Maternal mental health is a nuanced topic involving many diverse factors which shapes different outcomes from woman to woman. Women with maternal mental health concerns should practice gentle care with themselves to support themselves and their babies. Image Credit: RHN Team Picture Bank
Introduction
Part one of this maternal mental health series introduced the perinatal mental health landscape, maternal mental health, and key risk factors associated with common conditions. In part two, the goal is to further examine common perinatal mental health conditions and their potential impacts on breastfeeding initiation and outcomes.
It is important to remember that these conditions affect everyone differently, and symptoms and experiences may vary from person to person. Open and honest communication with healthcare providers is essential to ensure timely access to support, treatment, and mental health resources.
Maternal Mental Health Conditions
Prenatal and Postpartum Depression and Anxiety
Prenatal (during pregnancy and postpartum (after childbirth) depression and anxiety are among the most common perinatal health conditions. These conditions may include major depressive disorder, generalized anxiety disorder, and panic disorder, which can occur separately or together. Symptoms often extend beyond the normal adjustment period associated with pregnancy or new parenthood and may affect physical health, decision-making, bonding with an infant, and daily caregiving activities.
Hormonal changes, sleep disruption, and the physical and emotional adjustments that occur during the perinatal period can increase the risk of both new and recurring mental health conditions. Early recognition of symptoms is important so individuals can receive timely support and treatment.
Common Signs and Symptoms of Perinatal Depression and Anxiety Include:
- Persistent sadness or low mood (feeling down, depressed, or blue)
- Increased irritability or frustration
- Excessive worry or racing thoughts
- Intrusive or distressing thoughts (unwanted thoughts that may feel upsetting or difficult to control)
- Feelings of guilt, shame, inadequacy, or low self-esteem
- Difficulty concentrating or decision-making
- Fatigue or low energy beyond what is typically expected after childbirth
- Sleep disturbances unrelated to infant care
- Changes in appetite (eating more or less than usual) could result in poor or excessive weight gain for mom and baby in the prenatal period
- Reduced interest or pleasure in hobbies or usual activities (this could also include a lack of interest in one’s own pregnancy or the care one provides to their infant)
- Substance use in pregnancy
- Difficulty bonding with or feeling emotionally disconnected from one’s baby
While symptoms will vary from woman to woman, prenatal depression puts one at increased risk for developing postpartum depression. Early communication with a qualified clinician who provides care during the perinatal period is necessary and may include referrals to mental health counseling, psychiatric intervention, or higher-level interventions when necessary.
What about the “Baby Blues”?
The “baby blues” are defined as mild, temporary feelings of sadness, stress, irritability, or anxiety that commonly occur after childbirth. Nearly 80% of women who give birth experience symptoms of the baby blues. Symptoms usually begin within the first few days after delivery and often improve on their own within 1-2 weeks postpartum. The baby blues are often linked to rapid hormonal changes, sleep deprivation, physical recovery after childbirth, and adjusting to the responsibilities of caring for a newborn. As new parents adjust to these changes and gain confidence in caring for their baby, symptoms often improve. The baby blues are different from postpartum depression, which is more severe, lasts longer, and may require treatment such as counseling, therapy, or medication.
How do I know if it is the “baby blues” or postpartum depression?
| Baby Blues | Postpartum Depression |
| General restlessness or anxiousness | Feelings of overwhelming guilt, sadness or panic |
| Being impatient or grumpy | Being afraid to stay alone |
| Crying for no reason and feelings of sadness | Crying, anxiety, or worrying more than usual |
| Feeling like “I’m not myself” | Feeling hopeless or that you’re not good enough, feelings of harming yourself or your baby |
| Finding it difficult to concentrate | No energy and finding it hard to focus on basic tasks |
| Mood changes | Weight loss, weight gain, or appetite changes |
| Starts within a few days after birth usually lasts for 1-2 weeks Resolves on its own | Begins within 1-3 weeks after giving birth, up to 1 year postpartum Requires treatment to resolve |
Impact on Breastfeeding Outcomes
Perinatal depression and anxiety can affect breastfeeding in several ways, including how the body responds (physiological), how a mother feels emotionally (psychological), and how she approaches feeding her baby (behavioral pathways). These conditions may impact breastfeeding initiation, milk production, feeding confidence, and breastfeeding duration.
Physiologically, elevated stress hormones can interfere with oxytocin, the hormone responsible for triggering milk ejection (milk release or let-down). This may delay milk production, reduce milk removal during feedings, and delay the onset of adequate milk production. These challenges can increase stress and reduce confidence in breastfeeding.
Psychologically, perceived or actual low milk supply/production can heighten distress, particularly in the early postpartum period. Social media portrayals of oversupply or abundant milk storage may intensify self-doubt, even when feeding is adequate, further impacting mental health.
Feelings Often Associated with Lack of Milk Production may Include:
- Guilt
- Sadness
- Anxiety over whether one’s baby is getting enough
- Self-doubt regarding one’s ability to breastfeed
- Frustration or feelings of inadequacy
Intervention Strategies or Considerations for Support
Perinatal depression can and anxiety can affect breastfeeding initiation, confidence, and duration. However, early support and intervention can improve outcomes for both mother and baby. Routine screening during pregnancy and the postpartum period can help providers identify symptoms early and connect families with counseling, mental health services, and lactation support. Providers who offer integrated care and realistic guidance about breastfeeding, milk supply, and infant feeding patterns can help reduce anxiety and improve feeding confidence.
Consider the questions below and learn when your baby is getting enough milk and when to seek support.
How do I know that my baby is getting enough breastmilk?
- Adequate wet and dirty diapers
- Days 1-2: 1-2 wet diapers/day
- Day 3-4: 3-4 wet diapers/day
- Day 5 and beyond: 6+ wet diapers/day
- Stools will transition from dark meconium to greenish, then to yellow/seedy stools by day 4-5
- Steady weight gain
- It is normal for many babies to lose up to 10% of their birth weight in the first few days, by days 10-14 most have regained their birth weight
- Regular pediatrician visits are important to monitor growth
- Effective feeding behavior
- Baby feeds 8-12 times in 24 hours
- You can hear swallowing during the feeds
- Baby appears satisfied and relaxed after a feeding
- Breasts feel “softer” after nursing
- Good signs of hydration (pale yellow urine, moist lips, alertness that is appropriate for age)
Signs to Follow up with a Provider: Pediatrician or IBCLC (International Board Certified Lactation Consultant)
- Fewer than expected wet/dirty diapers
- Continued weight loss
- Baby seems persistently sleepy or has difficulty waking for feeds
- Painful latch or ineffective suckling
- Concerns about milk supply or infant intake
Postpartum Rage
Postpartum rage is an underrecognized symptom associated with some perinatal mood and anxiety disorders. It is characterized by intense irritability, anger, or emotional outbursts that may feel difficult to control. Although postpartum rage is not a formal medical diagnosis, it is commonly linked to postpartum depression and anxiety. Individuals experiencing postpartum rage may feel overwhelmed and react strongly to everyday stressors or minor triggers. These episodes are often followed by feelings of guilt or shame. Sleep deprivation, hormonal changes, and the stress of adjusting to parenthood may worsen symptoms.
Risk Factors for Postpartum Rage Include:
- History of depression or anxiety
- Sleep deprivation or chronic fatigue
- Lack of social or emotional support
- High stress or unrealistic expectations of motherhood
Impact on Breastfeeding Outcomes and Interventions
Postpartum rage can impact breastfeeding outcomes by increasing stress, lowering frustration tolerance during feeding challenges and contributing to feelings of disconnection from one’s baby. Emotional dysregulation may make it more difficult to navigate infant care strategies and common breastfeeding concerns, such as latch issues or perceived low milk supply. Supportive non-judgmental care is essential to help mothers feel safe discussing these experiences and accessing appropriate resources.
Breastfeeding Interventions may Include:
- Mental health screenings and referral to counseling or therapy
- Education on emotional regulation and coping strategies
- Strengthening support systems (partners or co-parents, family, peers)
- Addressing sleep and self-care needs when possible
Postpartum Psychosis
Postpartum psychosis is a rare but serious mental health emergency that typically occurs shortly after childbirth. It is characterized by the rapid onset of symptoms such as hallucinations (seeing or hearing things that are not real), delusions (strong beliefs that are not based in reality), disorganized thinking and confusion (an impaired perception of reality). Unlike many other perinatal mental health conditions, postpartum psychosis requires immediate medical attention because it may place both the parent and baby at risk. If postpartum psychosis is suspected, ensure everyone’s immediate safety and call 911 or seek emergency medical care right away. Early recognition of this disorder is critical, as symptoms escalate quickly and can impair a mother’s ability to care for her infant safely and effectively.
Risk Factors for Postpartum Psychosis Include:
- A history of bipolar disorder or a prior psychosis episode
- First-time motherhood
Impact on Breastfeeding Outcomes and Interventions
Postpartum psychosis has important implications for infant feeding and maternal care. Safety is the primary concern; temporary mother-infant separation or alternative feeding methods may be necessary during episodes of this condition.
Treatment for postpartum psychosis typically includes hospitalization and a multidisciplinary approach that may include:
- Psychiatric care
- Medical management
- Lactation support
Many mental health medications used to treat this condition can be passed through breastmilk, so medications must be carefully evaluated for compatibility with lactation while balancing maternal stabilization with infant safety and realistic feeding outcomes.
Search Your Mental Health Medicines in the LactMED Database
Birth Trauma
Birth trauma refers to the emotional or psychological distress following a difficult, frightening, or unexpected childbirth experience. Birth trauma may result from emergency medical interventions, preterm birth, infant medical complications, or infant loss. Some individuals may also feel traumatized because they felt unsupported, uninformed, or lacked control during labor and delivery. Symptoms may include anxiety, intrusive thoughts, avoidance behaviors, or symptoms similar to post-traumatic stress disorder (PTSD). These experiences may affect recovery, bonding, and emotional well-being during the postpartum period.
Risk Factors for Birth Trauma Include:
- Emergency or unplanned interventions (cesarean birth, also known as a c-section, instrumental delivery)
- Preterm birth, infant medical complications or events, or infant loss
- Perceived loss of control, lack of support, or lack of informed consent
- Poor communication or lack of support from health care providers
- Prior trauma or mental health conditions
Symptoms that indicate someone may be experiencing the impacts of birth trauma:
- Post-traumatic stress disorder (PTSD) like symptoms, including:
- Flashbacks
- Avoidance
- Hypervigilance
Impact on Breastfeeding Outcomes and Interventions
Birth Trauma can greatly impact breastfeeding by disrupting early bonding and can increase anxiety during feeding, which may contribute to physical and emotional tension and can further delay milk let-down. Some mothers may feel overwhelmed or disconnected from their babies, while other mothers may feel an immense amount of pressure to breastfeed to regain control, which can add additional stress.
Triggers from birth trauma experiences and their relationship to breastfeeding:
- Physical pain or complications affecting feeding
- Emotional triggers associated with infant care
- Difficulty with body autonomy and trust
Trauma-Informed Care Approaches
Trauma-informed care following birth trauma is an essential part of maternal mental health and breastfeeding outcomes. This approach emphasizes safety, trust, autonomy, and empowerment, recognizing that a mother’s previous birth experience may influence how she chooses to engage with her baby after delivery.
After a traumatic birth experience, some mothers may feel anxious, emotionally disconnected, or overwhelmed during breastfeeding. These feelings may interfere with milk production, milk ejection, feeding confidence, and bonding. Support from a trauma-informed certified lactation counselor (CLC) can help mothers feel safe, supported, and empowered while feeding their baby. Trauma-informed lactation support focuses on creating a calm, nonjudgemental environment while offering choices and flexibility that support both maternal mental health and infant feeding goals.
Find a trauma-informed lactation provider
Perinatal Eating Disorders
Eating disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder are serious mental and physical health conditions. These conditions affect how a person thinks about food, eating, and weight, which can influence eating behaviors and habits. Given that the perinatal period is a time when a mother’s nutritional needs increase to support her growing baby in the prenatal period and maternal recovery in the postpartum period, perinatal eating disorders can be dangerous conditions that may impact a woman’s ability to perform in other areas of life, like infant care.
Perinatal Eating Disorders may Include:
- Anorexia nervosa: a psychological disorder characterized by restricted dietary intake that leads to low body weight, an intense fear of gaining weight, and body dysmorphia (a condition involving persistent negative thoughts about one’s body or appearance).
- Bulimia nervosa: an eating disorder characterized by a cycle of binge eating (consuming large amounts of food at once) followed by inappropriate behaviors such as purging (induced vomiting, misuse of laxatives, excessive exercise, or fasting) to prevent weight gain.
- Binge eating disorder: consuming a large amount of food within a limited amount of time (typically 2 hours) accompanied by a feeling of loss of control.
These conditions can persist, develop again (relapse), or newly emerge during pregnancy and within the postpartum period. The physical and emotional changes that occur during the perinatal period, particularly during rapid shifts in body shape and weight, can intensify body image concerns and feelings of a loss of control. Additionally, societal pressures, including expectations to quickly “bounce back” after childbirth, may further exacerbate disordered eating behaviors.
Risk Factors for Perinatal Eating Disorders Include:
- A personal history of eating disorders
- A personal of body dysmorphia
- Anxiety
- Trauma
- An increased focus on weight gain during pregnancy
Disordered eating during the perinatal period can significantly impact a mothers nutrition status. Inadequate caloric intake, food restriction, or purging behaviors may deplete essential nutrient stores needed to support maternal recovery after childbirth, fetal development during pregnancy, and lactation outcomes. Common deficiencies may include protein, iron, calcium, vitamin D, B vitamins, and essential fatty acids, which can contribute to fatigue, impaired healing, and mood disturbances. While the body may prioritize breast milk production, this can come at the expense of maternal health. In some cases, insufficient energy intake may also affect milk production and overall lactation capacity.
Impact on Breastfeeding Outcomes and Interventions
Breastfeeding can present unique emotional and psychological challenges for individuals with a history of eating disorders. Increased caloric demands and hunger, body exposure, and concerns about weight retention may contribute to anxiety or distress. Some mothers may feel a heightened need for control over feeding routines or infant intake, while others may experience reassurance and bonding through breastfeeding. Because experiences vary, it is important to approach feeding with flexibility and without judgment, while closely monitoring both maternal well-being and infant growth.
Effective management of perinatal eating disorders requires a coordinated, interdisciplinary approach. Nutrition counseling can help support adequate food intake, restore nutrient balance, and meet the increased nutritional demands of pregnancy and lactation. Mental health treatment is essential to address underlying disordered eating patterns and co-occurring conditions such as anxiety or depression. Lactation support can further help develop individualized, sustainable feeding plans that prioritize maternal mental health and infant nutrition. Together, these supports promote improved outcomes for both mother and baby.
Perinatal Obsessive-Compulsive Disorder (OCD)
Perinatal obsessive-compulsive disorder (OCD) is a mental health condition that may occur during pregnancy or after childbirth. It is characterized by intrusive and distressing thoughts, often involving fears of harm coming to the baby. These thoughts are unwanted and upsetting, and individuals with perinatal OCD recognize that the thoughts are irrational or inconsistent with their values. To reduce anxiety, some individuals may develop compulsive behaviors such as repeated checking, avoidance, or mental rituals.
A key feature that distinguishes perinatal OCD from postpartum psychosis is that insight is preserved. As previously mentioned, women with postpartum psychosis experience delirium or feelings of disconnection from reality and a loss of insight, which may result in delusions or hallucinations that are perceived as real. Conversely, mothers with OCD recognize that their thoughts are irrational and are typically distressed by them.
Impact on Breastfeeding Outcomes and Interventions
Perinatal OCD can interfere with breastfeeding initiation or continuation, as mothers may avoid feeding or the feelings of close physical contact due to fear triggered by their intrusive thoughts. This avoidance can disrupt mother-infant bonding and increase feelings of guilt and anxiety, making the breastfeeding experience more challenging while also diminishing milk supply. Additionally, the proximity required during feeding may heighten anxiety symptoms.
Effective treatment for perinatal OCD often includes Cognitive Behavioral Therapy (CBT), particularly Exposure and Response Prevention (ERP), which helps individuals gradually face their fears without engaging in compulsive behaviors. Medication may also be considered when symptoms are moderate to severe, with careful evaluation of risks and benefits during pregnancy and lactation. Support from healthcare providers, lactation consultants, and mental health professionals is essential in promoting both maternal well-being and successful infant feeding.
Dysphoric Milk Ejection Reflex (D-MER)
Dysphoric Milk Ejection Reflex (D-MER) is not a mental health condition. It is a physical response that occurs during milk ejection (milk let-down) in some breastfeeding individuals. D-MER causes sudden feelings of sadness, anxiety, irritability, or emotional discomfort that typically lasts between 30 seconds and 2 minutes during breastfeeding or pumping.
Feelings Often Associated with D-MER Include:
- Sadness or hopelessness
- Self-hate or low self-esteem
- Thoughts of dread or a sinking feeling in one’s stomach
- Anger or extreme agitation
- Anxiety or irritability
As the name suggests, D-MER is a “reflex,” meaning that an individual has no control over the experience and cannot change the likelihood that they may develop it. The research on D-MER is still limited, but the available evidence suggests a hormonal connection. The condition does not have anything to do with not wanting to breastfeed or nipple pain, which are two common misconceptions. Instead, the body reacts to the release of milk in response to a sudden drop in specific hormones, such as dopamine (a hormone involved in mood and emotional regulation), which are typically associated with relaxation and stress relief during lactation. While it can be unsettling for those who experience it, symptoms typically resolve in a few weeks and healthy coping strategies during this time can promote positive self-care behaviors that reduce the distress of the condition.
Managing Symptoms of D-MER may Include:
- Increasing skin-to-skin contact between mother and baby
- Practice meditation or deep breathing exercises
- Practice relaxation techniques
- Listen to music, a podcast, or an audiobook, soak in a warm tub, talk to a friend on the phone before feedings, etc.
- Distractions
- Eat a snack, watch TV, or do other activities during let-down, such as folding laundry or playing with the baby (if pumping)
- Seek support
- If D-MER becomes overwhelming or begins to negatively affect mental health or confidence in one’s ability to breastfeed, speak with a lactation counselor, perinatal clinician (such as an OB-GYN), or mental health professional. Early support can make a meaningful difference.
Conclusion
Perinatal mental health conditions can affect breastfeeding, maternal recovery, and overall well-being in many different ways. Early support, open communication with healthcare providers, and access to mental health and lactation resources are important for both parent and baby.
Self-care during the perinatal period is also essential. Whether it involves resting, connecting with supportive friends or family, spending time outdoors, practicing skin-to-skin contact, or taking a few moments each day to recharge, caring for one’s mental health is an important part of caring for both parent and baby.
References:
- American College of Obstetricians and Gynecologists. (2026). Perinatal mental health. https://www.acog.org/programs/perinatal-mental-health/summary-of-perinatal-mental-health-conditions
- Centers for Disease Control and Prevention. (2024). CDC activities: Improving maternal mental health care. https://www.cdc.gov/reproductive-health/depression/cdc-activities.html
- Cleveland Clinic. (2023). Dysphoric milk ejection reflex (D-MER). https://my.clevelandclinic.org/health/diseases/24879-dysphoric-milk-ejection-reflex
- Hudepohl, N., MacLean, J., & Osborne, L. (2022). Perinatal Obsessive-Compulsive Disorder: Epidemiology, Phenomenology, Etiology, and Treatment. Current Psychiatry Reports, 24(4), 229–237. https://doi.org/10.1007/s11920-022-01333-4
- National Institute of Mental Health. (2023). Perinatal depression. https://www.nimh.nih.gov/health/publications/perinatal-depression
- Phillips, M. & Postpartum Support International. (2023). When eating disorders and perinatal mental health collide. https://postpartum.net/when-eating-disorders-and-perinatal-mental-health-collide/
- Postpartum Support International. (2024). Perinatal mental health. https://postpartum.net/perinatal-mental-health/
- Raza S. (2023). Postpartum psychosis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544304/
- Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4. (2023). Obstetrics and Gynecology, 141(6), 1232–1261. https://doi.org/10.1097/AOG.0000000000005200
- Watson, H., Zerwas, S., Torgersen, L., Gustavson, K., Diemer, E., Knudsen, G., Reichborn-Kjennerud, T., & Bulik, C. (2017). Maternal eating disorders and perinatal outcomes: A three-generation study in the Norwegian Mother and Child Cohort Study. Journal of Abnormal Psychology, 126(5), 552–564. https://doi.org/10.1037/abn0000241
- World Health Organization. (2026). Perinatal mental health. https://www.who.int/teams/mental-health-and-substance-use/promotion-prevention/maternal-mental-health
Authors:
- Julianna Lyle, CLC, Rural Health and Nutrition Extension Agent, Anderson and Abbeville Counties
Reviewers:
- Paris Mebane, Extension Associate, Rural Health and Nutrition
- Ellie Lane, Extension Associate, Rural Health and Nutrition
