JRSSEM 2022, Vol. 01, No.11, 1932 – 1940
E-ISSN: 2807 - 6311, P-ISSN: 2807 - 6494
DOI : https://jrssem.publikasiindonesia.id/index.php/jrssem/index
LITERATURE REVIEW: THE RELATIONSHIP OF ANXIETY
TOWARDS THE PRODUCTION OF BREAST MILK IN
POSTPARTUM MOTHERS
Fatmawati
1*
Berliana Maduratna Irawati
2
Hafidza Auliya
3
Brawijaya University, Malang, Indonesia
e-mail: [email protected]
1
2
3
*Correspondence: fatmawati@ub.ac.id
Submitted: 28 May 2022, Revised: 05 June 2022, Accepted: 15 June 2022
Abstract. The postpartum period is a vulnerable period for postpartum mothers because there
are several physiological and psychological changes after giving birth. Otherwise, the process of
lactation and milk production is influenced by hormones. Postpartum mothers usually feel tired
and experience psychological disorders such as anxiety about their condition and the condition of
their baby. This study aims to determine the conditions that interfere with the production of breast
milk in postpartum mothers. This study uses traditional literature review research methods,
analyzes articles that match the inclusion criteria, and focuses on the relationship between anxiety
and increased breastfeeding in postpartum mothers. Based on the results of this study, this
literature review used 10 journals with inclusion criteria, eight journals showed a significant
relationship between anxiety and breastfeeding in postpartum mothers. There was a decrease in
oxytocin levels and duration of breastfeeding which had an impact on the rate of exclusive
breastfeeding. In contrast, the other two journals did not find a significant relationship between
anxiety and oxytocin levels with the breastfeeding method used. Because there are variables that
are not examined.
Keywords: bleaching time; postpartum mother; carbamide peroxide.
Fatmawati, Berliana Maduratna Irawati, Hafidza Auliya | 1933
INTRODUCTION
The postpartum period is the most
vulnerable for postpartum mothers. The
postpartum period lasts from after delivery
is completed to 6 weeks or 42 days
(Purwoastuti & Walyani, 2017). During this
time, there are several changes in the
mother's physical and psychological. In
addition, during the puerperium, there is
also a process of formation and
expenditure of breast milk which is
influenced by the performance of several
hormones.
Breastmilk is very beneficial for mother
and baby. Breastfeeding can reduce infant
morbidity, optimize growth and help
intelligence development. The benefits for
breastfeeding mothers are helping to
extend the distance between pregnancies,
avoiding the risk of breast cancer, and
increasing the bond between mother and
baby. According to WHO, data on exclusive
breastfeeding coverage worldwide is only
around 36% in the 2007-2014 period.
Exclusive breastfeeding coverage in
Indonesia reaches 54%, this figure is the
target coverage that has been achieved.
Based on the 2018 National Basic Health
Research Report, 76.5% of mothers in East
Java breastfeed at the age of 0-23 months
of baby, while 23.5% of mothers decided
not to breastfeed at the age of 0-23 months
of baby. It is because of two main factors
breastfeeding, who did not discharge
(70.2%) and were hospitalized separately
(8.8%).
In fact, not all mothers with newborns
can breastfeed their babies well. This can be
influenced by the internal and external
factors of the mother. Internal factors that
can influence are low knowledge,
psychological condition, and mother's
attitude towards her condition. Meanwhile,
external factors include a husband or family
support, socio-cultural conditions, the
condition of the baby, increased promotion
of formula milk, maternal food, and the use
of contraceptives (Hanifah et al., 2017).
During breastfeeding, there are two
important processes. The process of
forming milk (the milk production reflex) is
influenced by the hormone prolactin and
the process of releasing milk (let down
reflex) is influenced by the hormone
oxytocin. However, this hormone can be
inhibited by one of the factors, namely
maternal psychological factors (Sherwood,
2015).
When the mother feels anxious or
stressed, the body responds by releasing
ACTH (adrenocorticotrophin hormone) by
the pituitary, it will stimulate the adrenal
glands to produce various hormones,
namely the hormone cortisol. This
hormone cortisol can provide negative
feedback to the pituitary gland so that
oxytocin levels in the body will be
disturbed. On the other hand, in a happy
state, the body releases endorphins which
can provide a sense of comfort and calm
during lactation. This makes the pituitary
produce the hormone oxytocin optimally.
Anxiety disorders and the lack of social
support that mothers need can act as
stressors. It has an impact on the mother's
lactation process, especially on the process
of expressing breast milk, and impact on
the duration of breastfeeding. This will
certainly affect the level of coverage of
1934 | Literature Review: The Relationship of Anxiety Towards The Production of Breast Milk
in Postpartum Mothers
exclusive breastfeeding in postpartum
mothers.
METHODS
This study used a traditional literature
review research method, analyzed the
articles that matched with inclusion criteria,
and focused on the relationship between
anxiety and increased breastfeeding in
postpartum mothers. The criteria used in
the literacy selection process are articles
from the Science Direct, PubMed, Research
Gate, and Google Scholar databases that
published years 2010 until 2020. The
articles used original research articles
related to psychological disorders in
postpartum mothers on the lactation
process.
RESULTS AND DISCUSSION
After the literature search process from
various databases according to the
inclusion criteria, 10 articles were taken for
further research. Seven studies discussed
the effect of anxiety on low breastfeeding
duration, two studies discussed the effect
of anxiety disorders and depression on
oxytocin levels in the postpartum mother's
body, and one study discusses the impact
of maternal anxiety on the prediction of the
preferred breastfeeding method.
This study was conducted in various
countries with various sample sizes and
criteria. Three studies were conducted in
America, two studies were conducted in
Iran, one study was conducted in Norway,
one study was conducted in India, one
study was conducted in Japan, one study in
the United Arab Emirates, and one study in
the UK.
Fatmawati, Berliana Maduratna Irawati, Hafidza Auliya | 1935
Table 1. The Results of the Research from 10 Journals
Number.
Researcher
Year
Results
1.
(Ystrom, 2012)
2012
In this study, it was found that there was a decrease in the number of mixed breastfeeding
and bottle breastfeeding methods to the low level of anxiety experienced by mothers during
postpartum.
In the results of the regression analysis, anxiety symptoms at 6 months postpartum can be
predicted by the number of mixed breastfeeding (β 0.08; 95% CI 0.05-0.11) and bottle
breastfeeding (β 0.24; 95% CI 0.21-0.28).
2.
(Whitley et al., 2020)
2019
There were no significant results between mothers who did not breastfeed at 2 months
postpartum with depression (16% v. 25%, p=0.22) or symptoms of anxiety (8% v. 11%,
p=0.53).
There was no change in the amount of oxytocin in the sample.
3.
(Riedstra & Aubuchon-Endsley,
2019)
2019
There was a correlation between the socio-economic level of stress (p=0.002) and anxiety
(p=0.007).
The ANCOVA test found significant results between anxiety and decreased breastfeeding
duration (p=0.009).
4.
(Arifunhera et al., 2016)
2015
The high HADS score was correlated with the low level of breastfeeding by the mother
(p=0.149).
It was found that anxiety has a relationship with poor breastfeeding attitudes, however,
postpartum anxiety was not an independent factor in breastfeeding attitudes in the results
of multivariate analysis.
5.
(Minamida et al., 2020)
2020
The STAI score does not determine the method of breastfeeding in the first month
postpartum.
There were no significant results between the exclusive breastfeeding group and the non-
exclusive group (p<0.05) in the three sampling times.
6.
(Radwan et al., 2020)
2020
It was found that the level of anxiety was moderate to high as measured by STAI (n=348,
1936 | Literature Review: The Relationship of Anxiety Towards The Production of Breast Milk in Postpartum Mothers
76.2%).
However, a high level of breastfeeding ability was found with a mean score of 52.2
(SD=11.92). This is because the social support that mothers receive from their husbands,
family, and friends is also high (n=387, 86.9%).
7.
(Fallon et al., 2018)
2017
A high PSAS score had a significant relationship to a decrease in the rate of exclusive
breastfeeding (OR 0.98).
Anxiety was also associated with negative perceptions of infant feeding behavior (p<0.001).
8.
(Jalal et al., 2017)
2017
There were significant results between increasing anxiety and decreasing rates of exclusive
breastfeeding (step p=0.004 and trait p=0.006).
The increase in the mean of maternal anxiety (OR 0.462) increased the chances of not
breastfeeding exclusively by 54%.
9.
(Stuebe et al., 2013)
2013
There was a decrease in the amount of oxytocin at week 8 in postpartum mothers with
symptoms of anxiety (p<0.05).
There was also a decrease in prolactin levels but it could not be said to be statistically
significant.
10.
(Assarian et al., 2014)
2014
There was a significant relationship between the mental health of the mother and her
breastfeeding status (p=0.001).
Found OR 1.83 where mothers who do not succeed in exclusive breastfeeding have a 1.83
times higher risk of experiencing psychological disorders.
Fatmawati, Berliana Maduratna Irawati, Hafidza Auliya | 1937
Discussion
After going through the literature
search process, it was found that 8 out of
10 articles studied described a significant
relationship between anxiety and the fluent
of breast milk production (Arifunhera et al.,
2016); (Assarian et al., 2014); (Fallon et al.,
2018); (Jalal et al., 2017); (Minamida et al.,
2020); (Radwan et al., 2020); (Riedstra &
Aubuchon-Endsley, 2019); (Stuebe et al.,
2013); (Woolhouse et al., 2016). The study
of (Stuebe et al., 2013) described a decrease
in oxytocin levels at the 8th week
postpartum in 48 samples who had
symptoms of anxiety and depression.
Anxiety, stress, and feeling of fear
experienced by postpartum mothers is the
factor that will form a blockade in the
letdown reflex process. This is caused by
the release of adrenaline which causes
vasoconstriction of the alveolar blood
vessels, so the oxytocin hormone cannot
work optimally (Purwoastuti & Walyani,
2017). The release of the hormone oxytocin
can be inhibited by catecholamines. The
release of catecholamines is stimulated by
stress and pain factors in postpartum
mothers (Cunningham et al., 2014).
The research of (Woolhouse et al., 2016)
explained the increase in anxiety that
occurs in postpartum mothers can be
caused by several factors, one is maternal
age <30 years. The researcher explained
that at this age, the majority of mothers
were primiparas who had no experience in
the lactation process. In addition to the age
factor, (Riedstra & Aubuchon-Endsley,
2019) in their research mentions that low
socioeconomic factors can also increase
postpartum mothers' anxiety.
The research of (Arifunhera et al., 2016)
investigated the factors related to a baby's
condition also have an impact on the
psychological state of the mother. Mothers
with babies whose birth in weight <2500
grams tend to have high HADS (Hospital
Anxiety & Depression Scale) scores. This is
related to the baby's sucking reflex being
less than perfect so that the resulting
stimulus is not optimal. These results are
supported by research by (Jalal et al., 2017)
that mothers with low birth weight (LBW)
had a 54% chance of not breastfeeding
their baby exclusively.
The opposite is explained by (Assarian
et al., 2014) in their research that mothers
who do not succeed in breastfeeding have
a 1.83 times higher risk of experiencing
stress and anxiety disorders compared to
mothers who successfully breastfeed. This
factor is in line with (Fallon et al., 2018) in
their research, where the mother's negative
perception of eating behavior in an infant
will increase anxiety and stress levels. So
that the rate of breastfeeding babies
exclusively for 6 months is low.
In the study of (Radwan et al., 2020) it
was found that the majority of postpartum
mothers' anxiety levels were at moderate to
high levels. This is certainly an obstacle to
improving the quality of breastfeeding in
the UEA. However, the results obtained on
the level of breastfeeding ability in
postpartum mothers are high with an
average score of 52.2. The results of the
relationship analysis regarding the high
social support provided by husbands,
family, and friends to postpartum mothers
it can affect the ability to breastfeed.
A study by (Ystrom, 2012) found a
significant relationship between the level of
1938 | Literature Review: The Relationship of Anxiety Towards The Production of Breast Milk
in Postpartum Mothers
anxiety in postpartum mothers with
breastfeeding methods. It was explained
that the anxiety experienced by mothers at
6 months postpartum could be predicted
by the number of mixed breastfeeding and
bottle breastfeeding studies. Researchers
also think that mothers with postpartum
anxiety need support during lactation and
mothers need to learn about efficient
coping strategies when experiencing
anxiety in the early postpartum period. This
is in line with the research of (Qiftiyah,
2018), the benefit of family support is the
management of stress by providing
services, care, and sources of information
needed to deal with stress and pressure
during the postpartum period.
In contrast with the research before,
(Whitley et al., 2020) did not find any
significant differences in oxytocin levels in
mothers with anxiety and depression
disorders with mothers without symptoms
in the 2nd and 6th months postpartum.
This can occur for several reasons, it is
because they use measuring instruments
that are less specific and also the presence
of other factors that affect oxytocin levels
that were not examined in this study.
(Minamida et al., 2020) explained in their
research that the anxiety in mothers cannot
predict the breastfeeding method that
mothers use in the first month of
postpartum. There was no significant
relationship between direct breastfeeding
and the addition of formula milk.
CONCLUSIONS
This study is a literature review study,
where the ten journals were obtained in
inclusion criteria. Based on the literature
review that has been carried out in the ten
journals, it can be concluded that there is a
significant relationship between anxiety
and the fluency of breast milk production
in postpartum mothers. A total of 8 journals
support the researcher's hypothesis. This is
related to the psychological state of the
mother with the duration of breastfeeding
and the success of the mother to
breastfeed exclusively. Meanwhile, there
were no significant results in the
relationship between both anxiety in
postpartum mothers and the levels of
oxytocin with the breastfeeding method
that the mother used in the other two
journals. This is because there are variables
that are not examined so the results are less
than optimal.
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© 2022 by the authors. Submitted
for possible open access publication
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Commons Attribution (CC BY SA) license
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