Social Science & Medicine 285 (2021) 114288

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Breastfeeding, maternal psychopathological symptoms, and infant problem

behaviors among low-income mothers returning to work
Qiong Wu *, Tatjana Farley, Ming Cui
Department of Human Development & Family Science, College of Health and Human Sciences, Florida State University, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Rationale: One of the biggest challenges for mothers returning to work after childbirth is breastfeeding. Studies
Breastfeeding documented the physical health benefits of breastfeeding for mothers and children. However, research findings
Maternal psychopathology concerning the longitudinal effects of breastfeeding on maternal and children’s mental health are mixed.
Infant problem behaviors
Objective: The current study investigated the longitudinal effects of the length of breastfeeding on maternal
Working mothers
psychopathological symptoms and infants’ problem behaviors, among a sample of low-income working mothers.
Methods: The sample included 285 infants and their mothers (primarily minority, low-income, and single) who
returned to work 3-month postpartum, recruited from an ethnically diverse and economically disadvantaged area
in a southern U.S. state. Mothers’ breastfeeding behaviors were assessed four times in the first year postpartum,
and mothers’ psychopathological symptoms and their infants’ problem behaviors were reported by mothers two
times, at 12-month and 24-month postpartum.
Results: Path models revealed that high maternal psychopathological symptoms in infancy worsened the effect of
breastfeeding on child externalizing behaviors in toddlerhood. Likewise, very high infant externalizing behaviors
worsened the effect of breastfeeding on maternal hostility one year later.
Conclusions: This study suggests the need for implementing prevention interventions with a lifecycle approach
and continued, tailored professional breastfeeding support after hospital discharge among at-risk working
mothers. Findings of this study can inform public policy by highlighting the importance of considering joint
breastfeeding support and mental health counseling in the delivery of services to mothers and their infants who
live in under-resourced environments and struggle with maternal psychopathology.

1. Introduction
The postpartum period is a vulnerable time for women. During the
first two years after childbirth, mothers struggle to adapt to the mother’s
role, as well as balancing other areas of life, such as physical, social, and
work life. Influenced by hormone changes as well as stress from
balancing work and family life, it is common for postpartum women to
experience psychopathological symptoms, such as depression, anxiety,
and hostility (Britton, 2011; Reck et al., 2009). Currently, over half of U.
S. mothers return to work by three months postpartum (Shepherd-Ba­
nigan and Bell, 2014). The transition back to work poses risk for the
mother’s own mental health as well as her young offspring (Li et al.,
2014; Strazdins et al., 2006). During this transition, economically
disadvantaged women may face unique challenges. These women are
more likely to return to work early due to a lack of financial support
during pregnancy leave, and have a higher chance working for
non-family-friendly employers, compared with those in better financial
situations (Tucker et al., 2010).
One of the biggest challenges that mothers returning to work face is
breastfeeding (Grzywacz et al., 2010; Guendelman et al., 2009). As
breastfeeding is commonly seen as a practice to improve mothers’ and
infants’ health as well as securing the mother-child bond (Oddy et al.,
2010; Ystrom, 2012), the American Academy of Pediatrics (AAP) rec­
ommends exclusive breastfeeding for the first six months (Gartner et al.,
2005). Nevertheless, low-income working mothers face unique chal­
lenges regarding breastfeeding, which is less addressed by the existing
literature. The current study sought to understand the relations among
maternal breastfeeding, maternal psychopathological symptoms and
infant problem behaviors, among low-income mothers who returned to
work three months after childbirth.

* Corresponding author. Department of Human Development & Family Science, College of Health and Human Sciences, Florida State University, 322 Sandels
Building, 120 Convocation Way, Tallahassee, FL, 32306, USA.
E-mail address: qwu3@fsu.edu (Q. Wu).

https://doi.org/10.1016/j.socscimed.2021.114288
Received 9 March 2021; Received in revised form 20 July 2021; Accepted 30 July 2021
Available online 31 July 2021
0277-9536/© 2021 Elsevier Ltd. All rights reserved.
Q. Wu et al.
1.1. Breastfeeding and maternal and child mental health
Several studies documented the physical health benefits of breast­
feeding on mothers and children. For example, breastfeeding is related
to lower risks for infections, illnesses, asthma, obesity, and cardiovas­
cular and metabolic diseases among children, as well as lower diabetes,
metabolic, and cardiovascular risks among mothers (Dieterich et al.,
2013). In contrast, research findings regarding the longitudinal effects of
breastfeeding on maternal and child mental health are relatively mixed.
Some studies suggest that longer breastfeeding is associated with
improved mental health outcomes in both mothers and children. For
example, breastfeeding over six months predicted fewer children’s
problem behaviors in middle childhood (Oddy et al., 2010) and lower
symptoms of anxiety and depression among mothers (Ystrom, 2012). In
contrast, researchers argue that the beneficial effects of breastfeeding
are largely accounted for by familial-level factors associated with
breastfeeding practices, such as race and socioeconomic status (Colen
and Ramey, 2014). Using a national representative sample, breastfed
children performed similarly in their longitudinal mental outcomes
compared to their bottle-fed siblings (Colen and Ramey, 2014). A ran­
domized controlled trial of a breastfeeding promotion intervention with
over 10,000 mothers increased maternal breastfeeding behaviors from 3
to 12 months postpartum. However, children’s problem behaviors and
maternal relational satisfaction did not differ between breastfed families
and bottle-fed ones (Kramer et al., 2008). Further, potential unfavorable
effects of breastfeeding are also documented. Negative breastfeeding
experiences were associated with the onset of maternal postpartum
depressive symptoms (Dias and Figueiredo, 2015). Three-month-old
breastfed infants had more negative emotion and lower abilities to
regulate emotions, compared with bottle-fed ones (de Lauzon-Guillain
et al., 2012).
The mixed findings may suggest that the effects of breastfeeding on
maternal and child mental health may not be straightforward, and may
depend on other factors. A few studies have sought to test the moderators
in the effects of breastfeeding on maternal and child outcomes. For
example, females who had high levels of antenatal anxiety and depres­
sion and stopped breastfeeding within six months postpartum were at
additional risks for postpartum anxiety and depression (Ystrom, 2012).
Breastfeeding predicted better intelligence in early and middle child­
hood (Caspi et al., 2007) and less depression in adulthood (Merjonen
et al., 2012) only among individuals with certain genotypes. Together,
these findings seem to suggest that the effects of breastfeeding on
mother-child mental health can be modulated by other factors, such as
the mother-child mutual influences.
1.2. Dyadic moderators in maternal symptoms and child behaviors
Indeed, theoretical perspectives on children’s development (Born­
stein and Lansford, 2010; Maccoby, 2014; Sameroff, 2010) presume not
only that the environment (such as maternal mental health) influences
children’s development but also that children actively engage and shape
their rearing environment, highlighting the dyadic, bidirectional nature
of mothers’ and children’s influences on each other. In conjunction with
these theories, maternal psychopathology, including internalizing (e.g.,
depression and anxiety) and externalizing (e.g., hostility) problems
(Burstein et al., 2006), consistently shows adverse effects on their young
children’s socioemotional development (Kaitz et al., 2010). Young
children of mothers with elevated psychopathological symptoms exhibit
high levels of negative expression, difficulty in regulating emotions, and
increased externalizing and internalizing behaviors (e.g., Kaitz et al.,
2010; Martinez-Torteya et al., 2014; Nicholson et al., 2011). In contrast,
longitudinal evidence of how infants affect maternal psychopathological
symptoms remains insufficient. Studies show that infant negative
emotion was related to higher levels of maternal depression and anxiety
in the first two years (Agrati et al., 2015; Britton, 2011). Children’s
internalizing/externalizing behaviors in middle childhood predicted
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Social Science & Medicine 285 (2021) 114288
parental hostility (Carrasco et al., 2009; Lewis et al., 2014).
Given the effect of breastfeeding and mother-child mutual influences
on maternal and child mental health, it is unclear how they work jointly
to affect maternal psychopathology and child behavioral problems.
Neurobiology research has also linked changes in breastmilk micro­
biome to both maternal distress and infant neurobiological development
(Kortesniemi et al., 2021; Piñeiro-Ramos et al., 2021). It is thus likely
that high levels of maternal psychopathological symptoms may weaken
beneficial effects of longer breastfeeding on infants. Similarly, it is
possible that when infants have high levels of behavioral problems,
longer breastfeeding can become a stressful experience and conse­
quentially reduce its benefits for mothers. In this way, the current study
expanded the existing research on breastfeeding with dyadic modera­
tors, that is, whether maternal mental health moderated the association
between breastfeeding and child problem behaviors, and vice versa.
1.3. Low-income, working mothers
Breastfeeding may bring unique challenges for low-income, working
mothers. Some of these challenges may include but not limited to: a lack
of supportive environment at work to feed the infant, worries, and pains
associated with feeding, additional errands carrying and cleaning the
breastfeeding tools, insufficient milk resulting from work stress, dis­
rupted sleeping schedules associated with nighttime feeding, and risks
for acute mastitis (Dias and Figueiredo, 2015; Gianni et al., 2019).
Commonly, working mothers drastically reduce their rates of breast­
feeding after they return to work (Guendelman et al., 2009). Mothers
with nonstandard schedule jobs tend to end breastfeeding even sooner,
and tend to feed their infants commercially prepared food, which may
posit health risks (Grzywacz et al., 2010; Zilanawala, 2017). However,
research efforts on the unique challenges of breastfeeding among
low-income, working mothers remain largely insufficient and highly
needed.
1.4. The current study
The current study investigated the prospective, bidirectional asso­
ciations among the length of maternal breastfeeding, mothers’ psycho­
pathological symptoms, and infants’ problem behaviors, among a
sample of mothers returning to work 3-month postpartum. We hypoth­
esized that maternal and child mental health variables at 12 months
would moderate the association between the length of breastfeeding and
maternal and child outcomes at 24 months. In particular, we expected
that high levels of maternal and child mental health concerns at 12
months would worsen the effects of breastfeeding on maternal and child
outcomes at 24 months; this effect would not be found when mothers
and infants had few mental health concerns at 12 months. The con­
ceptual model is included in Fig. 1. More specific expectations of the
Fig. 1. Conceptual model of the current study. The bold arrows indicate dyadic
moderation effects.
Q. Wu et al.
interactions are listed as follows.
Hypothesis 1. Maternal psychopathological symptoms (depression,
anxiety, and hostility) at 12 months would moderate the relations be­
tween the length of breastfeeding and toddlers’ problem behaviors
(externalizing and internalizing behaviors) at 24 months.
Expectation 1. High levels of maternal psychopathological symp­
toms would worsen the effect of longer breastfeeding on toddlers’
problem behaviors. This effect would not be found when mothers had
low psychopathological symptoms.
Hypothesis 2. Children’s problem behaviors at 12 months would
moderate the associations between breastfeeding and maternal psy­
chopathological symptoms at 24 months.
Expectation 2. High levels of children’s problem behaviors would
degrade the effect of longer breastfeeding on maternal psychopatho­
logical symptoms. This effect would not be present when children had
low problem behaviors.
2. Methods
2.1. Participants
This study utilized secondary data from a longitudinal research
project focusing on low-income working mothers and their young chil­
dren’s development. The participants were recruited from the Piedmont
Triad region of central North Carolina. Women were eligible if they
delivered a live birth within the past 3 months, intended to return to
work 27 or more hours per week, and whose household earnings were
within 185 % of federal poverty thresholds. The sample was primarily
minority (73.7 %), single mothers (64.9 %) that had graduated from
high school and had pursued some additional training but did not earn
an advanced degree (71.2 %).
2.2. Procedures
Trained research staff monitored the three dominant hospitals in the
Piedmont Triad region of central North Carolina for low-income new
mothers. Using the electronic medical record of delivery, staff identified
potentially study-eligible mothers (i.e., reported working for pay before
delivery, birth reimbursed by public sources) and requested permission
to release their names and contact information to study personnel. The
study team also visited Women, Infants and Children offices, Forsyth
and Guilford County public health departments, and local federally
qualified health centers to recruit low-income new mothers. The goal of
sampling was to create a representative sample of low-income working
mothers with young infants in the Piedmont Triad region of central
North Carolina to understand the postpartum experience of these
mothers.
When the potential study participant’s infant was approximately 2
months of age, mothers were screened for inclusion criteria, and eligible
mothers were enrolled. At infant age 3 months, research staff confirmed
inclusion criteria and obtained signed informed consent prior to data
collection. Mothers completed a battery of questionnaires in person
about demographic information, as well as questionnaires concerning
work and breastfeeding. Mothers were again contacted by phone when
children were 6 and 9 months, to track the changes in the mothers’ work
and breastfeeding. When the children were 12 (n = 243, 85.3 %) and 24
months of age (n = 225, 78.9 %), in-person assessments were completed
during which mothers responded to questions about breastfeeding, as
well as their own mental health and their infants’ problem behaviors.
The study was approved by the University’s Institutional Review Board
(IRB), and supported by IRBs of three additional academic institutions
and two hospitals (Grzywacz et al., 2016).
2.3. Measures
Length of breastfeeding was coded from two items on the
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Social Science & Medicine 285 (2021) 114288
Breastfeeding Questionnaire. Mothers responded to questions “This
week, did you feed (the target child) breast milk?” and “Has (the target
child) fed from your breast this week?“. Their responses were coded into
1 if they responded yes on either of the two items, and 0 if they
responded no to both of the items. Mothers were assessed four times (3-
month, 6-month, 9-month, and 12-month postpartum), and they re­
sponses across assessments were summed to represent their total length
of breastfeeding the target child (0 = less than 3 months, 69.5 %; 1 = 3–6
months, 10.9 %; 2 = 6–9 months, 8.8 %; 3 = 9–12 months, 4.2 %; 4 =
above 12 months, 6.7 %).
Maternal depressive, anxiety and hostility symptoms were self-reported
by mothers on the Brief Symptom Inventory (BSI; Derogatis, 1993) at
3-month, 12-month, and 24-month postpartum. The BSI is a 53-item
measure of self-reported psychopathological symptoms experienced in
the past week, rated on a 5-point Likert-type scale (0 = “not at all”, 4 =
“very much”). It includes specific symptom scales, such as depression (6
items), anxiety (6 items), and hostility (6 items), of which the mean
scores were used in the current study. The Cronbach’s αs were 0.83,
0.86, and 0.84 for depression, 0.76, 0.85, and 0.79 for anxiety, 0.65,
0.77, and 0.68 for hostility, at the 3-, 12-, and 24-month postpartum
assessments, respectively.
Children’s externalizing and internalizing behaviors were reported by
mothers using the Brief Infant-Toddler Social and Emotional Assessment
(BITSEA; Briggs-Gowan et al., 2004) at 12-month and 24-month post­
partum. The BITSEA is a 42-item parent-report questionnaire designed
to identify early risk for socioemotional/behavioral problems and/or
delays in socioemotional competence, among infants and toddlers. It
includes clinically significant items rated by infant mental health ex­
perts, and identifies infant externalizing and internalizing behaviors
reaching subclinical/clinical levels assessed by the Child Behavior
Checklist, with high discriminant validity and specificity (Briggs-Gowan
et al., 2004). Two subscales, externalizing (7 items, e.g., “is restless and
can’t sit still”) and internalizing behaviors (14 items, e.g., “seems ner­
vous, tense, or fearful”), were included in the current study. These items
were rated on a 3-point scale (0 = “not true/rarely”, 2 = “very true/of­
ten”). Cronbach’s αs were 0.62 and 0.64 for externalizing behaviors, as
well as 0.70 and 0.61 for internalizing behaviors, at the 12-month and
24-month postpartum assessments, respectively.
Covariates included child sex (1 = boy, 2 = girl), maternal minority
status (0 = White, non-Hispanic; 1 = minority race, 73.7 %), and maternal
single-parent status at 12 months postpartum (0 = not a single parent; 1
= single parent, 62.2 %). Mothers also reported their income at 12
months postpartum (0 = None/No one else had earnings, 1 = Less than
$15,000, 2 = $15,000 to $29,999, 3 = $30,000 to $44,999, 4 = $45,000
to 59,000, 5 = $60,000 to $74,999, 6 = Greater than $75,000). We
controlled for these factors because they could potentially confound
maternal breastfeeding, mental health, and child behavioral problems
(e.g., Nicholson et al., 2011; Oddy et al., 2010).
2.4. Analytic plan
Path models were conducted using the lavaan package (Rosseel,
2012) in R (R Core Team, 2014a, 2014b). To understand how each type
of maternal symptoms was uniquely associated with their children’s
behaviors, we estimated three maternal symptoms (depression, anxiety,
and hostility) using three separate path models. This decision was made
also because we had a relatively small sample size and there was po­
tential multicollinearity of maternal psychopathology variables. In each
path model, the length of breastfeeding predicted maternal symptoms
and child externalizing and internalizing behaviors. Further, the inter­
action terms between maternal symptoms and the length of breast­
feeding at T1 was entered to predict children’s
externalizing/internalizing behaviors at T2, and the interaction terms
between the length of breastfeeding and children’s external­
izing/internalizing behaviors at T1 predicted maternal symptoms at T2.
In probing significant interactions, low, medium, and high levels of
Q. Wu et al. Social Science & Medicine 285 (2021) 114288

moderating variables were centered at one standard deviation (SD)
below the mean, at the mean, and at one SD above the mean, respec­
tively. Low levels of maternal symptoms were centered at zero because
one SD below the mean was negative and exceeded the range of the
variable. To evaluate the model fit, we used the root mean squared error
of approximation (RMSEA) and comparative fit index (CFI), with a
RMSEA of 0.05 and below and CFI of 0.95 and above indicating good fit
and a RMSEA of 0.05–0.08 and CFI of 0.90–0.95 indicating acceptable
fit (Hu and Bentler, 1995).
Percentage of missing data ranged from 14.7 % to 35.1 % (see
Table 1). Little’s MCAR test (Little, 1988) revealed that data were
missing completely at random, χ2 (56) = 52.35, p = .61. As such, full
information maximum likelihood (FIML) algorithm was employed for
missing data estimation as recommended (Enders and Bandalos, 2001).
As the length of breastfeeding was skewed, maximum likelihood esti­
mation with robust (Huber-White) standard errors (MLR) was used to
estimate the model, as recommended for non-normal distributions,
especially in smaller samples (Chou et al., 1991; Li, 2016).
3. Results
3.1. Sample characteristics and preliminary analyses
The sample included 285 infants (53.0 % male, 47.0 % female) and
their mothers. The mean age of the mothers was 27.14 (SD = 5.26) at
recruitment. The majority of the mothers (63.9 %) were African Amer­
ican, with 26.3 % Caucasian, 3.5 % Hispanic, 1.1 % American Indian or
Alaskan Native, 0.4 % Asian, and 5.0 % other or mixed races. Mothers
also reported their highest levels of education, with 8.4 % as some high
school or GED, 22.1 % as high school graduate, 17.2 % as some voca­
tional school, 15.1 % as vocational school graduate, 22.5 % as some
college, 11.2 % as college graduate, and 3.5 % as post-graduate training.
At recruitment, 57.9 % of the mothers reported that they were single,
whereas 35.1 % reported married or living together, and 7.0 % reported
separated/divorced/widowed. At recruitment, mothers reported their
income as less than $15,000 (39.1 %), $15,000 to $29,999 (51.8 %),
$30,000 to $44,999 (8.5 %), and above $45,000 (0.7 %).
Descriptive statistics and bivariate correlations of the study variables
are shown in Table 1. The associations between 3-month maternal
psychopathology symptoms and the length of breastfeeding were not
significant, rs ≤ 0.05, ps ≥ .38. Using the clinical cutoff of subscale T-
scores (≥63), there was no difference in breastfeeding duration between
mothers with or without depression (t (281) = − 0.69, p = .49), anxiety (t
(281) = 0.22, p = .83), and hostility (t (281) = − 0.45, p = .66) at 3
months. Since early maternal psychopathology symptoms were not
prospectively associated with the length of breastfeeding, we only esti­
mated the associations between the length of breastfeeding and future
maternal and child mental health at 12 (T1) and 24 months (T2).
Breakdowns of maternal and child mental health variables at T1 and T2
by the length of breastfeeding are in Table 2. One-way ANOVA showed
that mothers breastfeeding for 9–12 months had higher depressive and
anxiety symptoms at T2 compared to those who breastfed for less than 3
months, 3–6 months, and 6–9 months; mothers breastfeeding for over 12
months had higher depressive symptoms at T2 than those who did for
3–6 months. Children who were breastfed for 6–9 months had higher
externalizing behaviors at T1 compared to those who stopped within 3
months.
3.2. Path analyses
Three models were estimated for maternal depressive symptoms,
anxiety, and hostility, respectively (Table 3). The model estimating
maternal depressive symptoms showed an acceptable model fit, χ2 (7) =
12.16, p = .10; RMSEA = 0.051 (CI.90 = 0.000, 0.092); CFI = . 965.
Consistent with Hypothesis 1, the length of breastfeeding moderated the
link between maternal depressive symptoms at T1 and child external­
izing behaviors at T2 (B = 0.38, SE = 0.16, t = 2.32, p = .02; Fig. 2a). In
line with Expectation 1, longer breastfeeding was associated with
increased child externalizing behaviors at T2 when maternal depressive
symptoms at T1 were high (B = 0.35, SE = 0.14, t = 2.45, p = .01), but no
association was found when maternal depressive symptoms were low (B
= − 0.00, SE = 0.10, t = − 0.00, p = .99) or medium (B = 0.13, SE = 0.10,
t = 1.38, p = .17).
The model estimating maternal anxiety symptoms showed a good fit,
χ2 (7) = 10.09, p = .18; RMSEA = 0.039 (CI.90 = 0.000, 0.081); CFI = .
979. Consistent with Hypothesis 1, maternal anxiety symptoms at T1
moderated the link between the length of breastfeeding and child
externalizing behaviors at T2 (B = 0.24, SE = 0.12, t = 1.99, p = .046;
Fig. 2b). In line with Expectation 1, longer breastfeeding was associated
with higher rates of child externalizing behaviors at T2 when maternal

Table 1
Descriptive statistics and bivariate associations among study variables.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

1. C sex
2. Minority -.03
3. Single parent .00 -.08
4. M income -.01 .11 -.17*
5. Breastfeeding -.00 .10 -.03 .04
6. M dep 12 m .01 -.05 .13 -.05 -.03
7. M dep 24 m .03 -.02 .05 .06 .17* .36***
8. M anx 12 m -.02 -.02 .06 .01 .02 .75*** .26***
9. M anx 24 m .01 -.15* .08 .07 .16* .22** .58*** .35***
10. M hos 12 m -.04 -.06 .10 -.09 -.08 .75*** .31*** .73*** .24***
11. M hos 24 m .04 -.11 .15 -.05 .04 .34*** .60*** .29*** .56*** .43***
12. C ext 12 m -.12 .16* .13 -.10 -.10 .11 .15* .15* .18** .22** .26***
13. C ext 24 m -.16* .08 .09 -.02 -.02 .14* .17* .14* .18** .26*** .22** .37***
14. C int 12 m -.12 .14* .05 -.10 -.10 .32*** .14* .25*** .16* .28*** .20** .48*** .33***
15. C int 24 m -.08 .10 .09 -.13 -.13 .26*** .14* .24*** .21** .36*** .23** .32*** .54*** .51***

N 285 285 185 243 285 243 225 243 225 243 225 242 225 237 220
Min 1.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Max 2.00 1.00 1.00 6.00 4.00 3.83 3.33 3.66 3.50 4.00 3.00 10.00 11.00 16.00 15.00
Mean – – – 1.72 0.68 0.35 0.30 0.31 0.31 0.48 0.42 2.28 2.71 4.81 5.10
SD – – – 0.72 1.20 0.58 0.52 0.58 0.51 0.58 0.47 2.03 2.19 3.17 3.14

Note. *p < .05, **p < .01, ***p < .001. M = mother. C = child. Child sex: 1 = boy, 2 = girl. Minority = mother’s minority status, 0 = White, non-Hispanic; 1 = minority
race. Single parent: 0 = not a single parent; 1 = single parent. Breastfeeding = length of breastfeeding, 0 = less than 3 months, 1 = 3–6 months, 2 = 6–9 months, 3 =
9–12 months, 4 = above 12 months. Dep = mother’s depressive symptoms. Anx = mother’s anxiety symptoms. Hos = mother’s hostility. Ext = child’s externalizing
behaviors. Int = child’s internalizing behaviors. The numbers 12 and 24 indicate the time of assessment (12-month and 24-month postpartum).

4
Q. Wu et al. Social Science & Medicine 285 (2021) 114288

Table 2
Descriptive statistics in mother and child mental health by breastfeeding length.
0-3 months 3-6 months 6-9 months 9-12 months > 12 months F

M SD M SD M SD M SD M SD

M dep 12 m 0.35 0.59 0.47 0.71 0.17 0.31 0.28 0.51 0.36 0.59 0.81
M dep 24 m 0.27a,c 0.45 0.16a 0.26 0.36a,c 0.64 0.83b 1.21 0.47b,c 0.51 3.65**
M anx 12 m 0.32 0.58 0.36 0.54 0.06 0.10 0.31 0.50 0.47 0.84 1.40
M anx 24 m 0.28a,c 0.45 0.20a 0.31 0.29a,c 0.50 0.74b 0.87 0.51b,c 0.86 2.77*
M hos 12 m 0.51 0.59 0.51 0.65 0.29 0.26 0.24 0.23 0.46 0.70 1.09
M hos 24 m 0.42 0.48 0.33 0.44 0.42 0.45 0.56 0.40 0.49 0.51 0.52
C ext 12 m 2.53a 2.20 1.78a,b 1.45 1.20b 1.28 1.50a,b 1.18 2.37a,b 1.71 2.93*
C ext 24 m 2.68 2.20 2.56 1.83 2.95 2.66 2.00 1.73 3.22 2.21 0.59
C int 12 m 4.91 3.34 4.85 2.84 4.60 2.44 3.80 2.66 4.58 3.24 0.34
C int 24 m 5.24 3.24 4.96 2.79 4.76 3.08 2.56 2.30 5.83 2.79 1.91

Note. *p < .05, **p < .01, ***p < .001. M = mother. C = child. Dep = mother’s depressive symptoms. Anx = mother’s anxiety symptoms. Hos = mother’s hostility. Ext
= child’s externalizing behaviors. Int = child’s internalizing behaviors. The numbers 12 and 24 indicate the time of assessment (12-month and 24-month postpartum).
Different subscripts within the same row indicate statistically significant mean differences (i.e., the means were statistically equivalent among groups with the
subscript a, but statistically different between groups with subscript a and b, etc.).

Table 3
Unstandardized regression coefficients for the path models.
Model of Depression Model of Anxiety Model of Hostility

B SE t B SE t B SE t
2 2 2
DV: M psychopathology 24 m R = .21 R = .26 R = .26
M psychopathology 12 m 0.33 0.09 3.74*** 0.25 0.08 3.18** 0.30 0.06 4.88***
Breastfeeding 0.06 0.06 0.95 − 0.05 0.06 − 0.78 0.02 0.04 0.52
C ext 12 m 0.04 0.02 1.90 0.04 0.02 2.16* 0.03 0.02 1.57
Breastfeeding × C ext 12 m 0.02 0.02 0.89 0.02 0.03 0.72 0.03 0.01 2.27*
C int 12 m − 0.01 0.02 − 0.42 0.00 0.01 − 0.28 0.01 0.02 0.54
Breastfeeding × C int 12 m 0.00 0.01 − 0.10 0.02 0.01 1.61 − 0.01 0.01 − 0.87
Single parent − 0.05 0.09 − 0.57 0.08 0.08 0.98 0.07 0.08 0.84
M income 0.06 0.05 1.18 0.10 0.05 1.96 0.02 0.03 0.51
C Sex 0.04 0.06 0.70 0.02 0.06 0.36 0.07 0.05 1.30
Minority − 0.07 0.06 − 1.06 − 0.24 0.07 − 3.52 − 0.13 0.07 − 1.82

DV: C ext 24 m R2 = .18 R2 = .17 R2 = .21

C ext 12 m 0.34 0.07 5.22*** 0.35 0.07 5.14*** 0.33 0.07 5.11***
Breastfeeding 0.00 0.10 0.00 0.03 0.12 0.22 0.01 0.11 0.09
M psychopathology 12 m 0.24 0.25 0.95 0.15 0.24 0.63 0.57 0.28 2.04*
Breastfeeding × M psychopathology 12 m 0.38 0.16 2.32* 0.24 0.12 1.99* 0.31 0.13 2.46*
Single parent 0.13 0.34 0.38 0.17 0.33 0.51 0.12 0.32 0.38
M income 0.07 0.17 0.42 0.04 0.17 0.26 0.07 0.17 0.40
C Sex − 0.51 0.26 − 1.94 − 0.50 0.26 − 1.90 − 0.44 0.26 − 1.69
Minority 0.07 0.28 0.24 0.08 0.27 0.31 0.14 0.27 0.51

DV: C int 24 m R2 = .25 R2 = .24 R2 = .29

C int 12 m 0.39 0.06 6.38*** 0.39 0.06 6.49*** 0.36 0.06 6.25***
Breastfeeding − 0.09 0.15 − 0.64 0.00 0.16 0.01 0.06 0.16 0.39
M psychopathology 12 m 0.59 0.40 1.50 0.82 0.39 2.12* 1.39 0.33 4.22***
Breastfeeding × M psychopathology 12 m 0.10 0.22 0.47 − 0.17 0.16 − 1.04 − 0.18 0.15 − 1.17
Single parent 0.22 0.47 0.47 0.12 0.48 0.26 0.04 0.45 0.08
M income − 0.35 0.25 − 1.39 − 0.43 0.25 − 1.75 − 0.37 0.24 − 1.56
C Sex − 0.17 0.36 − 0.49 − 0.18 0.35 − 0.51 − 0.15 0.35 − 0.42
Minority 0.45 0.40 1.15 0.45 0.40 1.13 0.53 0.39 1.37

Note. *p < .05, **p < .01, ***p < .001. Unstandardized coefficients are shown. DV: dependent variable. M = mother. C = child. Child sex: 1 = boy, 2 = girl. Minority =
mother’s minority status, 0 = White, non-Hispanic; 1 = minority race. Single parent: 0 = not a single parent; 1 = single parent. Breastfeeding = length of breastfeeding,
0 = less than 3 months, 1 = 3–6 months, 2 = 6–9 months, 3 = 9–12 months, 4 = above 12 months. Dep = mother’s depressive symptoms. Anx = mother’s anxiety
symptoms. Hos = mother’s hostility. Ext = child’s externalizing behaviors. Int = child’s internalizing behaviors. The numbers 12 and 24 indicate the time of assessment
(12-month and 24-month postpartum).

anxiety symptoms at T1 were high (B = 0.24, SE = 0.11, t = 2.23, p =
.03), but not when maternal anxiety symptoms were low (B = 0.03, SE =
0.12, t = 0.22, p = .82) and medium (B = 0.10, SE = 0.10, t = 0.98, p =
.33). Child externalizing behaviors at T1 predicted more maternal anx­
iety at T2 (B = 0.04, SE = 0.02, t = 2.16, p = .03), whereas maternal
anxiety at T1 predicted more child internalizing behaviors at T2 (B =
0.82, SE = 0.39, t = 2.12, p = .03). Minority mothers reported fewer
anxiety symptoms (B = − 0.24, SE = 0.07, t = − 3.52, p < .001).
The model estimating maternal hostility showed a good fit, χ2 (7) =
10.97, p = .14; RMSEA = 0.045 (CI.90 = 0.000, 0.093); CFI = . 983.
Consistent with Hypothesis 1, maternal hostility at T1 moderated the
link between the length of breastfeeding and child externalizing be­
haviors at T2 (B = 0.31, SE = 0.13, t = 2.46, p = .01; Fig. 2c). In
accordance with Expectation 1, longer breastfeeding was associated
with elevated child externalizing behaviors at T2 when maternal hostility
was high (B = 0.34, SE = 0.13, t = 2.64, p = .01), but not when maternal
hostility at T1 was low (B = 0.01, SE = 0.11, t = 0.09, p = .93) or me­
dium (B = 0.16, SE = 0.10, t = 1.68, p = .09). Additionally, consistent
with Hypothesis 2, child externalizing behaviors at T1 moderated the
path from the length of breastfeeding to maternal hostility at T2 (B =
0.03, SE = 0.01, t = 2.27, p = .02; Fig. 3). Similar to Expectation 2, under
very high child externalizing behaviors (two SD’s above the mean) at T1,

5
Q. Wu et al. Social Science & Medicine 285 (2021) 114288

Fig. 2. Interaction plots for breastfeeding length and maternal psychopathology predicting child externalizing behaviors. Note. *p < .05. M = mother. Unstan­
dardized coefficients are shown.

Fig. 3. Interaction plot for breastfeeding length and child externalizing behaviors predicting maternal hostility. Note. *p < .05, **p < .01, ***p < .001. C exter­
nalizing = child externalizing behaviors. Unstandardized coefficients are shown.

6
Q. Wu et al.
longer breastfeeding predicted higher maternal hostility at T2 (B = 0.18,
SE = 0.09, t = 2.04, p = .04). The length of breastfeeding was not
associated with maternal hostility when child externalizing behaviors
were low (B = 0.03, SE = 0.04, t = 0.66, p = .51), medium (B = 0.08, SE
= 0.05, t = 1.49, p = .14), or high (marginally significant, B = 0.13, SE =
0.07, t = 1.87, p = .06). Maternal hostility predicted more child inter­
nalizing behaviors (B = 1.39, SE = 0.33, t = 4.22, p < .001).
4. Discussion
This study investigated the relations among maternal psychopatho­
logical symptoms, her length of breastfeeding, and her infant’s problem
behaviors, among a sample of low-income, returning to work mothers
with newborns. Findings reveal that high levels of maternal psycho­
pathological symptoms brought negative effects of a longer breastfeed­
ing period on toddlers’ externalizing behaviors. Additionally, very high
levels of toddlers’ externalizing behaviors worsened the effect of a
longer breastfeeding on maternal hostility. Our investigation highlights
the dyadic nature of mother-child mutual influences in moderating the
association between breastfeeding and mother-child mental health
outcomes, among this unique population of low-income working
mothers.
Consistent with Hypothesis 1, maternal psychopathological symp­
toms moderated the prospective associations between the length of
breastfeeding and future child externalizing behaviors. In particular,
high maternal depressive, anxiety, and hostility worsened the effect of
longer breastfeeding on child externalizing behaviors. Possibly, during
breastfeeding, infants spend a long, intimate time with their mothers
who have elevated psychopathological symptoms. These mothers may
exhibit insensitive parenting behaviors characterized by showing
negative emotion expressions, interfering children’s activities, or being
unresponsive and non-supportive towards their infants’ activities, thus
increasing children’s externalizing behaviors over time (Kaitz et al.,
2010; Martinez-Torteya et al., 2014).
Additionally, recent evidence suggests that maternal depression and
anxiety can be linked with changes in milk metabolome, such as con­
centrations of short-chain fatty acids, caprate, and hypoxanthine (Kor­
tesniemi et al., 2021). It is further hypothesized that changes in breast
milk microbiome composition can affect infant neurodevelopment by
inducing alterations in gut microbiota (Gur et al., 2015; Piñeiro-Ramos
et al., 2021). Moreover, in a low-resourced setting, micronutrient
composition in breastmilk may be affected by maternal nutrition intake,
which may be associated with infant inflammation and altered neuro­
development (Kreb et al., 2017). These preliminary studies suggest that
nutritional and neurobiological mechanisms underly current findings
through which longer breastfeeding duration connects maternal and
child mental health issues, and invite further investigations into
breastfeeding and the neurobiology of infant development in a
lower-resourced environment.
Also consistent with Hypothesis 2, infant externalizing behaviors
moderated the effects of length of breastfeeding on later maternal hos­
tility. Very high toddler externalizing behaviors degraded the effect of
longer periods of breastfeeding on maternal hostility. This finding
extended studies reporting that children’s problem behaviors increased
parental hostility in middle childhood (e.g., Carrasco et al., 2009; Lewis
et al., 2014). Especially, breastfeeding an infant with elevated early
externalizing behaviors, such as fussing, kicking, and impulsivity, may
seem extra stressful for working mothers, resulting a gradual increase in
maternal hostility. This hostility may subsequentially increase child
externalizing behaviors given longer breastfeeding time, thus creating a
cycle of dysfunctional mother-child interchanges.
In additional to the moderating effects, we found that mothers’
anxiety predicted infants’ later internalizing behaviors, and maternal
hostility predicted both internalizing and externalizing behaviors pro­
spectively among their toddlers. Further, infants’ externalizing behav­
iors predicted maternal anxiety one year later, showing a pattern of
7
Social Science & Medicine 285 (2021) 114288
reciprocal negative influences between mothers and children with
mental health risks. Our finding is consistent with the transactional
model of children’s development (Sameroff, 2010) and supports the
dyadic investigation on mother-child mutual influences.
Taken together, this study supported the influence of dyadic mod­
erators on the effect of breastfeeding on maternal and infant mental
health. This study suggests that poor initial maternal and child mental
health can worsen the effect of longer breastfeeding on mother-child
outcomes, whereas this effect was not significant when mothers and
children have good mental health to begin with. Moreover, the mothers
in our sample returned to work at around 3-month postpartum, and they
struggled to balance work and maternal responsibilities. In this case,
breastfeeding their infants may bring additional stress to these working
mothers (Gianni et al., 2019; Grzywacz et al., 2010). Notably, 30.5 % of
mothers in the current sample continued to breastfeed after 3 months,
with 19.7 % made it over 6 months. These numbers may indicate that
there are motivating factors for these mothers to continue breastfeeding
despite those barriers. These motivating factors may include expecta­
tions from self and others, added health benefits, guidance from AAP
and health professionals, feelings of a closer maternal bond, and re­
sponsibilities towards family and children (Flacking et al., 2007; Tan­
ganhito et al., 2020). In understanding the unique needs in
low-resourced mothers with newborns, it is worth considering how the
factors encouraging breastfeeding work together with those that create
barriers in forming maternal breastfeeding behaviors, and how in­
terventionists and policy makers can help enhance protective factors or
reduce risk factors in facilitating maternal and child mental health.
4.1. Strengths, limitations, and implications
The current study has several significant strengths, including an
under-studied, unique sample with primary low-income, working, mi­
nority mothers, as well as a longitudinal design which follows these
families over two years postpartum. The current study provides valuable
insights into our growing understanding of the reciprocal nature of
mother-child dynamics, especially in a low-income context and under
varying lengths of breastfeeding. In particular, the current study sheds
light on the complex relations among maternal psychopathological
symptoms, breastfeeding, and child socioemotional outcomes. A better
understanding of the particulars of these interactions allows for the
development of more targeted and effective intervention efforts for
parents and their young children in low-resourced families.
Several limitations need to be considered when interpreting the
findings of the current study. First, the sample in the current study may
experience multiple risk factors, such as economic stress, minority sta­
tus, lower education, work-related stress, and single motherhood. The
lower-resourced context may bring about unique challenges on biolog­
ical (e.g., breastmilk microbiome) and behavioral levels (e.g., negative
mother-child interactions) that may reduce the benefits of breastfeed­
ing. As such, findings of this study may not be generalizable to higher-
income families. Additionally, we had a relatively small sample size.
We had sufficient power for hypothesis testing, with a power level of .81
to detect a moderation effect of a small effect size with a dyadic
moderation model, using Monte Carlo Simulation with 1000 simulation
replications. Future studies should replicate current findings with larger
sample sizes for more robust conclusions. Second, due to the availability
of data, maternal psychopathological symptoms and children’s problem
behaviors were assessed through maternal report alone, which may have
introduced shared method variance. In particular, maternal mental
health may have affected their evaluations to children’s behaviors
(Ordway, 2011), although we statistically controlled concurrent
covariance between maternal and child mental health for both pre­
dictors and outcome variables. The inclusion of independent or
multiple-reporter measures of maternal and child mental health is a
direction for future research. Third, although we were able to obtain an
acceptable reliability of the BITSEA, past research has reported
Q. Wu et al.
relatively high reliability in predominantly Caucasian, middle-class
samples (Briggs-Gowan et al., 2004). The relatively lower internal
consistency of the BITSEA among the current sample (primarily African
American, low-income) warrants attention of future research. Finally,
the intergenerational transmission of psychopathology within the family
is a complex process, which involves multiple risk and protective factors,
such as parental relationships, parenting, the number of children,
physical health of family members, and economic stress. Although we
controlled for the effects of several of these factors in the current study,
the joint effect of these factors may form unique pathways in the
intergenerational transmission of psychopathology. Thus, it is worth
investigating other familial risk and protective factors, and unpacking
how these processes work together and how child factors contribute to
mental health risks in low-resourced families.
The bidirectional connection of mental health concerns between
mothers and infants additionally suggests the need for implementing
prevention interventions with a lifecycle approach (Kerber et al., 2007).
That is, maternal health closely affects infant health, which then have
long-term implications for future parents. In this way, health risks at any
lifecycle stage have broader influences on the whole lifecycle; however,
intervention happening at any stage can also introduce immense bene­
fits to the whole lifecycle. Interventions with a lifecycle approach and
integrating multiple components, such as breastfeeding and mental
health counseling, have long-term advantages across the lifecycles of
mothers and children and benefit the whole community. In particular,
this study suggests the need for continued, tailored professional
breastfeeding support after hospital discharge, which has been associ­
ated with lower risk among working mothers (Gianni et al., 2019). This
study additionally suggests that targeting stress and worries associated
with breastfeeding could be helpful for intervention programs for
breastfeeding mothers, particularly for families at risk of adverse child
outcomes (such as parents with psychopathologies or children with
behavioral problems). Findings of this study can inform public policy by
highlighting the importance of considering factors such as a supporting
environment for breastfeeding as well as paid maternity leave, in the
delivery of services to mothers and their infants living in
under-resourced environments and/or struggling with maternal psy­
chopathology. This study provides a holistic picture of occupational and
mental health challenges in impoverished families, emphasizing the
need for coordinated, integrated care (e.g., mental health, work envi­
ronment, and primary care). With joint efforts promoting maternal
physical, mental, and occupational health, breastfeeding will serve as a
strong connection between mothers and infants that increases resilience
and engenders positive health outcomes in these high-risk, vulnerable
families.
Author CRediT statement
Qiong Wu: Conceptualization, Methodology, Software, Formal
analysis, Writing - Original Draft, Writing - Review & Editing, Visuali­
zation, Tatjana Farley: Writing - Original Draft, Writing - Review &
Editing, Visualization, Ming Cui: Methodology, Writing - Review &
Editing.
Declaration of competing interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants
were in accordance with the ethical standards of the institutional and/or
national research committee and with the 1964 Helsinki declaration and
its later amendments or comparable ethical standards.
Acknowledgements
Data collection of this project was supported by a grant from the
Eunice Kennedy Shriver National Institute of Child Health and Human
8
Social Science & Medicine 285 (2021) 114288
Development (R01- HD061010, PI: Dr. Joseph Grzywacz). NICHD had
no role in the study design, collection, analysis, or interpretation of the
data, writing the manuscript, or the decision to submit the paper for
publication. The authors thank Dr. Grzywacz for reading an early
version of the manuscript and providing critical feedback.
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