depression are all strong predictors of postpartum depression. Stress from baby care, low self-esteem, maternal neuroticism, and the infant's difficult disposition are all moderate predictors of postpartum depression. Obstetric and pregnancy complications, negative cognitive attributions, single marital status, poor partner relationships, and income as a factor of lower socioeconomic status were all found to be poor predictors of postpartum depression. Ethnicity, maternal age, educational level, parity, and gender were not found to be associated. 1 Mental-emotional disorders are more common in women than men in Indonesia, with a prevalence of 15 years or more. 3 Nonbreastfeeding (BF) mothers were more likely than BF mothers to experience postpartum depression symptoms. As a result, there may be a connection between depressive symptoms in new mothers and non-B. 4,5 Postpartum depression has a significant but limited impact on mother-infant relationships, as well as child growth and development, according to recent studies. Children whose mothers suffer from postpartum depression have more cognitive, behavioral, and interpersonal issues than children whose mothers are not depressed. In terms of children's growth and emotional development, the findings of this study show that postpartum depression has an early impact on babies, but not a long-term effect. Long-term effects on the child are likely to result from prolonged exposure to postpartum depressive episodes or frequent episodes of maternal depression. 1 Postpartum depression affects mothers, fathers, and babies, may cause chronic depressive disorder if not treated on time. Even if treated, postpartum depression can be a risk for future episodes of major depression in the mother. This can be a contributing factor to depression in dad as it will be a stressful event for the whole family. Untreated depression mothers can cause behavioral and emotional problems in their children. A common child development problem that can be seen is the delay in language development. In addition, they also suffer from sleep problems, eating problems, excessive crying, and attention-deficit / hyperactivity disorder (ADHD). 6 The possible negative effects of postpartum depression on mother-infant relationships and child growth highlight the importance of early detection and successful treatment models. Only a few public health intervention trials have shown that postpartum depression can be prevented or reduced in these outcomes. 1 It is very important to always do a physical examination and psychic mother on antenatal care is good at pregnancy or after giving birth in the first health facility either at the public health center, the Pratama clinic or in a specialist doctor's office content for early detection of interference psychic so that it can be determined immediately handling. 7 The aim of this research is to determine women who have an inability to breastfeed causes postpartum depression.

METHOD
This review was carried out on case studies related to an inability to breastfeed and postpartum depression. This type of research is descriptive, which is a research method with the main objective of making an objective description or description of a situation. The keywords used to search for journals with maximum accuracy in this study were postnatal depression / postpartum depression / puerperal depression and breastfeeding. The selection of the journal publication year was made between 2010 and 2020. The sample used in this review was obtained according to the following inclusion criteria: 1. Research journals are published in English and Indonesian 2. The topics of research journals are puerperal depression and breastfeeding 3. Research journal in full-text form 4. All studies are carried out by research methods regardless of methods. The research data were summarized from research journals that met the inclusion criteria. These studies independently summarize, compare and draw conclusions or consensus from reviews.

RESULT
Five case studies with different research findings on the relationship between postpartum depression and breastfeeding were included in this literature review. The first journal determines that postpartum mothers who do not exclusively breastfeed are more than twice as likely to experience postpartum depression than mothers who exclusively breastfeed OR 2.4 95% CI (1.16-5.18). According to the findings of the second journal, higher levels of depression and depressive symptoms were linked to shorter breastfeeding period. Four research focused on the length of exclusive breastfeeding and found that early breastfeeding termination is linked to postpartum depression and depressive symptoms in the postpartum era. In the majority of the sample examined, depressive symptoms were identified before the cessation of breastfeeding, and negative breastfeeding behaviors, difficulty breastfeeding, and lower self-esteem were also related to a higher incidence of postpartum depression and more depressive symptoms, and difficulty breastfeeding has also been linked to postpartum depression. The third journal found that the earlier mothers quit breastfeeding, the higher their postnatal depression ratings, which could be explained by their breastfeeding experience. Stopping breastfeeding for physical reasons or discomfort, in particular, can be linked to a higher Edinburgh Postnatal Depression Scale (EPDS) score than the length of breastfeeding itself (Pearson r = 0.267, P0.001). The fourth journal concluded that women who planned to breastfeed, as well as the majority of mothers who did not experience depressive symptoms during pregnancy, had a lower risk of depression at 8 weeks after giving birth. Breastfeeding reduced the risk of postpartum depression in mothers who intended to breastfeed, but it increased risk factors for postpartum depression in mothers who did not intend to feed the baby (OR 0.42; 95 percent CI 0.20, 0.90). According to recent journal articles, non-breastfeeding mothers have a higher mean BDI result three months after delivery. Based on table 1, it can be concluded that there is an effect of the inability to provide breast milk on the incidence of postpartum depression. Some journals explain the relationship between pregnancy depression and postpartum depression. Besides, some journals explain the reasons for mothers to stop breastfeeding. The greatest finding is that breastfeeding is firmly associated with a lower risk of depression at 8 weeks postpartum in mothers who planned to feed the baby. According to one study, mothers who breastfed their children had a lower risk of postpartum depression than mothers who had a moderate or severe risk of perinatal depression (-2 = 4.746, p 0.05), and mothers who did not feed the baby their children at the end of the first trimester had a significantly higher percentage.

Reasons to stop breastfeeding
There were 8-factor analysis results that explained 82, 42% of all variants with the main component analysis performed on items exploring breastfeeding cessation. The factors found were physical difficulties' (insufficient/low breastfeeding, fatigue), pain (pain, infection), discomfort (disturbing the mother's lifestyle, the mother felt more responsible than formula feeding), body image (no willingness to show breasts), embarrassment (dislike of feeding in public), peer pressure (pressure to stop breastfeeding from household or partner), unsupportive (lack of professional support, unsupportive partner), and medical reasons. 8 Controlling for maternal age and education, partial correlations revealed that the EPDS score was significantly positively correlated with physical difficulty, pain, lack of support, and pressure from someone else to stop, regardless of breastfeeding duration or preparedness to exclusively breastfeed. The higher the EPDS score the higher the agreement with these factors. EPDS scores and breastfeeding discontinuation due to discomfort showed a significant negative correlation. The EPDS score and body image, shame, or medical reasons did not show a significant association. 8

DISCUSS Correlation between breastfeeding and postpartum depression
One of the psychological disorders that occur in the puerperium is guilt for not being able to breastfeed the baby. Common symptoms of mothers who experience postpartum depression tend to withdraw from social life are indifferent, less sensitive, and less involved in relationships with their babies, feel that they cannot care for and care their babies, and have pain during the postpartum period. 9 Widarini, Arifah, and Werdani's (2020) research suggest results that exclusive breastfeeding practices provide a significant influence on the incidence of depressive symptoms in mothers during the puerperium. A mother who not exclusively breastfeeding is likely to experience depressive symptoms were two times higher than a mother who is exclusively breastfeeding. In addition to exclusive breastfeeding practices, the type of delivery is a risk factor associated with depressive symptoms in mothers at the puerperium. The group of mothers with the type of delivery with complications is more than twice as likely to be experiencing symptoms of depression during the puerperium. 10 The prediction of lower duration of breastfeeding in cases of postpartum depression and symptoms of postpartum depression was demonstrated by a prospective study that investigated the effects of postpartum depression on breastfeeding as well as the effects of the breast -feeding on postnatal depression. 11 It was also discovered that there had been an elevated incidence of postnatal depression in mothers who did not intend to breastfeed, despite the fact that these mothers did not exhibit depression symptoms prior to giving birth. 2 Other variables are significantly related, namely the type of delivery. In the group of mothers whose type of delivery was accompanied by complications twice as risky for experiencing symptoms of postpartum depression. 10 Factors unrelated to illness, such as women's preferences or hospital policy rather than etiological associations, are reflected in the rationales for the cryptic studies presented between breastfeeding and the incidence of postnatal depression. However, there is heterogeneity between depression assessment methods. Weak associations between obstetric complications were found in studies that diagnosed depression using the interview method but were sufficiently related to these factors to depression assessed by self-reported measures. While higher rates of obstetric complications may have a weak association with a diagnosis of postpartum depression, they are moderately associated with higher rates of self-reported depressive symptoms. 1 The third article, which explored the effect of postpartum depression and feeding the baby discontinuation, looked specifically at the causes of breastfeeding discontinuation to affect depression risk, such as: 1. Stopping nursing for physical difficulties or pain was associated with a higher EPDS score, rather than breastfeeding duration because they find breastfeeding difficult or embarrassing and this would feel more comfortable or content to use a bottle. 2. 2. If babies have physical difficulties breastfeeding (they are lethargic, suckle poorly, or catch on to the nipple), the mom's experience with breastfeeding can become more complex. Bad latching contributes to more intense or prolonged breastfeeding, which increases the likelihood of exhaustion in the mother, which may cause concern about the baby's possibly best. 3. They do not see quitting as beneficial for themselves (even though there will be pain and discomfort when they stop breastfeeding). However, they feel compelled to avoid nursing due to the discomforting nature of the process. This is demonstrated by the smaller EPDS score in the baseline study of mothers who decided to stop breastfeeding for social purposes, which may indicate that these mothers saw an advantage from doing so. 8 The critical period of decision-making for breastfeeding is divided into 6 periods, including during pregnancy, in the first 24 hours after birth, after delivery at weeks 1 to 2, after delivery at weeks 6 to 8, and 4 to 6 months afterward. delivery, and 12 months after delivery. The personality of a mother influences whether or not she will continue to feed the baby, how long she should breastfeed, and why she would handle emotional challenges while breastfeeding. A mother's selfefficacy in breastfeeding is influenced by how her previous breastfeeding experience, indirect experiences, verbal persuasion about breastfeeding, feelings of emotional pleasure, pain, fatigue, self-response to stress, and anxiety. Babies that are growing normally are an important indicator of successful breastfeeding and are also a motivating factor for mothers to continue breastfeeding their babies. 12

Correlation of depression before and after childbirth
Pregnancy depression is a greater indicator of postnatal depression for a limited timeframe of breastfeeding, according to several recent reports, and depressed pregnant women are at an increased risk for a decreased term of breastfeeding. These studies have highlighted the importance of detecting depression early in pregnancy in order to recognize women who are more likely to breastfeed for a shorter period of time and to learn more about the factors that underpin their breastfeeding conduct. 11 While it is critical to determine the best instrument for detecting postpartum depression, significant strides have also been made to classify women who are pregnant who would be at the potential for postnatal depression so that alternative precautionary measures can be introduced. 1 In the 4 th article, we found that the effect of breastfeeding on the mother's mood varies according to the mental health of the mother during pregnancy and whether the mother intends to breastfeed. Interestingly, among the group of mothers who had no plans to breastfeed, the risk of depression was higher among women who continued breastfeeding. Breastfeeding was associated with a lower risk of postpartum depression shown among women planning to breastfeed (such as for mothers who did not experience depression during pregnancy, although with a much lesser effect). However, there is a protective effect of breastfeeding in women who do not plan to breastfeed with a previous history of depression. Women who were depressed during pregnancy had a less protective effect against postpartum depression than planned breastfeeding, it appears that 4 weeks of exclusive breastfeeding provided a protective effect for this group, which was not the case for women who did not experience depression during pregnancy. 2 Depression is a frequent potential problem of labor, according to the fifth journal study. Breastfeeding mothers are less depressed and nervous than non-breastfeeding mothers. Based on this literature study, early recognition and intervention are needed in vulnerable groups of women and infants. 12 In some ways, exclusive breastfeeding is very beneficial for both the baby and the mother. According to a psychological perspective, breastfeeding is one of the most effective means of building maternal social relations. the benefits of breastfeeding from a psychological side are reducing inner conflicts, reducing mother's emotional antagonists, learning to love each other, as the beginning of mother and child intimacy, oral aggression catharsis, the basis of children's speech skills, as the beginning of learning for emotional control, can provide a feeling of calm, safety, and comfortable in the baby, and as the beginning of learning the baby's social interactions. 9 Thus, providing support to mothers and families to breastfeed and overcoming problems during breastfeeding is very important to make mothers willing and able to breastfeed so as to avoid postpartum depression which can harm the mother and the development of her baby. Limitations in this journal review are the factors that influence the inability to breastfeed on the incidence of postpartum depression that has not discussed in detail the influence of social, economic, and cultural aspects. Based on data from case studies, there are 2 reasons related to the inability of mothers to breastfeed with postpartum depression, namely difficulty (in mothers and their babies) and pain.

CONCLUSION
Very heterogeneous effects of breastfeeding were found on maternal depressive symptoms, important and mediated by breastfeeding intention during pregnancy. For women who plan to breastfeed their babies, the breastfeeding plan is associated with a lower risk of developing postpartum depression. The mother is unable to breastfeed and chooses to stop breastfeeding because of the difficulty and pain. Therefore, it is very important to continue research on the influence of the inability to breastfeed from the social, economic, and cultural aspects of the mother's life on the incidence of postpartum depression. Thus, health workers, especially midwives, can make promotional efforts to prevent various postpartum mental disorders.