京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20613号 / 医博第4262号 / 新制||医||1023(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 小川 修, 教授 篠原 隆司, 教授 近藤 玄 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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Yes / Objectives Preterm birth (PTB) and small for gestational age (SGA) are major causes of perinatal mortality and morbidity. Previous studies indicated a range of risk factors associated with these poor outcomes, including maternal psychosocial and economic wellbeing. This paper will explore a range of psycho-social and economic factors in an ethnically diverse population. Methods The UK’s Born in Bradford cohort study recruited pregnant women attending a routine antenatal appointment at 26–28 weeks’ gestation at the Bradford Royal Infirmary (2007–2010). This analysis includes 9680 women with singleton live births who completed the baseline questionnaire. Data regarding maternal socio-demographic and mental health were recorded. Outcome data were collected prospectively, and analysed using multivariate regression models. The primary outcomes measured were: PTB (<37 weeks’ gestation) and SGA (<10th customised centile). Results After adjustment for socio-demographic and medical factors, financial strain was associated with a 45 % increase in PTB (OR 1.45: 95 % CI 1.06–1.98). Contrary to expectation, maternal distress in Pakistani women was negatively associated with SGA (OR 0.65: CI 0.48–0.88). Obesity in White British women was protective for PTB (OR 0.67: CI 0.45–0.98). Previously recognized risk factors, such as smoking in pregnancy and hypertension, were confirmed. Conclusions This study confirms known risk factors for PTB and SGA, along with a new variable of interest, financial strain. It also reveals a difference in the risk factors between ethnicities. In order to develop appropriate targeted preventative strategies to improve perinatal outcome in disadvantaged groups, a greater understanding of ethno-specific risk factors is required

L’Assistance Médicale à la Procréation est considérée comme une solution thérapeutique en cas d’infertilité. Au-delà des questions économiques et éthiques qui sont soulevées au niveau de la société, l’impact sur la santé des enfants nés grâce à ces techniques pose de nombreuses questions. En effet, ces techniques ont été introduites chez l’homme sans aucun essai clinique ni aucune évaluation sur les effets à long terme sur la santé.Dans ce travail, nous présentons trois études réalisées à partir d’une cohorte de plus de 3000 enfants (singletons et jumeaux) constituée depuis 1994 au sein du service de médecine et de biologie de la reproduction de l’Hôpital Saint Joseph à Marseille. Nous avons évalué différents indicateurs de la santé périnatale (la prématurité, le faible poids et la macrosomie à la naissance, l’hypotrophie et l’hypertrophie pondérales par rapport à l’âge gestationnel et les anomalies congénitales), chez des enfants conçus à partir de différentes techniques : fécondation in vitro classique, fécondation in vitro avec micromanipulation, fécondation après transfert d’embryon congelé et fécondation après vitrification et réchauffement ovocytaire.Nos résultats ont suggéré que l’Assistance Médicale à la Procréation, quelle que soit la technique mise en œuvre, était associée à des problèmes de santé chez les enfants nés grâce à ces techniques. Il est nécessaire de continuer à développer des systèmes de surveillance visant à rendre plus performant le suivi de l’état de santé à long terme des enfants concernés, d’autant plus que de nouvelles techniques et procédés continueront à être développés. / Assisted reproductive technologies are considered as a therapeutic solution in infertility cases. Beyond the economic and ethical questions that arise at the societal level, the impact on children’s health born after these techniques raises many questions. Indeed, these techniques have been introduced to the human without any clinical trial or assessment of long-term health effects. The main interest of this thesis is to contribute to the existing debate on the safety of these techniques regarding children’s health and well-being and to open new perspectives for future research on this subject.This research presents three studies based on a cohort of more than 3000 children (singletons and twins) constituted since 1994 in the Medicine and Reproductive Biology Department at the Saint Joseph Hospital in Marseille. The thesis evaluates various indicators of perinatal health (preterm birth, low birth weight and macrosomia, small and large for gestational age, and congenital anomalies) in children conceived from different techniques: classical In Vitro fertilisation, In Vitro fertilisation with micromanipulation, fertilisation after frozen embryo transfer and fertilisation after vitrified/warmed oocyte.The results suggest that assisted reproductive technologies, regardless of the technique used, were associated with health problems in children born through these techniques. There is a need to continue to develop surveillance systems to improve the long-term monitoring of the health status of children, especially as new techniques and procedures will continue to be developed.

Introdução e objetivos – A finalidade prioritária no tratamento do diabetes mellitus gestacional (DMG) é alcançar níveis de glicemia materna tão próximos da normalidade quanto possível, a fim de reduzir os efeitos adversos associados à hiperglicemia na gestação. A auto verificação da glicemia capilar (perfil glicêmico) é o método mais usado para a monitorização do controle metabólico na gestação complicada por diabetes. Nosso objetivo foi analisar as associações entre os perfis glicêmicos maternos com os principais desfechos da gestação numa população de mulheres com DMG acompanhadas em ambulatório de pré-natal especializado em hospital universitário no sul do Brasil, Hospital de Clínicas de Porto Alegre (HCPA). Desenho e metodotologia – conduzimos um estudo de coorte prospectiva de gestantes referidas da rede de atenção primária de saúde pública para tratamento do DMG no HCPA, acompanhadas do diagnóstico ao parto. Pesquisamos associações entre os resultados dos perfis glicêmicos com o peso de nascimento e com o risco de recém-nascidos grandes para idade gestacional e de desfechos adversos perinatais. Resultados – acompanhamos 440 mulheres com DMG. A média do índice de massa corporal (IMC) foi 33.3kg/m2. 351 bebês (79.8%) mostraram peso adequado à idade gestacional no nascimento. As médias de glicemia nos perfis pré e pósprandiais aumentaram com o avanço na categoria de peso nascimento. Três ou mais perfis glicêmicos anormais foram o fator de risco mais robusto para o nascimento de bebês grandes (OR 3.15 1.51-6.55) e para o desenvolvimento de desfechos adversos perinatais (OR 2.28 1.59-3.29). O ganho de peso materno durante o tratamento associou-se ao risco de recém-nascido grande para idade gestacional, assim como o IMC pré-gestacional, esse último também fator de risco independente para eventos perinatais adversos. Conclusão – perfis glicêmicos anormais em mais de 2 ocasiões foram o fator de risco mais relacionado ao nascimento de um bebê grande para a idade gestacional e para o desenvolvimento de complicações neonatais. Efeito benéfico do tratamento do DMG, guiado pelos perfis glicêmicos, foi a maioria de recém-nascidos com peso adequado à idade gestacional nessa coorte, apesar da incidência de desfechos perinatais adversos não ter sido diferente entre as categorias de peso fetal de nascimento. / Background and objective – a priority target in the treatment of gestational diabetes mellitus (GDM) is attaining maternal glucose levels as close as possible to euglycemia, in order to decrease the adverse outcomes linked to hyperglycemia. Self-performed capillary glucose (glycemic profile) is the most widely used method for metabolic monitoring in pregnancy complicated by diabetes. We intended to analyze the associations of maternal glycemic profile to main pregnancy outcomes in a population of GDM women treated in a specialized prenatal clinic at a university hospital in South Brazil, Hospital de Clínicas de Porto Alegre (HCPA). Research design and methodology – we conducted a prospective cohort study of pregnant women, referred from public primary health care for treatment of GDM at HCPA, between 2008 and 2015. We searched associations of glycemic profiles to birth weight, large for gestational age newborn and adverse neonatal outcomes. Results – we followed 440 GDM women from diagnosis to delivery. Mean prepregnancy body mass index (BMI) was 33.3kg/m2; 351 babies (79.8%) had appropriate birth weight for gestational age. Mean glucose in pre-prandial and postprandial profiles increased with raising birth weight category. Three or more abnormal glycemic profiles showed the strongest association to a large baby (OR 3.15 1.51-6.55) and to a composite of adverse neonatal outcomes (OR 2.28 1.59- 3.29). Gestational weight gain in the course of treatment was associated to large babies, as pre-pregnancy BMI, the latter also an independent risk factor for adverse neonatal outcome. Conclusion – abnormal maternal glycemic profiles in more than two occasions were the stronger risk factor for delivering a large baby and for developing neonatal complications. A beneficial effect of GDM treatment, guided by glycemic profiles, was that most of our newborns had birth weight appropriate for gestational age, although incidence of adverse neonatal outcomes had been no different across birth weight categories.

Introdução e objetivos – A finalidade prioritária no tratamento do diabetes mellitus gestacional (DMG) é alcançar níveis de glicemia materna tão próximos da normalidade quanto possível, a fim de reduzir os efeitos adversos associados à hiperglicemia na gestação. A auto verificação da glicemia capilar (perfil glicêmico) é o método mais usado para a monitorização do controle metabólico na gestação complicada por diabetes. Nosso objetivo foi analisar as associações entre os perfis glicêmicos maternos com os principais desfechos da gestação numa população de mulheres com DMG acompanhadas em ambulatório de pré-natal especializado em hospital universitário no sul do Brasil, Hospital de Clínicas de Porto Alegre (HCPA). Desenho e metodotologia – conduzimos um estudo de coorte prospectiva de gestantes referidas da rede de atenção primária de saúde pública para tratamento do DMG no HCPA, acompanhadas do diagnóstico ao parto. Pesquisamos associações entre os resultados dos perfis glicêmicos com o peso de nascimento e com o risco de recém-nascidos grandes para idade gestacional e de desfechos adversos perinatais. Resultados – acompanhamos 440 mulheres com DMG. A média do índice de massa corporal (IMC) foi 33.3kg/m2. 351 bebês (79.8%) mostraram peso adequado à idade gestacional no nascimento. As médias de glicemia nos perfis pré e pósprandiais aumentaram com o avanço na categoria de peso nascimento. Três ou mais perfis glicêmicos anormais foram o fator de risco mais robusto para o nascimento de bebês grandes (OR 3.15 1.51-6.55) e para o desenvolvimento de desfechos adversos perinatais (OR 2.28 1.59-3.29). O ganho de peso materno durante o tratamento associou-se ao risco de recém-nascido grande para idade gestacional, assim como o IMC pré-gestacional, esse último também fator de risco independente para eventos perinatais adversos. Conclusão – perfis glicêmicos anormais em mais de 2 ocasiões foram o fator de risco mais relacionado ao nascimento de um bebê grande para a idade gestacional e para o desenvolvimento de complicações neonatais. Efeito benéfico do tratamento do DMG, guiado pelos perfis glicêmicos, foi a maioria de recém-nascidos com peso adequado à idade gestacional nessa coorte, apesar da incidência de desfechos perinatais adversos não ter sido diferente entre as categorias de peso fetal de nascimento. / Background and objective – a priority target in the treatment of gestational diabetes mellitus (GDM) is attaining maternal glucose levels as close as possible to euglycemia, in order to decrease the adverse outcomes linked to hyperglycemia. Self-performed capillary glucose (glycemic profile) is the most widely used method for metabolic monitoring in pregnancy complicated by diabetes. We intended to analyze the associations of maternal glycemic profile to main pregnancy outcomes in a population of GDM women treated in a specialized prenatal clinic at a university hospital in South Brazil, Hospital de Clínicas de Porto Alegre (HCPA). Research design and methodology – we conducted a prospective cohort study of pregnant women, referred from public primary health care for treatment of GDM at HCPA, between 2008 and 2015. We searched associations of glycemic profiles to birth weight, large for gestational age newborn and adverse neonatal outcomes. Results – we followed 440 GDM women from diagnosis to delivery. Mean prepregnancy body mass index (BMI) was 33.3kg/m2; 351 babies (79.8%) had appropriate birth weight for gestational age. Mean glucose in pre-prandial and postprandial profiles increased with raising birth weight category. Three or more abnormal glycemic profiles showed the strongest association to a large baby (OR 3.15 1.51-6.55) and to a composite of adverse neonatal outcomes (OR 2.28 1.59- 3.29). Gestational weight gain in the course of treatment was associated to large babies, as pre-pregnancy BMI, the latter also an independent risk factor for adverse neonatal outcome. Conclusion – abnormal maternal glycemic profiles in more than two occasions were the stronger risk factor for delivering a large baby and for developing neonatal complications. A beneficial effect of GDM treatment, guided by glycemic profiles, was that most of our newborns had birth weight appropriate for gestational age, although incidence of adverse neonatal outcomes had been no different across birth weight categories.

Introdução e objetivos – A finalidade prioritária no tratamento do diabetes mellitus gestacional (DMG) é alcançar níveis de glicemia materna tão próximos da normalidade quanto possível, a fim de reduzir os efeitos adversos associados à hiperglicemia na gestação. A auto verificação da glicemia capilar (perfil glicêmico) é o método mais usado para a monitorização do controle metabólico na gestação complicada por diabetes. Nosso objetivo foi analisar as associações entre os perfis glicêmicos maternos com os principais desfechos da gestação numa população de mulheres com DMG acompanhadas em ambulatório de pré-natal especializado em hospital universitário no sul do Brasil, Hospital de Clínicas de Porto Alegre (HCPA). Desenho e metodotologia – conduzimos um estudo de coorte prospectiva de gestantes referidas da rede de atenção primária de saúde pública para tratamento do DMG no HCPA, acompanhadas do diagnóstico ao parto. Pesquisamos associações entre os resultados dos perfis glicêmicos com o peso de nascimento e com o risco de recém-nascidos grandes para idade gestacional e de desfechos adversos perinatais. Resultados – acompanhamos 440 mulheres com DMG. A média do índice de massa corporal (IMC) foi 33.3kg/m2. 351 bebês (79.8%) mostraram peso adequado à idade gestacional no nascimento. As médias de glicemia nos perfis pré e pósprandiais aumentaram com o avanço na categoria de peso nascimento. Três ou mais perfis glicêmicos anormais foram o fator de risco mais robusto para o nascimento de bebês grandes (OR 3.15 1.51-6.55) e para o desenvolvimento de desfechos adversos perinatais (OR 2.28 1.59-3.29). O ganho de peso materno durante o tratamento associou-se ao risco de recém-nascido grande para idade gestacional, assim como o IMC pré-gestacional, esse último também fator de risco independente para eventos perinatais adversos. Conclusão – perfis glicêmicos anormais em mais de 2 ocasiões foram o fator de risco mais relacionado ao nascimento de um bebê grande para a idade gestacional e para o desenvolvimento de complicações neonatais. Efeito benéfico do tratamento do DMG, guiado pelos perfis glicêmicos, foi a maioria de recém-nascidos com peso adequado à idade gestacional nessa coorte, apesar da incidência de desfechos perinatais adversos não ter sido diferente entre as categorias de peso fetal de nascimento. / Background and objective – a priority target in the treatment of gestational diabetes mellitus (GDM) is attaining maternal glucose levels as close as possible to euglycemia, in order to decrease the adverse outcomes linked to hyperglycemia. Self-performed capillary glucose (glycemic profile) is the most widely used method for metabolic monitoring in pregnancy complicated by diabetes. We intended to analyze the associations of maternal glycemic profile to main pregnancy outcomes in a population of GDM women treated in a specialized prenatal clinic at a university hospital in South Brazil, Hospital de Clínicas de Porto Alegre (HCPA). Research design and methodology – we conducted a prospective cohort study of pregnant women, referred from public primary health care for treatment of GDM at HCPA, between 2008 and 2015. We searched associations of glycemic profiles to birth weight, large for gestational age newborn and adverse neonatal outcomes. Results – we followed 440 GDM women from diagnosis to delivery. Mean prepregnancy body mass index (BMI) was 33.3kg/m2; 351 babies (79.8%) had appropriate birth weight for gestational age. Mean glucose in pre-prandial and postprandial profiles increased with raising birth weight category. Three or more abnormal glycemic profiles showed the strongest association to a large baby (OR 3.15 1.51-6.55) and to a composite of adverse neonatal outcomes (OR 2.28 1.59- 3.29). Gestational weight gain in the course of treatment was associated to large babies, as pre-pregnancy BMI, the latter also an independent risk factor for adverse neonatal outcome. Conclusion – abnormal maternal glycemic profiles in more than two occasions were the stronger risk factor for delivering a large baby and for developing neonatal complications. A beneficial effect of GDM treatment, guided by glycemic profiles, was that most of our newborns had birth weight appropriate for gestational age, although incidence of adverse neonatal outcomes had been no different across birth weight categories.

Background: Optical coherence tomography (OCT), multifocal electroretinography (mfERG) and full-field electroretinography (ffERG) give important information about retinal structure and function. Purpose: To collect normative data of macular Cirrus Spectral domain (SD)-OCT assessments and of mfERG measurements of healthy children (papers I and II). To assess the macular thickness with Cirrus SD-OCT and the retinal function with ffERG in 6.5-year-old children born extremely preterm and in children born at term (papers III and IV). Methods: Study participants aged 5-15 years and living in Uppsala County were randomly chosen from the Swedish Birth Register (papers I and II). In papers III and IV, the study participants consisted of children born extremely preterm and children born at term – all were aged 6.5 years. In paper III, the children were living in Stockholm and Uppsala health care regions and, in paper IV, in Uppsala health care region only. Macular thickness was assessed with Cirrus SD-OCT and macular function with mfERG, using the Espion Multifocal system and DTL-electrodes. The retinal function was assessed with ffERG and DTL-electrodes, using the Espion Ganzfield system. Results: Altogether, 58 children participated in paper I and 49 children in paper II. In paper I, the repeatability and reproducibility of the OCT assessments were good. In paper II, the results of the mfERG measurements were in accordance with retinal cone density and there were no significant differences between the right and left eyes. In paper III, 134 preterm children and 145 children born at term constituted the study population. The central macular thickness was significantly thicker in the preterm group than in the control group. Within the preterm group, gestational age (GA), former retinopathy of prematurity (ROP) and male gender were all important risk factors for an increased macular thickness. In paper IV, 52 preterm children and 45 control children constituted the study population. Significantly lower amplitudes and prolonged implicit times of the combined rod and cone responses, as well as of the isolated cone responses, were found in the preterm group when compared with the control group. In paper IV, there was no association between GA, ROP or male gender and the ffERG assessments. Conclusion: Normative data of Cirrus SD-OCT and mfERG assessments were reported. The results of the assessments were reliable. Children aged 6.5 years, born extremely preterm, had a significantly thicker central macula and both rod and cone function were significantly reduced in comparison to children born at term. ROP had an influence on retinal structure but not retinal function in the present cohorts. Our results suggest that retinal development is abnormal in children born extremely preterm. Long-term follow-up studies are necessary in order to evaluate the functional ophthalmological outcome in this vulnerable population of children growing up today.

Objetivo: Analisar a influência dos cuidados maternos percebidos pelas mães sobre a frequência de aleitamento materno e aleitamento materno exclusivo, aos 3 e 6 meses de vida da criança em uma amostra expostas a diferentes ambientes intrauterinos. Métodos: Estudo observacional longitudinal, utilizando uma amostra de conveniência de mães e seus recém-nascidos, no qual os grupos foram classificados de acordo com as exposições maternas ocorridas no período gestacional, como diabetes mellitus, tabagismo ou desfecho do recém-nascido, como pequeno para idade gestacional, além de um grupo controle. Para algumas análises, os grupos em estudo foram subdivididos em grupo de condições intrauterinas adversas e grupo controle. A amostra foi selecionada em três hospitais de Porto Alegre, Rio Grande do Sul, Brasil, no período de 2011 a 2015. As mães e seus recém-nascidos foram avaliados ao nascimento, 7 e 15 dias, primeiro, terceiro e sexto mês de vida da criança. O aleitamento materno e o aleitamento materno exclusivo foram avaliados desde a entrevista do 15º dia até a entrevista do sexto mês de vida. Os questionários Parental Bonding Instrument (PBI), que avalia a percepção dos cuidados maternos e Edinburgh Postnatal Depression Scale (EPDS), que avalia a presença de sintomas depressivos após o parto, foram autoaplicados na entrevista do terceiro mês. Os testes utilizados foram ANOVA com post hoc de Tukey, teste Kruskal-Wallis com post hoc de Dunn, ANOVA de duas vias, ANCOVA e a Regressão de Poisson. As análises foram realizadas no programa Statistical Package for the Social Sciences versão 18.0. Resultados: A amostra foi composta de 212 duplas mãe/criança, 40 no grupo de mães com diabetes mellitus, 55 no grupo de tabagistas, 21 no grupo de nascidos pequenos para idade gestacional e 96 no grupo controle. A associação entre cuidado materno e amamentação entre os grupos em estudo mostrou que as mães que não praticavam mais o aleitamento materno no 3º mês de vida da criança apresentaram maiores escores na percepção de proteção e menores escores na percepção de cuidados maternos do que aquelas crianças que estavam em aleitamento materno exclusivo (p=0,038; p=0,017, respectivamente). O grupo controle apresentou maior escore na percepção de cuidados e menor escore na percepção de proteção materna em relação ao grupo de ambientes intrauterinos adversos (p=0,005, p=0,049, respectivamente). Em relação aos resultados da análise de regressão de Poisson entre amamentação, grupos, PBI e EPDS os dados mostram que, a cada um ponto a mais no protocolo de EPDS, o risco de não amamentar até 3 meses aumenta em 10,4% e até os 6 meses aumenta em 4,7% (p<0,001 e 0,004, respectivamente). Em relação ao aleitamento materno exclusivo, a cada um ponto a mais no protocolo de EPDS, o risco de não amamentar até 6 meses aumenta em 5,4% (p=0,002). As puérperas que perceberam restrição de carinho de suas mães aos 6 meses, apresentaram risco de 2,42% em relação à categoria de cuidado ótimo para não amamentar. Aquelas mães que perceberam suas mães como negligentes, apresentaram tendência de maior risco de 2,53% em relação à categoria de cuidado ótimo para não amamentar aos 6 meses de vida da criança. Conclusão: Os achados deste estudo sugerem que o estilo parental de baixo cuidado e de superproteção percebidos durante a infancia, interfere na frequencia do aleitamento materno e leva a sintomas depressivos após o parto. Demonstram, ainda, que os sintomas depressivos maternos após o parto influencia na frequencia da amamentação. / Objective: To analyze the influence of maternal care perceived by mothers on the frequency of breastfeeding and exclusive breastfeeding at 3 and 6 months of the child's life in a sample exposed to different intrauterine environments. Methods: A longitudinal observational study used a convenience sample of mothers and their newborns. They were classified according to maternal exposure occurring during pregnancy, such as diabetes mellitus, smoking or outcome newborn, the small for gestational age, and a control group. For some analyzes, the study groups were divided into two groups: the group of adverse intrauterine conditions and control group. The recruitment of participants was in three hospitals in Porto Alegre, Rio Grande do Sul, Brazil, from 2011 to 2015. The mothers and their newborns were evaluated at the newborns birth, 7 and 15 days, first, third and sixth month of child’s life. Breastfeeding and exclusive breastfeeding was evaluated from the 15th day to the sixth month of life, through questionnaires. The Parental Bonding Instrument questionnaires (PBI), which evaluates the perception of maternal care and Edinburgh Postnatal Depression Scale (EPDS), to assess the presence of depressive symptoms after delivery, were self-administered in the third month interview. The statistical tests used were ANOVA one-way with post hoc Tukey, Kruskal-Wallis test with post hoc Dunn, The two-way ANOVA, ANCOVA test and Poisson regression. Analyzes were performed using the Statistical Package for the Social Sciences version 18.0. Results: The sample was composed of 212 mothers with their child, 40 pairs in the diabetes mellitus group, 55 in the smokers group, 21 in small for gestational age group and 96 in the control group. The association between maternal care and breastfeeding among study groups showed that mothers who no longer practiced breastfeeding in the 3rd month of the child's life had higher scores in the perception of protection and lower scores in the perception of maternal care than those children who were in exclusive breastfeeding (p = 0.038, p = 0.017, respectively). The control group had higher scores of perceived care and lower perception of maternal protection in relation to the adverse intrauterine environment group (p=0.005, p=0.049, respectively). Regarding the results of the Poisson regression analysis between breastfeeding groups, PBI, and EPDS data show that each additional point on the EPDS protocol, the risk of not breastfeeding up to 3 months increased by 10.4% and up 6 months increases by 4.7% (p <0.001 and 0.004, respectively). Compared with exclusive breastfeeding, each additional point on the EPDS protocol, the risk of not breastfeeding up to 6 months increased by 5.4% (p = 0.002). The mothers realized that restriction affection from their mothers at 6 months had a risk of 2.42% compared to the great care category to not breastfeed. Those mothers who perceived their mothers as negligent tended to increase the risk of 2.53% compared to the great care category for not breastfeeding at 6 months of child's life. Conclusion: The findings of this study suggest that low care and overprotection parenting style perceived during childhood, interfere with the frequency of breastfeeding and leads to depressive symptoms after delivery. They also demonstrated those maternal depressive symptoms after birth influences breastfeeding frequency.