Maternal Psychological Distress and Lactation and Breastfeeding Outcomes: a Narrative Review

Emily M Nagel, Mariann A Howland, Cynthia Pando, Jamie Stang, Susan M. Mason, David A. Fields, Ellen W. Demerath

Research output: Contribution to journalReview articlepeer-review

33 Scopus citations


Purpose: Despite recommendations from the World Health Organization and the American Academy of Pediatrics to exclusively breastfeed infants for their first 6 months of life, 75% of women do not meet exclusive breastfeeding guidelines, and 60% do not meet their own breastfeeding goals. Numerous observational studies have linked maternal psychological distress (eg, perceived stress, anxiety, and depression) with nonoptimal breastfeeding outcomes, such as decreased proportion and duration of exclusive breastfeeding. The physiological mechanisms underlying these associations, however, remain unclear. Methods: For this narrative review, we evaluated the evidence of relationships between maternal psychological distress and lactation and breastfeeding outcomes in pregnancy and post partum and the possible physiological mechanisms that facilitate these relationships. We searched PubMed using the following terms: stress, anxiety, depression, breastfeeding, and lactation. Additional search by hand was conducted to ensure a thorough review of the literature. Findings: Among the studies examined, methods used to assess maternal psychological distress were not uniform, with some studies examining perceived distress via a variety of validated tools and others measuring biological measures of distress, such as cortisol. Evidence supports a role for psychological distress in multiple breastfeeding outcomes, including delayed secretory activation and decreased duration of exclusive breastfeeding. One physiological mechanism proposed to explain these relationships is that psychological distress may impair the release of oxytocin, a hormone that plays a critical role in milk ejection during lactation. Continued impairment of milk ejection may lead to decreased milk production because of incomplete emptying of the breast during each feed. Maternal distress may also yield elevated levels of serum cortisol and decreased insulin sensitivity, which are associated with decreased milk production. The relationship between psychological distress and breastfeeding is likely to be bidirectional, however, in that breastfeeding appears to reduce maternal distress, again possibly via effects on the pleasure or reward pathway and calming effects of oxytocin on the mother. This finding suggests that interventions to support lactation and breastfeeding goals in women who score high on measures of psychological distress would be beneficial for both maternal and infant well-being. Implications: Evidence to date suggests that maternal psychological distress may impair lactation and breastfeeding outcomes, but stronger study designs and rigorous assessment methods are needed. A better understanding of the physiological mechanisms leading to impaired lactation may assist in the development of early interventions for mothers experiencing distress. In addition, stress-reducing programs and policies should be investigated for their potential to improve breastfeeding outcomes.

Original languageEnglish (US)
Pages (from-to)215-227
Number of pages13
JournalClinical Therapeutics
Issue number2
StatePublished - Feb 2022

Bibliographical note

Funding Information:
Emily M. Nagel is supported by an grant T32DK083250 from the National Institute of Diabetes and Digestive and Kidney Diseases. Mariann A. Howland is supported by a National Science Foundation Graduate Research Fellowship (00074041). Cynthia Pando is supported by grant T32HD095134 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. David A. Fields and Ellen W. Demerath are supported by grant R01HD080444 Eunice Kennedy Shriver National Institute of Child Health and Human Development. The authors have indicated that they have no other conflicts of interest regarding the content of this article.

Publisher Copyright:
© 2021 Elsevier Ltd


  • breastfeeding
  • lactation
  • maternal psychological distress
  • physiologic mechanisms


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